Trauma and Orthopaedic Classifications: A Comprehensive Overview

By Peter V. Giannoudis

This illustrated textbook is an essential and invaluable guide to young clinicians and researchers of Trauma and Orthopaedics, reporting all classification systems which are currently utilised in the clinical setting. It includes classifications relevant to both Elective Orthopaedic Practice and Orthopaedic Trauma.

Clear graphic illustrations accompany the description of all different classification schemes in a comprehensive manner, together with a structured presentation of existing clinical evidence. In this manner each chapter of the different anatomical sites and pathologies assists the decision making of the readers regarding treatment strategy as well as informed consent of their patients. It is envisaged that this textbook will be a point of reference not only to the surgeons in training (residents) but also to senior surgeons and academic clinicians.

• Language: English
• Publisher: Springer
• Release date: Dec 12, 2014
• ISBN: 9781447165729

Book preview

Part I

Upper Limb Trauma

© Springer-Verlag London 2015

Nick G. Lasanianos, Nikolaos K. Kanakaris and Peter V. Giannoudis (eds.)Trauma and Orthopaedic Classifications10.1007/978-1-4471-6572-9_1

1. Acromioclavicular (AC) Joint Dislocation

Nick G. Lasanianos¹   and Michalis Panteli¹  

(1)

Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK

Nick G. Lasanianos (Corresponding author)

Email: [e-mail]

Michalis Panteli

Email: [e-mail]

Description

Allman/Rockwood Classification

In 1967 Allman proposed a classification system referring to three types of acromioclavicular joint dislocations (ACJ) [1]. The system was modified by Rockwood who added another three types (types 4, 5 and 6) to complete the classification [2]. The injuries are classified on the basis of findings from physical examination and radiological imaging (anteroposterior and axillary shoulder views). The degree of damage to the acromioclavicular and coracoclavicular ligaments, as well as to the deltoid and trapezius attachments, are also considered, (Fig. 1.1).

A328656_1_En_1_Fig1_HTML.gif

Fig. 1.1

The six types of AC joint dislocation according to the Allman / Rockwood classification (type I simple sprain of AC joint; type II subluxation-severe sprain of AC joint with intact coraco-clavicular ligaments; type III superior dislocation of AC joint with disruption of coraco-clavicular ligaments; type IV posterior dislocation of AC joint with disruption of coraco-clavicular ligaments; type V gross superior dislocation of AC joint; type VI inferior dislocation of AC joint)

I.

Sprain of the acromioclavicular ligament only.

II.

Acromioclavicular ligaments and joint capsule disruption.

Coracoclavicular ligaments (CC) are intact;

Subluxation of the acromioclavicular joint with vertical displacement of the articular surface of the clavicle about 50 % apposition.

III.

Acromioclavicular ligaments and joint capsule disruption.

Coracoclavicular ligaments disruption.

Dislocation of the acromioclavicular joint with the clavicle displaced superiorly, with complete (100 %) loss of contact between the clavicle and acromion articular surfaces.

IV.

Acromioclavicular ligaments and joint capsule disruption.

Coracoclavicular ligaments disruption.

Dislocation of the acromioclavicular joint with the clavicle displaced posteriorly into or through the trapezius muscle (posterior displacement confirmed on axillary radiograph).

V.

Acromioclavicular ligaments and joint capsule disruption.

Coracoclavicular ligaments disruption.

Dislocation of the acromioclavicular joint with the clavicle displaced grossly superiorly (100–300 % of normal); Complete detachment of the deltoid and trapezius muscles from the distal clavicle.

VI.

Acromioclavicular ligaments and joint capsule disruption.

Coracoclavicular ligaments disruption.

Dislocation of the acromioclavicular joint with the clavicle displaced inferior to the acromion and towards the coracoid process.

Treatment Strategy

Type I and II:

These injuries are generally accepted to be treated non-operatively at the acute setting [3].

Type III:

A consensus has not been established for the optimal management of acute type III injuries. Many surgeons believe that this degree of displacement leads to muscle-fatigue, discomfort and difficulties when handling heavy loads [4–6]. As a result, operative intervention is recommended for heavy labourers and younger patients who are engaged in sports or are unsure of their future careers.

Type IV, V and VI:

These injuries generally require surgical repair [6]. Because the clavicle is so far displaced from the acromial process in the posterior, superior, or inferior direction respectively, non-operative management is inadequate. The patient continues to experience pain and dysfunction if the articulation is not reduced and stabilised.

Non-operative treatment refers to a short period of sling support (few days to a few weeks) and physiotherapy [7]. Full activities resume as comfort allows.

Numerous techniques have been reported for surgical management:

Reduction of ACJ ± repair CC ligament using various methods:

Bosworth screw [8, 9] – Reported high incidence of failures and technically demanding.

K wires across ACJ [10, 11] – Reported failures/migration of K wires around the shoulder.

Suture/tape loops around base of coracoid and through clavicle (PDS tape, Ethibond, Anchors into coracoid)

Artificial ligament reconstruction – (braided polyester)

Hook plate

Arthroscopic assisted reduction/reconstruction

Resection of lateral end of clavicle and transfer of the coracoacromial (CA) ligament into the end of the clavicle. Temporary fixation by suture fixation or screw fixation from the clavicle to the coracoid process (Weaver-Dunn [12]).

References

1.

Allman Jr FL. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg Am. 1967;49(4):774–84.PubMed

2.

Rockwood CA, Young DC. Chapter 12 Acromioclavicular and sternoclavicular joints. In: Rockwood CA, Masten FA, editors. The shoulder. Philadelphia: Saunders – Elsevier; 1998. p. 483–553.

3.

Tossy JD, Mead NC, Sigmond HM. Acromioclavicular separations: useful and practical classification for treatment. Clin Orthop Relat Res. 1963;28:111–9.PubMed

4.

Ceccarelli E, Bondi R, Alviti F, Garofalo R, Miulli F, Padua R. Treatment of acute grade III acromioclavicular dislocation: a lack of evidence. J Orthop Traumatol. 2008;9(2):105–8.PubMedCentralPubMedCrossRef

5.

Smith TO, Chester R, Pearse EO, Hing CB. Operative versus non-operative management following Rockwood grade III acromioclavicular separation: a meta-analysis of the current evidence base. J Orthop Traumatol. 2011;12(1):19–27.PubMedCentralPubMedCrossRef

6.

Tamaoki MJ, Belloti JC, Lenza M, Matsumoto MH, Gomes Dos Santos JB, Faloppa F. Surgical versus conservative interventions for treating acromioclavicular dislocation of the shoulder in adults. Cochrane Database Syst Rev. 2010;(8):CD007429.

7.

Henry MD. Acromioclavicular dislocations. Minn Med. 1929;12:431–3.

8.

Stewart R. Acute acromioclavicular joint dislocation: internal fixation of the clavicle and coracoid process of the scapula with a vitallium screw. Minn Med. 1946;29:357–60.

9.

Bosworth BM. Acromioclavicular dislocation: end-results of screw suspension treatment. Ann Surg. 1948;127(1):98–111.PubMedCentralPubMedCrossRef

10.

Bloom FA. Wire fixation in acromioclavicular dislocation. J Bone Joint Surg Am. 1945;27:273–6.

11.

Murray G. The use of longitudinal wires in the treatment of fractures and dislocations. Am J Surg. 1945;67:156–7.CrossRef

12.

Weaver JK, Dunn HK. Treatment of acromioclavicular injuries, especially complete acromioclavicular separation. J Bone Joint Surg Am. 1972;54(6):1187–94.PubMed

13.

Reid D, Polson K, Johnson L. Acromioclavicular joint separations grades I–III: a review of the literature and development of best practice guidelines. Sports Med. 2012;42(8):681–96.PubMedCrossRef

14.

Spencer Jr EE. Treatment of grade III acromioclavicular joint injuries: a systematic review. Clin Orthop Relat Res. 2007;455:38–44.PubMedCrossRef

© Springer-Verlag London 2015

Nick G. Lasanianos, Nikolaos K. Kanakaris and Peter V. Giannoudis (eds.)Trauma and Orthopaedic Classifications10.1007/978-1-4471-6572-9_2

2. Sternoclavicular Joint Injuries

Nick G. Lasanianos¹   and Michalis Panteli¹  

(1)

Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK

Nick G. Lasanianos (Corresponding author)

Email: [e-mail]

Michalis Panteli

Email: [e-mail]

Description

The sternoclavicular joint is diarthrodial and is the only true articulation between the upper extremity and the axial skeleton [1]. The articular surface of the clavicle is much larger than the articular facet on the sternum and both surfaces are covered with fibrocartilage.

Detailed classifications are confusing and difficult to remember. The following classifications are based on the direction of the displacement and the amount of soft tissue trauma (Fig. 2.1 ) [2].

A328656_1_En_2_Fig1_HTML.gif

Fig. 2.1

The three grades of sternoclavicular dislocations classified on the basis of severity of soft tissue trauma (grade A mild sprain; grade B moderate sprain; grade C dislocation)

Classification Based on the Direction of the Displacement

A.

Anterior Dislocation

Anterior dislocation is the most common type of sternoclavicular dislocation. The medial end of the clavicle is displaced anteriorly or anterosuperiorly to the anterior margin of the sternum.

B.

Posterior Dislocation

Posterior sternoclavicular dislocation is uncommon. The medial end of the clavicle is displaced posteriorly, posteroinferiorly, or posterosuperiorly with respect to the sternum.

Classification Based on the Amount of Soft Tissue Trauma in Three Grades

A.

Mild Sprain

Incomplete ligamentous tears of the sternoclavicular and costoclavicular ligaments.

B.

Moderate Sprain

Rupture of the sternoclavicular and partial rupture of the costoclavicular ligament.

C.

Dislocation

Rupture of both the sternoclavicular and costoclavicular ligaments.

Treatment Strategy

Anterior dislocation:

Acute anterior dislocations can usually be treated non-operatively. However the interposition of the joint capsule, or of the ligaments can make the joint irreducible [3]. Additionally, maintaining reduction of anterior dislocations is often difficult.

Closed reduction technique for Anterior Sternoclavicular dislocation includes the following [4]:

Place the patient in a supine position on the stretcher.

Place a 3- to 4-in. thick bolster (rolled sheet or sandbag) between the scapula and spine (to help separate the clavicle from the manubrium).

Have an assistant abduct (to 90°) and extend (to 10–15°) the shoulder on the affected side whilst applying traction.

If reduction does not occur, apply pressure/push the medial clavicle in a posterior – inferior direction.

Posterior dislocation:

Acute posterior dislocations are more significant injuries because of their potential association with vascular injuries to the intrathoracic and superior mediastinal structures [5]. They are typically reduced in an operating room with the patient under general anaesthesia.

Closed reduction technique for Anterior Sternoclavicular dislocation includes the following:

Place the patient in a supine position on the stretcher.

Place a 3- to 4-in. thick bolster (rolled sheet or sandbag) between the scapula and spine (to help separate the clavicle from the manubrium).

Abduct (90°) and extend (10–15°) the shoulder on the affected side, whilst applying traction to the arm (an assistant applies countertraction to the trunk at the same time).

If traction fails to reduce the dislocation, pull the medial clavicle forward, whilst an assistant maintains traction and abduction to the affected limb.

Treatment options for recurrent/unreduced anterior or posterior SCJ dislocations may include open reduction and internal fixation, excision of medial clavicle, or acceptance of some degree of permanent instability, depending on the patient’s characteristics and functionality.

If an operation is performed, the critical part of the procedure is the stabilisation of the medial end of the clavicle to the first rib. Proposed fixation techniques include use of Kirschner wires, plates and suture wires. Another surgical option in neglected cases may be arthroplasty of the sternoclavicular joint with preservation or reconstruction of the costoclavicular ligament when ruptured.

References

1.

Bahk MS, Kuhn JE, Galatz LM, Connor PM, Williams Jr GR. Acromioclavicular and sternoclavicular injuries and clavicular, glenoid, and scapular fractures. J Bone Joint Surg Am. 2009;91(10):2492–510.PubMed

2.

Rockwood CA. Disorders of the sternoclavicular joint. In: Rockwood CA, Green DP, editors. Fractures, vol. 1. 2nd ed. Philadelphia: W. B. Saunders; 1990.

3.

Spencer Jr EE, Kuhn JE. Biomechanical analysis of reconstructions for sternoclavicular joint instability. J Bone Joint Surg Am. 2004;86-A(1):98–105.PubMed

4.

Yeh GL, Williams Jr GR. Conservative management of sternoclavicular injuries. Orthop Clin North Am. 2000;31(2):189–203.PubMedCrossRef

5.

Noda M, Shiraishi H, Mizuno K. Chronic posterior sternoclavicular dislocation causing compression of a subclavian artery. J Shoulder Elbow Surg. 1997;6(6):564–9.PubMedCrossRef

6.

Thut D, Hergan D, Dukas A, Day M, Sherman OH. Sternoclavicular joint reconstruction–a systematic review. Bull NYU Hosp Jt Dis. 2011;69(2):128–35.PubMed

© Springer-Verlag London 2015

Nick G. Lasanianos, Nikolaos K. Kanakaris and Peter V. Giannoudis (eds.)Trauma and Orthopaedic Classifications10.1007/978-1-4471-6572-9_3

3. Clavicle Fractures

Nick G. Lasanianos¹   and Michalis Panteli¹  

(1)

Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK

Nick G. Lasanianos (Corresponding author)

Email: [e-mail]

Michalis Panteli

Email: [e-mail]

Description

Allman Classification (Modified by Neer)

In 1967 Allman [1] presented a three-type anatomic classification for clavicle fractures (Fig. 3.1 ):

A328656_1_En_3_Fig1_HTML.gif

Fig. 3.1

The three groups of clavicle fractures according to the Allman classification system (group 1 middle third; group 2 distal to coraco-clavicular ligaments; group 3 proximal/medial end fractures)

Type 1: fractures of middle third (most common type).

Type 2: fractures distal to the coraco-clavicular ligament.

Type 3: fractures of proximal/medial end of the clavicle.

Neer made a significant revision to the Allman classification by suggesting sub-divisions to types 2 and 3 of the already described classification [2, 3]:

TYPE 2 – Fractures of the distal one third

Subtypes

A

Minimally displaced/inter-ligamentous

B

Fracture displaced medial to the coracoclavicular (C-C) ligaments

B1

Intact conoid and trapezoid (C-C) ligaments

B2

Either the conoid is torn or both the conoid and trapezoid are torn

C

Fractures extending to the articular surface

D

Fractures in children, intact C-C ligaments attached to periosteal sleeve, proximal fragment displaced

E

Comminuted fractures

TYPE 3 – Fractures of the proximal/medial one third

Subtypes

A

Minimal displacement

B

Displaced

C

Intra-articular

D

Epiphyseal separation (observed in patients younger than 25 years)

E

Comminuted

Treatment Strategy

TYPE 1(middle one third fractures) [4–6]

Non-operative therapy in most cases

Consider operative repair if high risk of non-union [7]

a.

Clavicle shortening >20 mm

b.

Female gender

c.

Older age

d.

Fracture displacement or comminution (skin pressure)

e.

Significant associated injuries

TYPE 2(distal one third fractures) [3]

Subtypes I, III, V: Non-operative therapy as with Allman Group 1 fractures [7]

Neer subtype II or displaced fractures of other types: Operative treatment

Children with subtype IV: Typically treated as acromioclavicular joint (ACJ) injuries.

TYPE 3(proximal/medial one third fractures)

Neurovascular injury: Emergent orthopaedic referral

Non-displaced (typical): Non-operative therapy

Displaced

a.

Neurovascular injury present

i.

Emergent reduction is critical

ii.

Towel clip can be used to grasp clavicle and apply anterior traction

b.

No neurovascular injury

i.

Clavicle CT scan to visualise any posterior fragments and/or displacement

Non - operative treatment of clavicle fractures consists of sling support for 6 weeks. During this period, the patient should perform pendulum exercises for the shoulder and active range of motion of the elbow and the hand. After 6 weeks, the patient should begin passive assisted motion of the shoulder and progress to active range of motion as tolerated. Use of the sling may be discontinued when pain subsides.

For the surgical fixation of a midshaft clavicle fracture, two methods are commonly used. Both methods involve open reduction of the fracture, followed by either insertion of an intramedullary device or fixation with a plate and screws [8]. Fractures of the distal third are treated operatively as ACJ injuries.

CC Coraco-Clavicular

aScrew back-out, plate migration, acromion hole widening, disengage from clavicle, unhooked from acromion, loss of reduction, broken wire

References

1.

Allman Jr FL. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg Am. 1967;49(4):774–84.PubMed

2.

Neer 2nd CS. Fracture of the distal clavicle with detachment of the coracoclavicular ligaments in adults. J Trauma. 1963;3:99–110.PubMedCrossRef

3.

Neer 2nd CS. Fractures of the distal third of the clavicle. Clin Orthop Relat Res. 1968;58:43–50.PubMed

4.

Canadian Orthopaedic Trauma S. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007;89(1):1–10.CrossRef

5.

Gossard JM. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br. 1998;80(3):558.PubMed

6.

Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br. 1997;79(4):537–9.PubMedCrossRef

7.

Robinson CM, Cairns DA. Primary nonoperative treatment of displaced lateral fractures of the clavicle. J Bone Joint Surg Am. 2004;86-A(4):778–82.PubMed

8.

Mueller M, Burger C, Florczyk A, Striepens N, Rangger C. Elastic stable intramedullary nailing of midclavicular fractures in adults: 32 patients followed for 1–5 years. Acta Orthop. 2007;78(3):421–3.PubMedCrossRef

9.

McKee RC, Whelan DB, Schemitsch EH, McKee MD. Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials. J Bone Joint Surg Am. 2012;94(8):675–84.PubMedCrossRef

10.

Duan X, Zhong G, Cen S, Huang F, Xiang Z. Plating versus intramedullary pin or conservative treatment for midshaft fracture of clavicle: a meta-analysis of randomized controlled trials. J Shoulder Elbow Surg. 2011;20(6):1008–15.PubMedCrossRef

11.

Virtanen KJ, Malmivaara AO, Remes VM, Paavola MP. Operative and nonoperative treatment of clavicle fractures in adults. Acta Orthop. 2012;83(1):65–73.PubMedCentralPubMedCrossRef

12.

Lenza M, Belloti JC, Andriolo RB, Gomes Dos Santos JB, Faloppa F. Conservative interventions for treating middle third clavicle fractures in adolescents and adults. Cochrane Database Syst Rev. 2009;(2):CD007121.

13.

Lenza M, Belloti JC, Gomes Dos Santos JB, Matsumoto MH, Faloppa F. Surgical interventions for treating acute fractures or non-union of the middle third of the clavicle. Cochrane Database Syst Rev. 2009;(4):CD007428.

14.

Oh JH, Kim SH, Lee JH, Shin SH, Gong HS. Treatment of distal clavicle fracture: a systematic review of treatment modalities in 425 fractures. Arch Orthop Trauma Surg. 2011;131(4):525–33.PubMedCrossRef

© Springer-Verlag London 2015

Nick G. Lasanianos, Nikolaos K. Kanakaris and Peter V. Giannoudis (eds.)Trauma and Orthopaedic Classifications10.1007/978-1-4471-6572-9_4

4. Scapula Fractures

Nick G. Lasanianos¹   and Michalis Panteli¹  

(1)

Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK

Nick G. Lasanianos (Corresponding author)

Email: [e-mail]

Michalis Panteli

Email: [e-mail]

Description

Zdravkovic and Damholt Classification

This anatomic classification, (Fig. 4.1) was reported by Zdravkovic and Damholt in 1974 [1].

A328656_1_En_4_Fig1_HTML.gif

Fig. 4.1

The three types of scapula fractures according to the Zdravkovic and Damholt system: line A represents fractures of the scapula body; line B Apophyseal fractures of the acromion; line C Apophyseal fractures of the coracoid process; line D superolateral angle fractures of the glenoid; line E superolateral angle fractures of the scapular neck

It includes three types as follows:

Type I Fracture of the body of the Scapula (A line)

Type II Apophyseal fractures:

i.

Acromion (B line)

ii.

Coracoid (C line)

Type III Superolateral angle fractures:

i.

Glenoid (D line)

ii.

Scapular neck (E line)

Treatment Strategy

Type I

Most non-articular fractures of the scapula are treated non-operatively with brief sling immobilisation for comfort and early shoulder range of motion [2]. Non-union is believed to be rare.

Type II

As with type I fractures, Coracoid and Acromial fractures are traditionally treated non-operatively. However in case of gross displacement fixation should be considered since mal-union or non-union will result to Acromioclavicular joint dysfunction.

Type III

Operative treatment is controversial [3], but relative indications include:

Displaced intra-articular glenoid fractures involving >25 % of the articular surface.

Scapular neck fractures with >40o of angulation.

Scapular neck fracture with associated clavicle fracture (floating shoulder).

Articular step off greater than 2 mm coracoid fractures resulting in AC joint dysfunction.

Displaced glenoid fractures are usually treated with open reduction and internal fixation with screws. Arthroscopic reduction and internal fixation has also been successful for some fracture patterns. Os acromiale should be ruled out prior to treating an acromial fracture. Tension band wiring or dorsal plating may also stabilise these fractures. Coracoid fractures leading to a acromioclavicular separation (relevant to a grade III ACJ dislocation) should be treated with open reduction and internal fixation with a transclavicular screw and suturing.

MUA Manipulation under anaesthetic, HO Heterotopic ossification

References

1.

Zdravkovic D, Damholt VV. Comminuted and severely displaced fractures of the scapula. Acta Orthop Scand. 1974;45(1):60–5.PubMedCrossRef

2.

Dimitroulias A, Molinero KG, Krenk DE, Muffly MT, Altman DT, Altman GT. Outcomes of nonoperatively treated displaced scapular body fractures. Clin Orthop Relat Res. 2011;469(5):1459–65.PubMedCentralPubMedCrossRef

3.

Gauger EM, Cole PA. Surgical technique: a minimally invasive approach to scapula neck and body fractures. Clin Orthop Relat Res. 2011;469(12):3390–9.PubMedCentralPubMedCrossRef

4.

Lantry JM, Roberts CS, Giannoudis PV. Operative treatment of scapular fractures: a systematic review. Injury. 2008;39(3):271–83.PubMedCrossRef

5.

Zlowodzki M, Bhandari M, Zelle BA, Kregor PJ, Cole PA. Treatment of scapula fractures: systematic review of 520 fractures in 22 case series. J Orthop Trauma. 2006;20(3):230–3.PubMedCrossRef

© Springer-Verlag London 2015

Nick G. Lasanianos, Nikolaos K. Kanakaris and Peter V. Giannoudis (eds.)Trauma and Orthopaedic Classifications10.1007/978-1-4471-6572-9_5

5. Glenoid Fractures

Nick G. Lasanianos¹   and Michalis Panteli¹  

(1)

Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK

Nick G. Lasanianos (Corresponding author)

Email: [e-mail]

Michalis Panteli

Email: [e-mail]

Description

Ideberg Classification (Modified by Goss)

In 1995 Ideberg et al. [1] presented a series of 338 scapular fractures with special reference to 100 intra-articular glenoid fractures. Out of this series emerged the Ideberg classification, which involved a five-type classification system. Goss modified type V fractures and added a sixth type [2] (Fig. 5.1).

A328656_1_En_5_Fig1_HTML.gif

Fig. 5.1

The six types of glenoid fractures according to the Ideberg classification system as modified by Goss: type I avulsion fractures of the rim; type II horizontal fracture line across the glenoid fossa; type III oblique fracture line across the glenoid fossa; type IV transverse fracture through medial border of the blade; type V separation of the inferior glenoid; type VI comminuted glenoid fracture

Type I

a.

Avulsion fracture of the anterior rim

b.

Avulsion fracture of the posterior rim

Type II Horizontal fracture through glenoid fossa with displacement of inferior fragment

Type III Oblique fracture running through glenoid and onto superior scapular border (seen with acromioclavicular and coracoids process fractures)

Type IV Transverse fracture running through medial border of the blade

Type V Type IV with added separation of inferior glenoid fragment.

Combination fractures:

a.

Types II and IV

b.

Types III and IV

c.

Types II, III and IV

Type VI Comminuted fracture of the glenoid

Treatment Strategy

The type of treatment for all types is based on the degree of displacement and instability [2].

Non-displaced or minimally displaced fractures require immobilization in a sling for 1 week, followed by progressive ROM and physiotherapy.

The following patterns of injury require open reduction and internal fixation [3]

Displaced fractures with – subluxation of humeral head >10 mm

Displacement of the glenoid cavity anteriorly >25 % of articular surface

Displacement of the glenoid cavity posteriorly >33 % of articular surface

>5 mm articular step-off

Fixation is generally provided with 3.5 mm reconstruction plates, and/or 3.5 mm or 4.0 mm cannulated screws.

Type VI fractures may not be amenable to any kind of fixation since the outcome is expected to be poor.

In general, 7.4 % of the operatively treated scapula fractures involve the glenoid rim, whereas 48.6 % involve the glenoid fossa (± associated scapula body fracture) [4].

References

1.

Ideberg R, Grevsten S, Larsson S. Epidemiology of scapular fractures. Incidence and classification of 338 fractures. Acta Orthop Scand. 1995;66(5):395–7.PubMedCrossRef

2.

Goss TP. Fractures of the glenoid cavity. J Bone Joint Surg Am. 1992;74(2):299–305.PubMed

3.

Kavanagh BF, Bradway JK, Cofield RH. Open reduction and internal fixation of displaced intra-articular fractures of the glenoid fossa. J Bone Joint Surg Am. 1993;75(4):479–84.PubMed

4.

Lantry JM, Roberts CS, Giannoudis PV. Operative treatment of scapular fractures: a systematic review. Injury. 2008;39(3):271–83.PubMedCrossRef

5.

Zlowodzki M, Bhandari M, Zelle BA, Kregor PJ, Cole PA. Treatment of scapula fractures: systematic review of 520 fractures in 22 case series. J Orthop Trauma. 2006;20(3):230–3.PubMedCrossRef

© Springer-Verlag London 2015

Nick G. Lasanianos, Nikolaos K. Kanakaris and Peter V. Giannoudis (eds.)Trauma and Orthopaedic Classifications10.1007/978-1-4471-6572-9_6

6. Coracoid Fractures

Nick G. Lasanianos¹   and Michalis Panteli¹  

(1)

Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK

Nick G. Lasanianos (Corresponding author)

Email: [e-mail]

Michalis Panteli

Email: [e-mail]

Description

Eyres and Brooks Classification

In 1995 Eyres et al. [1] reported a series of 12 coracoid process fractures, suggesting a classification system based on the anatomy of the fracture (Fig. 6.1).

A328656_1_En_6_Fig1_HTML.gif

Fig. 6.1

The five types of coracoid fractures: type I coracoid tip fracture; type II mid coracoid process fracture; type III basal fracture; type IV fracture of the superior body of scapula; type V extension of the glenoid fossa

Type I: Coracoid tip or epiphyseal fracture

Type II: Mid process

Type III: Basal fracture

Type IV: Involvement of superior body of scapula

Type V: Extension into the glenoid fossa

The above mentioned types can be sub grouped as A or B according to the presence or absence of associated injuries to the acromioclavicular joint, which affects scapular stability.

Treatment Strategy

Types I, II and III as well as undisplaced fractures of any type

Non-operative treatment with immobilisation in a sling for 1 week, followed by progressive ROM exercises and physiotherapy [2–7].

Type IV and V

Surgical stabilisation is recommended when the base of the coracoid, and either the body of the scapula or the glenoid fossa are involved [8–10].

Other indications for surgery are dissociation of the scapula and clavicle (caused by acromioclavicular dislocation or clavicular fracture) and obstruction to the shoulder reduction due to the fragment/s of the coracoid.

Most scapular fractures make a full functional recovery, but when the glenoid, acromion or coracoid process is involved, there may be poor results in up to 90 % of patients.

The most common procedure that has been described is open reduction and internal fixation with a malleolar screw for the coracoid fracture and percutaneous pin fixation for either an acromioclavicular dislocation or a fracture of the clavicle.

References

1.

Eyres KS, Brooks A, Stanley D. Fractures of the coracoid process. J Bone Joint Surg Br. 1995;77(3):425–8.PubMed

2.

Barentsz JH, Driessen AP. Fracture of the coracoid process of the scapula with acromioclavicular separation. Case report and review of the literature. Acta Orthop Belg. 1989;55(3):499–503.PubMed

3.

Boyer Jr DW. Trapshooter’s shoulder: stress fracture of the coracoid process. Case Rep J Bone Joint Surg Am. 1975;57(6):862.

4.

Montgomery SP, Loyd RD. Avulsion fracture of the coracoid epiphysis with acromioclavicular separation. Report of two cases in adolescents and review of the literature. J Bone Joint Surg Am. 1977;59(7):963–5.PubMed

5.

Protass JJ, Stampfli FV, Osmer JC. Coracoid process fracture diagnosis in acromioclavicular separation. Radiology. 1975;116(1):61–4.PubMedCrossRef

6.

Rounds RC. Isolated fracture of the coracoid, process. J Bone Joint Surg Am. 1949;31A(3):662.PubMed

7.

Urist MR. Complete dislocations of the acromiclavicular joint; the nature of the traumatic lesion and effective methods of treatment with an analysis of forty-one cases. J Bone Joint Surg Am. 1946;28(4):813–37.PubMed

8.

Ogawa K, Yoshida A, Takahashi M, Ui M. Fractures of the coracoid process. J Bone Joint Surg Br. 1997;79(1):17–9.PubMedCrossRef

9.

Wilber MC, Evans EB. Fractures of the scapula. An analysis of forty cases and a review of the literature. J Bone Joint Surg Am. 1977;59(3):358–62.PubMed

10.

Wong-Chung J, Quinlan W. Fractured coracoid process preventing closed reduction of anterior dislocation of the shoulder. Injury. 1989;20(5):296–7.PubMedCrossRef

11.

Li J, Sun W, Li GD, Li Q, Cai ZD. Fracture of the coracoid process associated with acromioclavicular dislocation: a case report. Orthop Surg. 2010;2(2):165–7.PubMedCrossRef

© Springer-Verlag London 2015

Nick G. Lasanianos, Nikolaos K. Kanakaris and Peter V. Giannoudis (eds.)Trauma and Orthopaedic Classifications10.1007/978-1-4471-6572-9_7

7. Rotator Cuff Tears

Nick G. Lasanianos¹   and Michalis Panteli¹  

(1)

Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK

Nick G. Lasanianos (Corresponding author)

Email: [e-mail]

Michalis Panteli

Email: [e-mail]

Description

Patte Classification

In 1990 Patte [1] reported the following classification system for Rotator Cuff Tears, which described full thickness tears in two dimensions. The proposed method of classification is based on the:

(1)

Extent of the tear.

(2)

Topography of the tear in the frontal plane (Fig. 7.1).

A328656_1_En_7_Fig1_HTML.gif

Fig. 7.1

The three stages of the Patte classification system regarding the retraction in the frontal plane: stage 1 proximal stump close to bony insertion; stage 2 proximal stump at level of humeral head; stage 3 proximal stump at level of the glenoid

(3)

Topography of the tear in the sagittal plane (Fig. 7.2).

A328656_1_En_7_Fig2_HTML.gif

Fig. 7.2

The six segments of the Patte classification system regarding the topography of the cuff tears in the sagittal plane: segment 1 isolated Subscapularis tear; segment 2 isolated Coracohumeral tear; segment 3 isolated Supraspinatus tear; segment 4 complete Supraspinatus and incomplete Infraspinatus tear; segment 5 complete Supraspinatus and Infraspinatus tear; segment 6 complete Subscapularis, Supraspinatus and Infraspinatus tears

(4)

Trophic quality of the muscle of the torn tendon.

(5)

State of the long head of the biceps (LHB).

The Patte classification system exploits the advances in diagnostic imaging and is useful in the assessment of non-operatively treated patients [2–4].

Extent of Tear

Group I: Partial tears or full-substance tears measuring less than 1 cm in sagittal diameter at bony detachment

a.

Deep, partial tears

b.

Superficial tears

c.

Small, full-substance tears

Group II: Full-substance tears of entire supraspinatus

Group III: Full-substance tears involving more than one tendon

Group IV: Massive tears with secondary OA

Patte Classification for Cuff Tear Retraction in the Frontal Plane

CT arthrogram as well as MR arthrogram can give proper information on the extent of the tear as well as the vitality of the cuff muscle.

Stage 1: Proximal stump close to bony insertion

Stage 2: Proximal stump at level of humeral head

Stage 3: Proximal stump at level of glenoid

Patte Topographic Classification of Rotator Cuff Tears in the Sagittal Plane

Segment 1: Isolated Subscapularis tear. Usually traumatic associated with Long Head of Biceps. dislocation.

Segment 2: Isolated Coracohumeral ligament tear.

Segment 3: Isolated Supraspinatus tear. (Seg 3 + Seg 1 combination = anterosuperior defect).

Segment 4: Complete Supra and one-half Infraspinatus tear.

Segment 5: Complete Supra and Infraspinatus tear.

Segment 6: Complete Subscapularis, Supra and Infraspinatus tear

Treatment Strategy (Based on the Extent of Tear)

Group I

Lesions rarely exhibit an operative indication. Physiotherapy aiming to eliminate subacromial impingement usually results in satisfactory pain relief. Surgical repair when indicated is easily achieved either by suturing or by reattachment to bone. The necrotic tissue must be resected before repair.

Group II

Defects should be treated surgically. Nonetheless the intact LHB allows enough elevation of the arm so that the patient is not ready to accept surgery. Moreover it has not been proven that Group II tears do necessarily progress to Group III without surgery. Reinsertion of the tendon is generally easy after mobilisation of the remaining portion of this tendon. A plastic procedure may be needed in up to 25 % of the patients.

Group III

Defects are serious and demand early surgical reconstruction. Plastic repair is indicated in up to 50 % of the patients.

Group IV

Lesions often limit the possibility of repair, and an arthroplasty thus becomes necessary. Nonetheless arthroplasty yields mediocre results with respect to function, although the patients appreciate the resultant pain relief.