Differentiating and treating lateral clavicle fractures: a new simple classification system

Abstract

Background: Existing classification systems for lateral clavicle fractures have low interobserver reliability and provide limited information for treatment decisions. The aim of this study was to introduce a new classification system and to evaluate its comprehensiveness, inter- and intraobserver reliability, and concordance of associated treatment strategy for lateral clavicle fractures compared with existing classifications.

Methods: Four raters, all experienced in shoulder surgery, independently assessed routine radiographs of 100 patients with lateral clavicle fractures. They were asked to classify the fractures according to the Neer and Jäger/Breitner classification systems, as well as a new classification system, and to determine appropriate treatment for each case based on the new classification system. The assessment was performed at 2 different time points 6 weeks apart. The new classification divides the fractures into 3 zones according to the attachment of the coracoclavicular (CC) ligaments, as well as displacement (1: lateral to the CC ligament attachment; 2: at the attachment of the CC ligaments; 3: medial to the CC ligament attachment; a: nondisplaced, b: displaced). Furthermore, 30 orthopedic surgeons were surveyed about their knowledge regarding the Neer and Jäger/Breitner classification systems.

Results: Inter-rater reliability was moderate for the Neer classification (κ = 0.565), substantial for the Jäger/Breitner classification (κ = 0.781) and for the new classification system (κ = 0.798). Although 28 cases with the Neer classification and 28 cases with the Jäger/Breitner classification could not be classified by at least 1 of the raters, 99% of the cases could be classified with the new classification. Intrarater reliability was moderate for the Neer classification (κ = 0.693) and for the Jäger/Breitner classification (κ = 0.660) and substantial for the new classification system (κ = 0.762). The inter- and intrarater reliability of treatment choice was regarded as substantial (κ = 0.659, κ = 0.738, respectively). Although the raters would treat 94%-99% of all cases classified as subgroup b surgically, only 0%-26% of cases classified as subgroup a were classified as requiring surgery. The knowledge of Jäger/Breitner and Neer classification among the surgeons surveyed was relatively poor: None of the 30 surgeons was able to describe the fracture types of Neer classification, while 2 of 30 surgeons could detail all types of Jäger/Breitner classification.

Conclusion: Our study demonstrated a high inter- and intrarater reliability of the new classification system and the associated treatment choices. Furthermore, the new classification system appears capable of categorizing the vast majority of lateral clavicle fractures.

Keywords: Distal clavicle fracture; classification systems; inter-rater agreement; intrarater agreement; reliability; shoulder surgery.