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Year: 2014
Scapula fractures: interobserver reliability of classification and treatment
Neuhaus, Valentin ; Bot, Arjan G J ; Guitton, Thierry G ; Ring, David C
Abstract: OBJECTIVES:There is substantial variation in the classification and the management of
scapula fractures. The first purpose of this study was to analyze the interobserver reliability of the
OTA/AO and the New International Classification of scapula fractures. The second purpose was to
assess the proportion of agreement among orthopaedic surgeons on operative or nonoperative treatment.
DESIGN:: Web-based reliability study SETTING:: Independent orthopaedic surgeons from several countries were invited to classify scapular fractures in an online survey. PARTICIPANTS:One-hundred and
three orthopaedic surgeons evaluated 35 movies of 3DCT-reconstruction of selected scapular fractures,
representing a full spectrum of fracture patterns. MAIN OUTCOME MEASUREMENTS:Fleiss’ kappa
() was used to assess the reliability of agreement between the surgeons. RESULTS:: The overall agreement on the OTA/AO Classification was moderate for the types (A, B, and C, = 0.54) with a 71%
proportion of rater agreement (PA) as well as for the nine groups (A1 to C3, = 0.47) with a 57%
PA. For the New International Classification, the agreement about the intra-articular extension of the
fracture (Fossa (F), = 0.79) was substantial, the agreement about a fractured body (Body (B), =
0.57) or process was moderate (Process (P), = 0.53), however PAs were more than 81%. The agreement
on the treatment recommendation was moderate ( = 0.57) with a 73% PA. CONCLUSIONS:The New
International Classification was more reliable. Body and process fractures generated more disagreement
than intra-articular fractures and need further clear definitions.
DOI: https://doi.org/10.1097/BOT.0b013e31829673e2
Posted at the Zurich Open Repository and Archive, University of Zurich
ZORA URL: https://doi.org/10.5167/uzh-78945
Journal Article
Published Version
Originally published at:
Neuhaus, Valentin; Bot, Arjan G J; Guitton, Thierry G; Ring, David C (2014). Scapula fractures:
interobserver reliability of classification and treatment. Journal of Orthopaedic Trauma, 28(3):124-129.
DOI: https://doi.org/10.1097/BOT.0b013e31829673e2
ORIGINAL ARTICLE
Scapula Fractures: Interobserver Reliability of
Classification and Treatment
Valentin Neuhaus, MD, Arjan G. J. Bot, MD, Thierry G. Guitton, MD, PhD, and
David C. Ring, MD, PhD; The Science of Variation Group
Objectives: There is substantial variation in the classification and
management of scapula fractures. The first purpose of this study was
to analyze the interobserver reliability of the OTA/AO classification
and the New International Classification for Scapula Fractures. The
second purpose was to assess the proportion of agreement among
orthopaedic surgeons on operative or nonoperative treatment.
Design: Web-based reliability study.
Setting: Independent orthopaedic surgeons from several countries
were invited to classify scapular fractures in an online survey.
Participants: One hundred three orthopaedic surgeons evaluated
35 movies of three-dimensional computerized tomography reconstruction of selected scapular fractures, representing a full spectrum
of fracture patterns.
Main Outcome Measurements: Fleiss kappa (k) was used to
assess the reliability of agreement between the surgeons.
Results: The overall agreement on the OTA/AO classification was
moderate for the types (A, B, and C, k = 0.54) with a 71% proportion
of rater agreement (PA) and for the 9 groups (A1 to C3, k = 0.47) with
a 57% PA. For the New International Classification, the agreement
about the intraarticular extension of the fracture (Fossa (F), k = 0.79)
was substantial and the agreement about a fractured body (Body (B),
k = 0.57) or process was moderate (Process (P), k = 0.53); however,
PAs were more than 81%. The agreement on the treatment recommendation was moderate (k = 0.57) with a 73% PA.
Conclusions: The New International Classification was more
reliable. Body and process fractures generated more disagreement
than intraarticular fractures and need further clear definitions.
Key Words: OTA/AO fracture classification, New International
Classification for Scapular Fractures, reliability, scapula
(J Orthop Trauma 2014;28:124–129)
Accepted for publication April 10, 2013.
From the Orthopaedic Hand Service, Massachusetts General Hospital, Boston, MA.
No funding was received in direct support of this study. No authors have any
connections to either of the classification systems.
V. Neuhaus has received a grant from the Bangerter Foundation Switzerland.
A.G. J. Bot has received grants from VSB fonds, Beurs Prins Bernhard
Cultuur fonds, beurs/Banning-de Jong fonds, Stichting Anna fonds, the
Netherlands. T. G. Guitton had no conflicts of interest. D. C. Ring has no
conflicts related to this research.
Reprints: David C. Ring, MD, PhD, Orthopaedic Hand Service, Yawkey
Center, Suite 2100, Massachusetts General Hospital, 55 Fruit St, Boston,
MA 02114 (e-mail: dring@partners.org).
Copyright © 2013 by Lippincott Williams & Wilkins
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INTRODUCTION
Our traditional complacence with fractures of the shoulder
girdle was altered by recent data showing that operative
treatment of displaced clavicle fractures reduces the risk of
nonunion and pain as well as improves functional results.1–3
Now, some are suggesting that more frequent operative treatment
of scapula fractures should be considered.4–9 The indications for
surgery are not clearly defined, and the role of classification
schemes is uncertain. A New International Classification for
Scapular Fractures was recently developed by a study group of
6 orthopaedic trauma surgeons hoping to develop a better fracture classification system and later to clarify the prognostic value
of it for indications for operative treatment.10
This study sought to compare the OTA/AO classification
with the New International Classification for Scapular Fractures. Our primary study aim was to measure the reliability of
the OTA/AO classification and the New International Classification for Scapula Fractures. The second aim was to evaluate
the agreement on operative treatment.
PATIENTS AND METHODS
Study Design
Orthopaedic surgeons from 25 countries participating in
the Science of Variation Group, a web-based collaborative of
experienced orthopaedic surgeons, were invited to evaluate and
rate 35 movies of three-dimensional computerized tomography
(3DCT) reconstruction of scapular fractures in an online survey
in May and June 2012.11 The movies were presented online
in a random order and were assessed independently by the
raters. A description of the OTA/AO12 classification and
the New International Classification10 was provided for each
movie. No other information (additional injuries, treatment,
outcome) was made available. The raters were asked to classify
the presented scapular fractures (OTA/AO and the New International Classification) and to propose operative or nonoperative treatment in young, active, and healthy patients. There was
no time limit to complete the questionnaire.
Raters
One hundred sixty-eight (21%) of the 802 invited
surgeons agreed to participate in the study (a large percentage
of our collaborative do not treat scapula fractures), and 103
surgeons (61%) completed all questions (Table 1). They were
not involved in the treatment of the patients presented in this
study cohort and did not receive any incentives other than an
acknowledgement in this article.
J Orthop Trauma Volume 28, Number 3, March 2014
J Orthop Trauma Volume 28, Number 3, March 2014
Reliability of Scapula Fracture Classification
TABLE 1. Surgeons’ Demographics
Parameter
All questions answered
Sex
Male
Female
Area of practice
Australia
Canada
Europe
United Kingdom
United States
Other
Years of independent practice
0–10
More than 10 years
Specialization
Orthopaedic traumatology
Shoulder and elbow
Hand and wrist
General orthopaedics or other
n
103
96
7
4
4
28
3
47
17
51
52
44
23
25
11
n, number of surgeons.
Fractures
Under Institutional Review Board approval (protocol #:
2009-P-001019/89; Massachusetts General Hospital), a total of
457 scapular fractures were identified from a prospectively collected trauma database (from 2002 to 2011) at two level 1 trauma
centers. Inclusion criteria were as follows: (1) adult patients ($18
years) and (2) adequate quality (slice thickness #2.5 mm) and
completeness of computed tomographies for 3D reconstruction,
leaving a cohort of 225 suitable fractures. Thirty-five fractures
were selected with complete, high-quality CTs and representing
a full spectrum of scapular fracture patterns. Sex, age, side,
concomitant injuries, Injury Severity Score, radiological measurements (intraarticular step-off, medialization, translation, angulation, glenopolar angle, presence of a double disruption of the
superior shoulder suspensory complex), and the received treatment (either operative or nonoperative) were independently of
the surgeons’ ratings recorded for readers information. The radiographic measurements were performed with the Aquarius workstation (Version 4.4.6; TeraRecon, Inc., San Mateo, CA) for one
institution and with the Centricity software (GE Healthcare,
Buckinghamshire, United Kingdom) for the other institution by
an independent experienced orthopaedic surgeon. The movies
were created with Osirix13 (OsiriX Foundation/Pixmeo, Geneva,
Switzerland) and were rotating (360 degrees around a vertical
axis with a duration of 10 seconds) 3DCT reconstructions of the
whole scapula with humerus and clavicle subtracted. The raters
could replay the videos as needed.
Statistical Analysis
For each fracture, the most commonly proposed answers
and the proportion of agreement (in percentage, PA) were
presented and analyzed. The multirater agreement of the
Ó 2013 Lippincott Williams & Wilkins
FIGURE 1. Anterior and Y-view of the 3DCT reconstruction
(fracture 11). Surgeons had problems deciding if the body
and/or the process was involved. Editor’s note: A color image
accompanies the online version of this article.
nominal variables (OTA/AO classification; the New International Classification; recommended treatment) were calculated
with the Fleiss generalized Kappa,14,15 which is a statistical
chance-corrected measure for assessing multirater agreement
with binary or nominal ratings. The calculated measures are
presented as a value between 0 and 1 and are called Kappa
value. They were interpreted in accordance to the guidelines by
Landis and Koch16: 0.01–0.20 represent slight agreement,
0.21–0.40 fair agreement, 0.41–0.60 moderate agreement,
0.61–0.80 substantial agreement, and above 0.81 is considered
almost perfect agreement. In another study, a value of 0.70 was
considered an adequate sign of reliability.17
RESULTS
OTA/AO Classification
The proportion of the most proposed AO group of all
answers varied between 26% and 99% for the 35 cases. The
FIGURE 2. Forty-three percent of the raters classified fracture
9, which is very similar to fracture 3, as a C2 fracture (total
articular; intraarticular fracture with neck) and 40% as a C3
fracture (intraarticular fracture with body). Editor’s note: A
color image accompanies the online version of this article.
www.jorthotrauma.com |
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J Orthop Trauma Volume 28, Number 3, March 2014
Neuhaus et al
TABLE 2. OTA/AO Classification
Fracture No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
Raters (n)
Most Proposed
AO Type
% All Answers
162
153
137
131
131
129
124
119
115
114
111
110
109
108
107
106
106
105
103
103
103
103
103
103
103
103
103
103
103
103
103
103
103
103
103
C3
A3
C2
A3
A3
A1
A3
C3
C2
A2
B1
A3
C3
A3
A1
A3
C3
A3
A3
A3
B1
C3
B1
C3
B3
A3
C3
C2
B3
C1
A3
C3
A3
C3
C3
59
95
26
99
99
99
75
70
43
94
41
78
52
82
93
88
69
35
96
84
34
40
72
56
75
88
61
60
43
64
77
69
82
69
55
Parameter
Overall
3 Types (A, B, C)
9 Groups (A1 - C3)
Years of practice
0–10
More than 10 years
Specialization
Orthopaedic traumatology
Shoulder and elbow
Hand and wrist
Agreement
New International Classification
Agreement about the intraarticular extension of the
fracture was substantial (k = 0.79, PA 90%), and for shoulder
and hand surgeons almost perfect (k = 0.83 and k = 0.80,
respectively). The agreement about a fractured body (k =
0.57, PA 82%) or process was moderate (k = 0.53, PA
80%). Another source of disagreement was fracture of the
glenoid neck (Fig. 3), which was less of a problem with the
OTA/AO classification. The further in-depth classification
showed a fair agreement for body fractures (B1, B2, or B
not applicable; k = 0.35, PA 58%) and a moderate agreement
on fractures involving the fossa (F0, F1, F2, or F not applicable; k = 0.59, PA 74%) as well as process fractures (P1, P2,
P3, or P not applicable; k = 0.46, PA 73%) (Table 3).
Recommended Treatment
Nonoperative treatment was most often recommended in 21 fractures and operative treatment in 14 fractures.
Kappa
PA (%)
Moderate
Moderate
0.54
0.47
71
57
Moderate
Moderate
0.48
0.46
58
56
Moderate
Moderate
Moderate
0.46
0.51
0.43
56
61
53
most proposed AO group was A3 in 13 fractures, C3 in 10
fractures, B1 in 3 fractures, C2 in 3 fractures, and other
groups in 6 fractures. The overall agreement on the OTA/AO
classification was moderate for the 3 types of fracture (k =
0.54) with a 71% PA and for the 9 groups of fracture (k =
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0.47) with a 57% PA. There was a higher agreement on type
A fractures (k = 0.72), and a lower one on type C (k = 0. 46)
and B (k = 0.37) fractures. Although the agreements on the
groups A1 (k = 0.77), A3 (k = 0.74), and A2 (k = 0.65) were
highest, they were lowest for the C1 (k = 0.25), C2 (k = 0.20),
and B2 (k = 0.02) fractures. Most disagreements were
between B1 (anterior rim fracture), C2 (intraarticular fracture
with neck), and A2 (coracoid fracture). For example, 41% of
the raters classified fracture 11 (Fig. 1) as an AO type B1
(partial articular; anterior rim fracture), 28% as an A2 (extraarticular coracoid fracture), and 19% as a C2 (intraarticular
fracture with neck). Another point of disagreement was
between C2 (intraarticular fracture with neck) and C3 (intraarticular fracture with body) in certain circumstances (Fig. 2).
The years of practice did not affect the degree of overall
agreement. Shoulder surgeons were more likely to agree on
the OTA/AO classification (Table 2).
FIGURE 3. Glenoid neck fracture (fracture 30) caused a high
disagreement in the New International Classification; it was
classified as a body fracture in 63% and as an intraarticular
fracture in 54%. Editor’s note: A color image accompanies
the online version of this article.
Ó 2013 Lippincott Williams & Wilkins
J Orthop Trauma Volume 28, Number 3, March 2014
Reliability of Scapula Fracture Classification
TABLE 3. New International Classification for Scapular Fractures
Fracture No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
Raters (n)
Body (B)
% All Answers
Fossa (F)
% All Answers
Process (P)
% All Answers
162
153
137
131
131
129
124
119
115
114
111
110
109
108
107
106
106
105
103
103
103
103
103
103
103
103
103
103
103
103
103
103
103
103
103
Fractured
Fractured
Not fractured
Fractured
Fractured
Not fractured
Fractured
Fractured
Not fractured
Not fractured
Not fractured
Fractured
Fractured
Fractured
Not fractured
Fractured
Fractured
Fractured
Fractured
Fractured
Not fractured
Fractured
Not fractured
Fractured
Not fractured
Fractured
Fractured
Not fractured
Fractured
Fractured
Fractured
Fractured
Fractured
Fractured
Fractured
81
99
55
100
100
98
92
79
51
98
95
96
80
99
79
98
90
89
98
99
81
87
100
78
98
99
77
85
67
63
97
89
99
89
86
Intraarticular
Extraarticular
Intraarticular
Extraarticular
Extraarticular
Extraarticular
Extraarticular
Intraarticular
Intraarticular
Extraarticular
Intraarticular
Extraarticular
Intraarticular
Extraarticular
Extraarticular
Extraarticular
Intraarticular
Extraarticular
Extraarticular
Extraarticular
Intraarticular
Intraarticular
Intraarticular
Intraarticular
Intraarticular
Extraarticular
Intraarticular
Intraarticular
Intraarticular
Intraarticular
Extraarticular
Intraarticular
Extraarticular
Intraarticular
Intraarticular
97
98
68
99
98
100
98
96
97
99
77
93
93
96
99
97
97
61
100
97
90
94
100
97
99
99
99
98
99
54
97
97
99
97
82
Not involved
Not involved
Involved
Not involved
Not involved
Involved
Involved
Not involved
Involved
Involved
Involved
Not involved
Not involved
Not involved
Involved
Not involved
Involved
Not involved
Not involved
Not involved
Involved
Involved
Not involved
Involved
Not involved
Not involved
Not involved
Involved
Not involved
Not involved
Not involved
Not involved
Not involved
Not involved
Not involved
99
100
52
99
94
98
61
62
72
99
68
95
79
100
81
98
73
66
96
99
64
81
100
55
100
100
96
57
99
97
100
98
99
85
94
For Body (B)
For Fossa (F)
Agreement
For Process (P)
Parameter
Agreement
Kappa
PA (%)
Kappa
PA (%)
Kappa
PA (%)
Overall
Years of practice
0–10
More than 10 years
Specialization
Orthopaedic traumatology
Shoulder and elbow
Hand and wrist
Moderate
0.57
82
Substantial
0.79
90
Moderate
0.53
81
Moderate
Moderate
0.59
0.57
83
80
Substantial
Substantial
0.79
0.79
90
90
Moderate
Moderate
0.55
0.52
82
80
Moderate
Substantial
Moderate
0.55
0.61
0.53
80
85
79
Substantial
Almost perfect
Almost perfect
0.78
0.83
0.80
89
92
90
Moderate
Moderate
Moderate
0.52
0.54
0.52
81
81
80
The agreement was moderate (k = 0.57) with an average
PA of 73%, ranging from 52% to 98% with similar agreement for operative and nonoperative recommendations.
More experienced doctors were less likely to recommend
operative treatment. The specialization did not affect the
treatment recommendation (Table 4).
Ó 2013 Lippincott Williams & Wilkins
Agreement
DISCUSSION
We found moderate overall agreement regarding classification of scapular fractures, better for articular than for
body or process involvement. The average proportion of
observers agreeing with the most popular treatment recommendation was 73%.
www.jorthotrauma.com |
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Neuhaus et al
TABLE 4. Recommended Treatment
Fracture
No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
Raters
(n)
Recommended
Treatment
% All
Answers
162
153
137
131
131
129
124
119
115
114
111
110
109
108
107
106
106
105
103
103
103
103
103
103
103
103
103
103
103
103
103
103
103
103
103
Operative
Nonoperative
Nonoperative
Nonoperative
Nonoperative
Nonoperative
Nonoperative
Operative
Operative
Operative
Nonoperative
Nonoperative
Nonoperative
Nonoperative
Nonoperative
Nonoperative
Operative
Nonoperative
Nonoperative
Nonoperative
Nonoperative
Operative
Operative
Operative
Nonoperative
Nonoperative
Operative
Operative
Operative
Operative
Nonoperative
Operative
Nonoperative
Operative
Nonoperative
82
98
58
98
91
52
56
89
90
52
65
96
72
63
84
95
69
81
98
83
78
52
97
91
79
88
87
97
55
87
71
90
88
92
90
Parameter
Overall
Recommended treatment
Years of practice
0–10
More than 10 years
Specialization
Orthopaedic traumatology
Shoulder and elbow
Hand and wrist
Agreement
Kappa
PA (%)
Moderate
0.45
73
Moderate
Moderate
0.48
0.41
75
71
Moderate
Moderate
Moderate
0.44
0.45
0.48
72
73
74
Readers should consider several limitations. The data
may not be valid outside the group of surgeons that
participate in the Science of Variation Group, although we
feel that the large number of surgeons of various specialties
and countries improves external validity beyond that of the
typical reliability study. Nearly 40% of the participating
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surgeons did not answer all questions, which may have
influenced our results. We did not measure the time surgeons
spent looking at the movies, which could also correlate with
agreement. In trying to present as many different fracture
patterns as possible, we may have introduced a spectrum bias.
For instance, intraarticular fractures were overrepresented.17
However, an overpresentation of intraarticular fractures can
rather positively contribute to the study as these fractures
have more impact on the treatment decision and outcome.
Other downsides were that surgeons could not rotate the 3D
models to their needs, and Osirix may have affected the image
resolution and consequently the interpretation of the fracture
patterns by rendering issues. However, all surgeons had the
same kind of movies to interpret, which equalizes these problems. And last, there was no way to assess accuracy as there is
no gold standard/reference classification.
The OTA/AO classification distinguishes extra-articular
(type A), partial articular (type B), and complete articular
(type C) fractures. Although the agreement for type A scapula
fractures was substantial, the agreement about types B and C
was moderate or even fair for some subgroups. In comparison,
the overall agreement for diaphyseal fractures was higher in
one recent study and the level of experience and specialization
did not affect their results.18 In our study, shoulder specialists
had the best agreement. Perhaps an in-depth knowledge and
greater familiarity with complex scapular anatomy and injuries
may contribute to better understanding and classification of
the fractures. Level of training is often associated with greater
reliability when surgeons in training are observers,19 but level
of experience did not affect agreement in our study of fully
trained surgeons. The lesser experience of younger surgeons
may be balanced by their greater familiarity with 3DCTs and
greater reliance on the definitions.11
The New International Classification for Scapula
Fractures distinguishes fractures extending into the body,
fossa, or processes. This classification had almost perfect
agreement if the fracture lines extend into the glenoid fossa
and moderate agreement on body and process fractures. In
comparison, the expert panel in the development study10 had
comparable agreement on intraarticular (k = 0.78) but
a clearly higher agreement on process (k = 0.61) or body
fractures (k = 0.75), which may indicate that their intensive
dispute and training about scapula fracture classification and
their knowledge about the definitions improved their agreement. This new classification helped us to better understand
the reasons for disagreement of the raters with the OTA/AO
classification.
Some surgeons advocate more frequent operative treatment of scapula fractures.4–9 In 40% of our selected fractures,
more than 50% of the surgeons recommended operative
treatment. The agreement on treatment recommendation
was only moderate, remains controversial, and merits further
study.
In conclusion, the simpler New International Classification proved more reliable than the OTA/AO classification.
Surgeons find it more difficult to distinguish body and process
fractures than glenoid fractures. Improved definitions and
training may further help to improve reliability of scapula
fracture classification.20
Ó 2013 Lippincott Williams & Wilkins
J Orthop Trauma Volume 28, Number 3, March 2014
ACKNOWLEDGMENTS
The Science of Variation Group authorship: Mahmoud
I. Abdel-Ghany; Jeffrey Abrams; Joshua M. Abzug; Lars E.
Adolfsson; George W. Balfour; H. Brent Bamberger DO;
Antonio Barquet; Michael Baskies; W. Arnold Batson;
Taizoon Baxamusa; Grant J. Bayne; Thierry Begue; Michael
Behrman; Daphne Beingessner; Jan Biert; Julius Bishop;
Mateus Borges Oliveira Alves; Martin Boyer; Drago Brilej;
Peter R.G. Brink; Lance M. Brunton; Richard Buckley;
Juan Carlos Cagnone; Ryan P. Calfee; Luiz Augusto B.
Campinhos; Charles Cassidy; Louis Catalano III; Karel
Chivers; Pradeep Choudhari; Matej Cimerman; Joseph M.
Conflitti; Ralph M. Costanzo; Brett D. Crist; Brian J. Cross;
Phani Dantuluri; Michael Darowish; Ramon de Bedout;
Thomas DeCoster; David G. Dennison; Peter H. DeNoble;
Gregory DeSilva; Thomas Dienstknecht; Scott F. Duncan;
Xavier A. Duralde; Holger Durchholz; Kenneth Egol; Carl
Ekholm; Nelson Elias; John M. Erickson; J. Daniel Espinosa
Esparza; C. H. Fernandes; Thomas J. Fischer; Martin
Fischmeister; Forigua Jaime E.; Charles L. Getz; Richard
S. Gilbert; Vincenzo Giordano; David L. Glaser; Taco
Gosens; Michael W. Grafe; Jose Eduardo Grandi Ribeiro
Filho; Robert R.L. Gray; Lawrence V. Gulotta; Nigel William
Gummerson; Eric Mark Hammerberg; Edward Harvey; R.
Haverlag; Patrick D.G. Henry; Jonathan L. Hobby; Eric P.
Hofmeister; Thomas Hughes; John Itamura; Peter Jebson;
Richard Jenkinson; Kyle Jeray; Christopher M. Jones;
Jedediah Jones; Axel Jubel; Scott G. Kaar; K. Kabir; F.
Thomas D. Kaplan; Stephen A. Kennedy; Michael W.
Kessler; Hervey L. Kimball; Peter Kloen; Cyrus Klostermann; Georges Kohut; G.A. Kraan; Anze Kristan; Mark I.
Loebenberg; Kevin J. Malone; l. Marsh; Paul A. Martineau;
John McAuliffe; Iain McGraw; Samir Mehta; Milind
Merchant; Charles Metzger; S. A. Meylaerts; Anna N. Miller;
Jennifer Moriatis Wolf; Joel Murachovsky; Anand Murthi;
Michael Nancollas; Betsy M. Nolan; Timothy Omara; Reza
Omid; Jose A. Ortiz; Joachim P. Overbeck; Richard S. Page;
Alberto Pérez Castillo; Rodrigo Pesantez; Daniel Polatsch; G.
Porcellini; Michael Prayson; M. Quell; Matthew M. Ragsdell;
James G. Reid; J. M. Reuver; Marc J. Richard; Martin
Richardson; Marco Rizzo; Sergio Rowinski; Jorge Rubio;
Carlos G. Sánchez Guerrero; Wojciech Satora; Peter Schandelmaier; Johan H. Scheer; Andrew Schmidt; Todd A. Schubkegel; Leah M. Schulte; Evan D. Schumer; Benjamin W. Sears;
Adam B. Shafritz; Nicholas L. Shortt; Todd Siff; Dario Mejia
Silva; Raymond Malcolm Smith; Sander Spruijt; Jason A.
Stein; Emilija Stojkovska Pemovska; Philipp N. Streubel;
Carrie Swigart; Marc Swiontkowski; George Thomas; Eric
T. Tolo; Matthias Turina; Minos Tyllianakis; Michel P. J.
van den Bekerom; Huub van der Heide; M.A.J. van de Sande;
P.V. van Eerten; Diederik O.F. Verbeek; David Victoria Hoffmann; A.J.H. Vochteloo; Robert Wagenmakers; Christopher J.
Wall; Richard Wallensten; Daniel C. Wascher; Lawrence
Ó 2013 Lippincott Williams & Wilkins
Reliability of Scapula Fracture Classification
Weiss; J. Michael Wiater; Brian P.D. Wills; Jeffrey Wint;
Thomas Wright; Jason P. Young; Charalampos Zalavras;
Robert D. Zura; Karol Zyto.
REFERENCES
1. McKee RC, Whelan DB, Schemitsch EH, et al. Operative versus
nonoperative care of displaced midshaft clavicular fractures:
a meta-analysis of randomized clinical trials. J Bone Joint Surg
Am. 2012;94:675–684.
2. Althausen PL, Shannon S, Lu M, et al. Clinical and financial comparison
of operative and nonoperative treatment of displaced clavicle fractures.
J Shoulder Elbow Surg. 2013;22:608–611.
3. Pandya NK, Namdari S, Hosalkar HS. Displaced clavicle fractures in
adolescents: facts, controversies, and current trends. J Am Acad Orthop
Surg. 2012;20:498–505.
4. Anavian J, Conflitti JM, Khanna G, et al. A reliable radiographic measurement technique for extra-articular scapular fractures. Clin Orthop
Relat Res. 2011;469:3371–3378.
5. Anavian J, Khanna G, Plocher EK, et al. Progressive displacement of
scapula fractures. J Trauma. 2010;69:156–161.
6. Anavian J, Wijdicks CA, Schroder LK, et al. Surgery for scapula process fractures: good outcome in 26 patients. Acta Orthop. 2009;80:
344–350.
7. Cole PA. Scapula fractures. Orthop Clin North Am. 2002;33:1–18, vii.
8. Cole PA, Gauger EM, Herrera DA, et al. Radiographic follow-up of 84
operatively treated scapula neck and body fractures. Injury. 2012;43:
327–333.
9. Cole PA, Talbot M, Schroder LK, et al. Extra-articular malunions of the
scapula: a comparison of functional outcome before and after reconstruction. J Orthop Trauma. 2011;25:649–656.
10. Harvey E, Audige L, Herscovici D Jr, et al. Development and validation
of the new international classification for scapula fractures. J Orthop
Trauma. 2012;26:364–369.
11. Guitton TG, Ring D. Interobserver reliability of radial head fracture
classification: two-dimensional compared with three-dimensional CT.
J Bone Joint Surg Am. 2011;93:2015–2021.
12. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification
compendium—2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21:S1–S133.
13. Rosset A, Spadola L, Ratib O. OsiriX: an open-source software for
navigating in multidimensional DICOM images. J Digit Imaging. 2004;
17:205–216.
14. Venkataraman G, Ananthanarayanan V, Paner GP. Accessible calculation of multirater kappa statistics for pathologists. Virchows Arch. 2006;
449:272.
15. King JE. Generalized kappa & other indices of interrater reliability.
Available at: http://www.ccitonline.org/jking/homepage/interrater.html.
Accessed November 1, 2012.
16. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159–174.
17. Jaeger M, Lambert S, Sudkamp NP, et al. The AO Foundation and Orthopaedic Trauma Association (AO/OTA) scapula fracture classification system: focus on glenoid fossa involvement. J Shoulder Elbow Surg. 2013;22:
512–520.
18. Meling T, Harboe K, Enoksen CH, et al. How reliable and accurate is the
AO/OTA comprehensive classification for adult long-bone fractures?
J Trauma Acute Care Surg. 2012;73:224–231.
19. Petrisor BA, Bhandari M, Orr RD, et al. Improving reliability in the
classification of fractures of the acetabulum. Arch Orthop Trauma Surg.
2003;123:228–233.
20. Buijze GA, Guitton TG, van Dijk CN, et al. Training improves interobserver reliability for the diagnosis of scaphoid fracture displacement. Clin
Orthop Relat Res. 2012;470:2029–2034.
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