A Concise and Comprehensive Description of Shoulder Pathology and Procedures: The 4D Code System

Table 6

Summary of the elements of the 4D code with its possible codes and corresponding descriptions.

Components	Classification systems	Variables	Descriptions
Fundamental elements
Sidedness		R	Right
		L	Left
Time code		D−	Time of presentation
		D	Before surgical repair
		D+	Immediately postop
		D+nM	n months postop; W for weeks; Y for years
Subscapularis	Lafosse et al. [4]	0, 1–5	(Table 1)
Long head of biceps		BN	Biceps is normal
		BP	Biceps is pathological
		BA	Biceps is absent or tenotomized
		BT	Biceps is tenodesed
Supraspinatus	Patte [7]	0, 1–3	(Figure 4)
Infraspinatus
Teres minor
Secondary elements
AC		AC	AC joint is arthritic
		ACR	s/p AC joint resection
Glenohumeral arthritis	Samilson and Prieto [8]	GH1–3	(Table 2)
Labrum	Synder et al. [16]	SL1–7	SLAP tear (Table 3)
		SLD	Status post SLAP debridement
		SLR	Status post SLAP repair
		Lx-y	Labral detachment from x to y o’clock
		LD	Status post labral debridement
		LR	Status post labral repair
Tear configuration		U	U-shaped tear
		V	V-shaped tear
		AL	Anterior L-shaped tear with anterior corner detachment
		PL	Posterior L-shaped tear with posterior corner detachement
Partial thickness tear	Ellman [2]	A1–3	Articular-sided tear, (Table 4)
		B1–3	Bursal-sided tear, (Table 4)
		I	Interstitial tear
Calcific tendonitis		C	Presence of calcific tendonitis
Fatty infiltration	Goutallier et al. [10]	Gabcd	Subscapularis, supraspinatus, infraspinatus, teres minor (Table 5)
Nerve pathology		SSN	Suprascapular nerve injury
		SSNR	Status post SSN release
		AXN	Axillary nerve injury
		LTN	Long thoracic nerve injury