Diagnosing displaced four-part fractures of the proximal humerus: a review of observer studies

Abstract

Displaced four-part fractures comprise 2-10 % of all proximal humeral fractures. The optimal treatment is unclear and randomised trials are needed. The conduct and interpretation of such trials is facilitated by a reproducible fracture classification. We aimed at quantifying observer agreement on the classification of displaced four-part fractures according to the Neer system. Published and unpublished data from five observer studies were reviewed. Observers agreed less on displaced four-part fractures than on the overall Neer classification. Mean kappa values for interobserver agreement ranged from 0.16 to 0.48. Specialists agreed slightly more than fellows and residents. Advanced imaging modalities (CT and 3D CT) seemed to contribute more to classification of displaced four-part patterns than in less complex fracture patterns. Low observer agreement may challenge the clinical approach to displaced four-part fractures and poses a problem for the interpretation and generalisation of results from future randomised trials.

Epidemiology of proximal humerus fractures

“…In our sample, the most frequent fracture was two-part (62 %), which is more than twice the number in Edinburg where the one-part was leading with 49 % [9]. The difference may be explained by poor intra-and interobserver sensitivity of all proximal humerus classifications [22,23].…”

The use of a new locking 90° blade plate in the treatment of atrophic proximal humerus nonunions

“…Indications for open reduction and internal fixation of proximal humerus fractures in patients older than sixty years require continued analysis [2,19]. Nonunions of the proximal and distal humerus remain difficult to treat, mainly because achieving stable fixation to maintain the intraoperative reduction is unpredictable [1].…”

Application of computer-assisted novel 3D reconstruction and simulation in orthopaedic surgical treatment of complex proximal humeral fractures

“…However, it is not available especially for very complex fracture cases. This is, to a great extent, due to the fact that the more difficult the cases are, the deeper recognization and better operation planning surgeons need [4][5][6][7][8].…”

“…These images are often available in flat films or viewed on a computer screen layer by layer. In order to have a correct clinical evaluation and good preoperative planning especially for complex and intractable cases, biomimetic tridimensional (3D) reconstruction modeling and simulation have been recently introduced in orthopaedic surgery [4][5][6][7]. In this study, the clinical application and outcome of a computer-aided novel 3D visualization and biomodeling in CPHF surgical treatment were explored on basis of our work.…”