Classification of proximal humerus fractures: The contribution of the scapular lateral and axillary radiographs

A Comprehensive Radiologic Review of Shoulder Girdle Trauma

Radiologic knowledge of different fracture patterns involving the shoulder girdle is an important tool to generate clinically relevant reports, identify concomitant injuries, guide management decisions, and predict and minimize complications, such as nonunion, osteoarthritis, osteonecrosis, and hardware failure. Complex unstable injuries like scapulothoracic dissociation can also occur because of shoulder girdle trauma. Management options may vary from conservative to surgical, depending on the fracture type and patient factors. Injuries around the shoulder girdle can involve the glenohumeral articulation, scapula, superior shoulder suspensory complex, acromioclavicular joints, and scapulothoracic articulation.

Utility of lateral scapular radiographs in initial evaluation of nontraumatic shoulder conditions

Background

Lateral scapular radiographs have been routinely included in the initial radiographic examination of both traumatic and nontraumatic shoulder conditions. With the advance of modern imaging modalities, the clinical utility of the lateral scapular view has become questionable. The purpose of the study was to assess the utilization of the lateral scapular view among the members of the American Shoulder and Elbow Surgeons (ASES) and to determine the clinical utility of the lateral scapular view in the initial evaluation of nontraumatic shoulder conditions.

Methods

The study consisted of two parts. The first part involved an online survey of ASES members, which asked them 3 questions regarding their preference for radiographic evaluation of new patients with nontraumatic shoulder pain. The second part involved a clinical vignette-based survey, where 4 shoulder surgeons at our institution were given 50 clinical vignettes and asked to independently answer 4 questions regarding the most probable diagnosis, abnormal radiographic findings, further imaging studies, and treatment plan for each case. The survey was repeated twice; the first was given without a lateral scapular view, and the second given 4 weeks later with a lateral scapular view included. We obtained diagnostic accuracy and percent agreement of each surgeon over two surveys and intraobserver and interobserver reliability on each variable.

Results

Of a total of 235 ASES members who responded to the online survey, 193 (82.1%) indicated their routine use of a lateral scapular view. The most common reason for obtaining the view was better characterization of acromion morphology (75.4%). The clinical vignette-based survey showed substantial intrarater reliability (κ > 0.6) of the 4 surgeons between the two surveys for the most probable diagnosis, abnormal x-ray findings, and further imaging studies, while the intrarater reliability for treatment plan was moderate (κ = 0.548). The mean diagnostic accuracy of the 4 surgeons was almost equal (74% vs. 75%) between the surveys. Overall, each surgeon's percent agreement across the 2 surveys was over 70%. None of the 4 surgeons recommended a lateral scapular view for further imaging during the first survey; each wanted either advanced imaging (computed tomography, magnetic resonance imaging) or none.

Discussion

The addition of a lateral scapular radiograph in the presence of other orthogonal views does not appear to improve surgeons' diagnostic accuracy or affect their decision-making on the treatment plan in nontraumatic shoulder conditions. The clinical utility of the lateral scapular view may need to be reassessed in this setting.

Reliability and reproducibility of the new AO/OTA 2018 classification system for proximal humeral fractures: a comparison of three different classification systems

Background

The classification systems for proximal humeral fractures routinely used in clinical practice include the Neer and Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 2007 systems. Currently used systems have low inter- and intraobserver reliability. In 2018, AO/OTA introduced a new classification system with the aim of simplifying the coding process, in which the Neer four-part classification was integrated into the fracture description. The aim of the present work is to assess the inter- and intraobserver agreement of the new AO/OTA 2018 compared with the Neer and AO/OTA 2007 classifications.

Materials and methods

A total of 116 radiographs of consecutive patients with proximal humeral fracture were selected and classified by three observers with different levels of experience. All three observers independently reviewed and classified the images according to the Neer, AO/OTA 2007, and new AO/OTA 2018 systems. To determine the intraobserver agreement, the observers reviewed the same set of radiographs after an interval of 8 weeks. The inter- and intraobserver agreement were determined through Cohen’s kappa coefficient analysis.

Results

The new AO/OTA 2018 classification showed substantial mean inter- (k = 0.67) and intraobserver (k = 0.75) agreement. These results are similar to the reliability observed for the Neer classification (interobserver, k = 0.67; intraobserver, k = 0.85) but better than those found for the AO/OTA 2007 system, which showed only moderate inter- (k = 0.57) and intraobserver (k = 0.58) agreement. The two more experienced observers showed better overall agreement, but no statistically significant difference was found. No differences were found between surgical experience and agreement regarding specific fracture types or groups.

Conclusions

The results showed that the Neer system still represents the more reliable and reproducible classification. However, the new AO/OTA 2018 classification improved the agreement among observers compared with the AO/OTA 2007 system, while still maintaining substantial descriptive power and simplifying the coding process. The universal modifiers and qualifications, despite their possible complexity, allowed a more comprehensive fracture definition without negatively affecting the reliability or reproducibility of the classification system.

Level of evidence: Level III, diagnostic studies

Accurate Measurement of Greater Tuberosity Displacement Without Computed Tomography: Validation of a Method on Plain Radiography to Guide Surgical Treatment

INTRODUCTION

Residual displacement of greater tuberosity (GT) fractures has been shown to negatively affect shoulder function. However, accurate measurement of GT displacement remains a problem with errors up to 13 mm on plain radiography (XR). A new GT ratio for measuring fracture displacement on XR is described, validated, and correlated with computed tomography (CT) and surgical decision making.

METHODS

A retrospective review of shoulder radiographs was performed from 2007 to 2010 to identify all cases of isolated GT fractures with both XR and CT. The GT ratio was performed on all XR and correlated with superior GT displacement measured on CT. The GT ratio was then tested for accuracy of surgical decision using 5-mm superior displacement on CT as the cutoff. Finally, the inter- and intraobserver reliabilities of the GT ratio were calculated and compared with the Neer and Arbeitsgemeinschaft fur Osteosynthesefragen (AO) classifications.

RESULTS

Forty cases of acute GT fractures with XR and CT were identified. The GT ratio correlated very well with superior displacement on CT (Pearson correlation = 0.852, P < 0.01) and accurately classified GT fractures as "surgical" (n = 9, 23%) or "nonsurgical" (n = 31, 77%). GT ratios ≤0.00 were nonsurgical, ≥0.50 were surgical, and 0.00-0.50 warranted further imaging (P < 0.01). The GT ratio performed as well as or better than the AO and Neer classifications for inter- and intraobserver reliabilities.

CONCLUSIONS

The GT ratio described in this study correlates very well with CT for superior GT fracture displacement. It involves significantly less radiation and accurately classifies GT fractures as nonsurgical (ratio < 0.00), surgical (ratio > 0.50), or as benefiting from further imaging (0.00-0.50). It performs as well or better than the Neer or AO classification.

LEVEL OF EVIDENCE

Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Fractures of the proximal humerus

Fractures of the proximal humerus have been diagnosed and managed since the earliest known surgical texts. For more than four millennia the preferred treatment was forceful traction, closed reduction, and immobilization with linen soaked in combinations of oil, honey, alum, wine, or cerate. The bandages were further supported by splints made of wood or coarse grass. Healing was expected in forty days. Different fracture patterns have been discussed and classified since Ancient Greece. Current classification of proximal humeral fractures mainly relies on the classifications proposed by Charles Neer and the AO/OTA classification. Since the late 1980's it has been known that intra- and inter-observer variation was high within the two systems. I conducted a series of observer studies to qualify the disagreement further and to study to what extent improvement of agreement could be obtained. No clinically significant differences in observer agreement were found at different levels of clinical experience, by reducing the number of categories, or by adding high quality radiographs, CT or 3D CT scans. A consistently low agreement on the Neer classification within and between untrained orthopaedic doctors was found. However, we also found that inter-observer agreement on treatment recommendation was higher than the agreement on the Neer classification. In a randomized trial we found that agreement could improve significantly by training of doctors, especially among specialists. However, classification of proximal humeral fractures remains a challenge for the conduct, reporting, and interpretation of clinical trials. The evidence for the benefits of surgery in complex fractures of the proximal humerus is weak. In three systematic reviews I studied the outcome after locking plate osteosynthesis or reverse arthroplasty in complex fractures patterns. No randomized trials or well-conducted comparative studies were identified. High failure rates suggest that the use of these implants for complex fractures of the humerus should not be used outside clinical protocols. I recommend the conduct of randomized trials, and a design of such study is proposed.

Evolution of treatment of of the proximal humerus fractures (review)

The article in generalized form acquaints with the publications devoted to the bases of proximal humeral fractures treatment. A brief digression on anatomy and biomechanics of the humeral joint allows to consider the main morphological features of it. The most commonly used classification of proximal humeral fractures concisely classify many types of damage. According to the clinical and anatomical characteristics of fractures tracked the historical aspect, the development and the current state of the most common methods of treatment. In his review collected works authors share their experience in the application of methods. It allows to further the perspective directions.

Functional and quality-of-life results of displaced and nondisplaced proximal humeral fractures treated conservatively

OBJECTIVES

Functional and quality-of-life outcomes of conservatively treated proximal humeral fractures.

DESIGN

Prospective study.

SETTING

University orthopedic department at a hospital.

PATIENTS/PARTICIPANTS

Seventy consecutive patients between the ages of 60 and 85 years.

INTERVENTION

Conservative treatment.

MAIN OUTCOME MEASUREMENTS

Functional outcome measured according to the Constant score, quality of life assessed using EuroQol-5D, and fracture pattern analyzed with x-ray and computed tomography scan.

RESULTS

: All fractures consolidated uneventfully with no loss of reduction in either group. Four-part fractures obtained the worst functional results (33.66) followed by three-part fractures (54.64) and finally two-part fractures (65.88 and 71). Mild pain was expected in three- and four-part fractures, whereas two-part fractures achieved near complete pain relief. Nondisplaced fractures obtained a final Constant score of 73.58 and displaced fractures a score of 59.41 with significant differences in all Constant score items with the exception of external rotation. Although patients older than 75 years scored lower (54.63) than those younger than 75 years (70.83), there was no difference in the quality-of-life perception.

CONCLUSION

Conservative treatment of proximal humeral fractures in those patients older than age 75 years provides good pain relief with limited functional outcome. Despite limited functional outcome, this appears to have no effect on the quality-of-life perception in the population studied. Four-part fractures present the worst results and treatment options may need to be discussed with the patient to adjust treatment to patient expectations.

Classification and treatment of proximal humerus fractures: inter-observer reliability and agreement across imaging modalities and experience

SUMMARY

Proximal humerus fractures (PHF) are common injuries, but previous studies have documented poor inter-observer reliability in fracture classification. This disparity has been attributed to multiple variables including poor imaging studies and inadequate surgeon experience. The purpose of this study is to evaluate whether inter-observer agreement can be improved with the application of multiple imaging modalities including X-ray, CT, and 3D CT reconstructions, stratified by physician experience, for both classification and treatment of PHFs.

METHODS

Inter-observer agreement was measured for classification and treatment of PHFs. A total of sixteen fractures were imaged by plain X-ray (scapular AP and lateral), CT scan, and 3D CT reconstruction, yielding 48 randomized image sets. The observers consisted of 16 orthopaedic surgeons (4 upper extremity specialists, 4 general orthopedists, 4 senior residents, 4 junior residents), who were asked to classify each image set using the Neer system, and recommend treatment from four pre-selected choices. The results were evaluated by kappa reliability coefficients for inter-observer agreement between all imaging modalities and sub-divided by: fracture type and observer experience.

RESULTS

All kappa values ranged from "slight" to "moderate" (k = .03 to .57) agreement. For overall classification and treatment, no advanced imaging modality had significantly higher scores than X-ray. However, when sub-divided by experience, 3D reconstruction and CT scan both had significantly higher agreement on classification than X-ray, among upper extremity specialists. Agreement on treatment among upper extremity specialists was best with CT scan. No other experience sub-division had significantly different kappa scores. When sub-divided by fracture type, CT scan and 3D reconstruction had higher scores than X-ray for classification only in 4-part fractures. Agreement on treatment of 4 part fractures was best with CT scan. No other fracture type sub-division had significantly different kappa scores.

CONCLUSIONS

Although 3D reconstruction showed a slight improvement in the inter-observer agreement for fracture classification among specialized upper extremity surgeons compared to all imaging modalities, fracture types, and surgeon experience; overall all imaging modalities continue to yield low inter-observer agreement for both classification and treatment regardless of physician experience.

Classification and treatment of proximal humerus fractures: inter-observer reliability and agreement across imaging modalities and experience

SUMMARY

Proximal humerus fractures (PHF) are common injuries, but previous studies have documented poor inter-observer reliability in fracture classification. This disparity has been attributed to multiple variables including poor imaging studies and inadequate surgeon experience. The purpose of this study is to evaluate whether inter-observer agreement can be improved with the application of multiple imaging modalities including X-ray, CT, and 3D CT reconstructions, stratified by physician experience, for both classification and treatment of PHFs.

METHODS

Inter-observer agreement was measured for classification and treatment of PHFs. A total of sixteen fractures were imaged by plain X-ray (scapular AP and lateral), CT scan, and 3D CT reconstruction, yielding 48 randomized image sets. The observers consisted of 16 orthopaedic surgeons (4 upper extremity specialists, 4 general orthopedists, 4 senior residents, 4 junior residents), who were asked to classify each image set using the Neer system, and recommend treatment from four pre-selected choices. The results were evaluated by kappa reliability coefficients for inter-observer agreement between all imaging modalities and sub-divided by: fracture type and observer experience.

RESULTS

All kappa values ranged from "slight" to "moderate" (k = .03 to .57) agreement. For overall classification and treatment, no advanced imaging modality had significantly higher scores than X-ray. However, when sub-divided by experience, 3D reconstruction and CT scan both had significantly higher agreement on classification than X-ray, among upper extremity specialists. Agreement on treatment among upper extremity specialists was best with CT scan. No other experience sub-division had significantly different kappa scores. When sub-divided by fracture type, CT scan and 3D reconstruction had higher scores than X-ray for classification only in 4-part fractures. Agreement on treatment of 4 part fractures was best with CT scan. No other fracture type sub-division had significantly different kappa scores.

CONCLUSIONS

Although 3D reconstruction showed a slight improvement in the inter-observer agreement for fracture classification among specialized upper extremity surgeons compared to all imaging modalities, fracture types, and surgeon experience; overall all imaging modalities continue to yield low inter-observer agreement for both classification and treatment regardless of physician experience.

Indications for computed tomography (CT-) diagnostics in proximal humeral fractures: a comparative study of plain radiography and computed tomography

BACKGROUND

Precise indications for computed tomography (CT) in proximal humeral fractures are not established. The purpose of this study was a comparison of conventional radiographic views with different CT reconstructions with 2 D and 3 D imaging to establish indications for additional CT diagnostics depending on the fractured parts.

METHODS

In a prospective diagnostic study in two level 1 trauma centers, 44 patients with proximal humeral fractures were diagnosed with conventional X-rays (22 AP + axillary views, 22 AP + scapular Y-views) and CT (multi-planar reconstruction (MPR) and maximum intensity projection (MIP)) with 2 D and 3 D imaging. 3 observers assessed the technical image quality, the assessment of the relevant anatomical structures (2-sample-t-test) and the percentage of the osseous overlap of the proximal humerus (Welch-test) using a scoring system. The quality of the different diagnostic methods was assessed according to the number of fractured parts (Bonferroni-Holm adjustment).

RESULTS

There was significantly more overlap of the fractured region on the scapular Y-views (mean 71.5%, range 45-90%) than on axillary views (mean 56.2%, range 10.5-100%). CT-diagnostics allowed a significantly better assessment of the relevant structures than conventional diagnostics (p < 0.05) independently of the fracture severity (two-, three-, and four-part fractures).

CONCLUSION

Conventional X-rays with AP view and a high-quality axillary view are useful for primary diagnostics of the fracture and often but not always show a clear presentation of the relevant bony structures such as both tuberosities, the glenoid and humeral head. CT with thin slices technology and additional 3 D imaging provides always a clear presentation of the fractured region. Clinically, a CT should be performed--independently of the number of fractured parts--when the proximal humerus and the shoulder joint are not presented with sufficient X-ray-quality to establish a treatment plan.

Classification and imaging of proximal humerus fractures

The decision to operate and the selection of the appropriate surgical modality for proximal humerus fractures are largely based on the fracture pattern. Understanding the particular fracture pattern in each case is complicated. Most well-accepted classification systems were developed based on radiographs complemented by intraoperative findings. Three-dimensional reconstructions based on CT currently available in most institutions allow a much better understanding of complex fractures. Modern thinking about fracture classification probably should be revisited in the light of improved imaging techniques.

Isolated fractures of the greater tuberosity of the proximal humerus

This review addresses isolated greater tuberosity fractures of the proximal humerus. The important aspects of the epidemiology, anatomy, fracture classification, associated injuries, and treatment are discussed. Although isolated greater tuberosity fractures are well recognized, there are few studies that specifically evaluate the outcome of these injuries. Our experience and review of the recent literature suggest that more precise evaluation of diagnostic criteria, treatment selection, and outcome is required.

Osteoarthrosis following the Putti-Platt operation

The objective of this study was to search for any degenerative changes in the shoulder joint following the Putti-Platt operation in a long-term follow up study, as most papers regarding that operation report a redislocation rate and a limitation of external rotation, but only a few mention osteoarthrosis (OA). Patients operated on between 1945 and 1971 answered a questionnaire and were invited for a clinical examination including standard X-rays of the shoulder. These films were compared with those taken preoperatively. OA was classified according to the Samilson and Prieto grading. Twenty-six patients could be re-examined on average 26 years after the operation. Fifteen had evident radiological signs of OA. According to Samilson and Prieto there were 11 mild, 2 moderate and 2 severe cases of OA. Nine patients had a Hill-Sachs defect and 3, a Bankart lesion. Patients over the age of 25 years at the time of the first dislocation developed OA more often. Following the Putti-Platt operation one has to expect radiological signs of OA in a long-term follow-up. Mainly minor forms are seen. Older patient age at the time of the first dislocation is a predisposing factor for the development of OA.