Classification and Imaging of Proximal Humerus Fractures

doi:10.1016/j.ocl.2008.05.002

Orthopedic Clinics of North America

Volume 39, Issue 4, October 2008, Pages 393-403

https://doi.org/10.1016/j.ocl.2008.05.002 Get rights and content

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.

Section snippets

Neer classification

In 1970, Neer [3] published his classification of proximal humerus fractures. Traditional classification schemes focused on the mechanism of injury [6], [7] or on the level of the fracture [8], [9]. Neer noted that fracture level was of little assistance, as proximal humeral fractures frequently involved multiple levels. Additionally, these classification systems placed displaced and nondisplaced fractures in similar categories. Neer based his pathoanatomic classification system (Fig. 2) on the

Bone density assessment

Critical evaluation of the radiographic and clinical parameters to determine physiologic age is more appropriate than decisions based on chronologic age. One part of the decision-making process on the treatment of proximal humerus fractures is based on bone quality—specifically the presence or absence of osteoporosis. Bone mineral density can be roughly determined by radiographic evaluation and can have a considerable effect on treatment options [26]. Tingart and colleagues [27] identified a

Summary

The evaluation and treatment of proximal humerus fractures has evolved substantially over the last few decades. The indications for surgery have continued to expand reflecting the increased functional demands of patients and improvements in internal fixation and arthroplasty techniques. The knowledgeable selection of nonoperative treatment, internal fixation, or arthroplasty requires an understanding of the unique features of the different fracture patterns and their natural history. Over time,

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Cited by (29)

The Use of Acupuncture in the Management of Patients With Humeral Fractures: A Systematic Review and Meta-analysis
2021, Journal of Manipulative and Physiological Therapeutics
The purpose of this study was to conduct a systematic review and meta-analysis of the effects of acupuncture on humeral fractures.
Randomized controlled trials were searched systematically from inception to January 2020 using the Cochrane Central Register of Controlled Trials, Embase, PubMed, Web of Science, China National Knowledge Infrastructure, and 7 Korean databases. Pain scale and Japanese Orthopaedic Association scores were the primary and secondary measurements. A risk-of-bias assessment and meta-analysis were conducted.
Seven randomized controlled trials were included in the systematic review; the quality of the studies was ambiguous. The meta-analysis showed that acupuncture improved the pain severity score compared with conventional therapies (standard mean difference = −4.55, 95% confidence interval, −7.48 to −1.61, I² = 98%, P < .00001) but did not improve the Japanese Orthopaedic Association score (standard mean difference = 4.99, 95% confidence interval, −0.31 to 10.30, I² = 99%, P < .00001).
Our meta-analysis shows that acupuncture reduced pain after proximal humeral fracture, in addition to common rehabilitative modalities. However, the conclusion of this review should be cautiously applied in clinical practice owing to the low quality of the included studies.
An exemplar pyramid feature extraction based humerus fracture classification method
2020, Medical Hypotheses
Citation Excerpt :
The evaluation and treatment of proximal humerus fractures has improved significantly over the past few decades. These developments continued due to improvements in increased functional demands of patients and internal fixation, surgery indications and arthroplasty techniques [25]. Various classification systems have been proposed to guide treatment decisions.
Humerus fracture have been widely seen disease in the orthopedic clinics and classification of them is a hard process for orthopedist. The main aim of the proposed method is to classify humerus fracture by using a naïve and multileveled method. We collected a novel humerus fracture X-ray image dataset. This dataset consists of 115 images. In this paper, a novel stable feature extraction method is presented to classify humerus fractures. This method is called exemplar pyramid method and it is inspired by exemplar facial expression recognition methods. To classify humerus fractures, X-ray images were employed as input. In this study, X-ray images are resized to 512 × 512 sized image. Then, the used humerus fracture images are divided into 64 × 64 size of exemplars. To create levels, maximum pooling which has been mostly used in deep networks is used and four levels are created. Histogram of oriented gradients (HOG) and local binary pattern (LBP) are employed for feature generation. The most discriminative ones of the generated and concatenated features are selected by using ReliefF and Neighborhood Component Analysis (NCA) based two levelled feature selector (RFNCA).
To emphasize success of the proposed exemplar pyramid model based feature generation, four conventional classifiers are chosen for classification and the proposed exemplar pyramid model achieved 99.12% classification accuracy by using leave one out cross validation (LOOCV). Results and tests clearly illustrates success of the proposed exemplar pyramid model based humerus fracture classification method. The results also shown that the proposed exemplar pyramid model achieved higher classification rate than Orthopedist specialized in shoulder.
Imaging to improve agreement for proximal humeral fracture classification in adult patient: A systematic review of quantitative studies
2020, Journal of Clinical Orthopaedics and Trauma
Citation Excerpt :
Therefore, x-ray should remain first line imaging. Pain from repositioning often prevents collection of adequate x-ray views, whereas CT avoids repositioning.14,15,36,39 By improving agreement about classification, CT likely produces more consistent decision making and better patient outcomes, thereby mitigating legal ramifications and lowering overall cost.13,15
Proximal humeral fracture classification has low reproducibility. Many studies have tried to increase inter- and intra-observer agreement with more sophisticated imaging. The aim of this review was to determine which imaging modality produces the best inter- and intra-observer agreement for proximal humeral fracture classification in adults and to determine if this varies with observer experience or fracture complexity. OvidMEDLINE, The Cochrane Library, EBSCO CINAHL and Elsevier Scopus were searched on July 22nd, 2018. Quantitative studies comparing at least two imaging modalities for inter- or intra-observer agreement of proximal humeral fracture classification in adults were eligible for inclusion in this systematic literature review. Two reviewers independently screened and extracted data. Study quality was appraised using a modified Downs and Black checklist. The search strategy identified 1987 studies, of which 15 met the eligibility criteria. All included studies addressed inter-observer agreement and 8 provided results for intra-observer agreement. A narrative synthesis was performed. Trends were compared between studies as clinical heterogeneity and the statistical measures used by included studies prevented meta-analysis. Inter- and intra-observer agreement was found to increase from radiographs (x-ray) to two-dimensional (2D) computed tomography (CT) to three-dimensional (3D) CT. 2D and 3D CT may improve inter-observer agreement to a greater extent in less experienced observers and in more complex fractures. Future studies should compare 2D and 3D CT with subgroups categorising surgeon experience and fracture complexity. X-ray should be used for initial assessment; however doctors should have a low threshold for ordering CT.
PROSPERO number: CRD42018094307.
The reliability and reproducibility of the Hertel classification for comminuted proximal humeral fractures compared with the Neer classification
2016, Journal of Orthopaedic Science
Citation Excerpt :
The Neer classification is based on the existence of displacements of one or more of the major segments of the proximal humerus: the articular surface, the greater and the lesser tuberosity, and the shaft. Displacement is defined as an at least 1-cm distance and/or a 45° angle between fragments [22,23]. All images were classified independently by two senior shoulder expert trauma surgeons (DDH and NWLS) and by two senior radiologists with primary orthopedic trauma focus (GSRM and LFMB).
The Neer classification is the most commonly used fracture classification system for proximal humeral fractures. Inter- and intra-observer agreement is limited, especially for comminuted fractures. A possibly more straightforward and reliable classification system is the Hertel classification. The aim of this study was to compare the inter- and intra-observer variability of the Hertel with the Neer classification in comminuted proximal humeral fractures.
Four observers evaluated blinded radiographic images (X-rays, CT-scans, and CT-scans with 3D-reconstructions) of 60 patients. After at least two months classification was repeated.
Inter-observer agreement on plain X-rays was fair for both Hertel (κ = 0.39; 95% CI 0.23–0.62) and Neer (κ = 0.29; 0.09–0.42). Inter-observer agreement on CT-scans was substantial (κ = 0.63; 0.56–0.72) for Hertel and moderate for Neer (κ = 0.51; 0.29–0.68). Inter-observer agreement on 3D-reconstructions was moderate for both Hertel (κ = 0.60; 0.53–0.72) and Neer (κ = 0.51; 0.39–0.58).
Intra-observer agreement on plain X-rays was fair for both Hertel (κ = 0.38; 0.27–0.59) and Neer (κ = 0.40; 0.15–0.52). Intra-observer agreement on CT-scans was moderate for both Hertel (κ = 0.50; 0.38–0.66) and Neer (κ = 0.42; 0.35–0.52). Intra-observer agreement on 3D-reconstructions was moderate for Hertel (κ = 0.55; 0.45–0.64) and substantial for Neer (κ = 0.63; 0.48–0.79).
The Hertel and Neer classifications showed a fair to substantial inter- and intra-observer agreement on the three diagnostic modalities used. Although inter-observer agreement was highest for Hertel classification on CT-scans, Neer classification had the highest intra-observer agreement on 3D-reconstructions. Data of this study do not confirm superiority of either classification system for the classification of comminuted proximal humeral fractures.
Proximal humerus fractures: Hemiarthroplasty and reverse shoulder arthroplasty
2015, Shoulder and Elbow Trauma and its Complications: The Shoulder: Volume 1
Three- and four-part fractures of the proximal humerus are challenging to manage. Hemiarthroplasty and reverse shoulder arthroplasty (RSA) are frequently used to treat severe proximal humeral fractures. Surgical decision making is dependent on a number of factors including age, tuberosity comminution, fracture type, and patient preoperative activity level. Good outcomes can be achieved with both hemiarthroplasty and RSA if the surgeon makes wise decisions regarding patient selection and follows established technical guidelines. RSA is appropriate for elderly patients with three- and four-part proximal humeral fractures. Critical to the successful functional outcomes and stability of RSA is reconstruction of the tuberosities. Hemiarthroplasty has waning indications currently. Still, hemiarthroplasty is appropriate for those patients between the ages of 40 and 60 with severe head-splitting fractures, fracture-dislocations, and varus-angulated four-part fractures. Appropriate tuberosity reconstruction is paramount in hemiarthroplasty. Outcomes can be good for hemiarthroplasty when younger patients are chosen, and the tuberosity reconstruction is adequate. Recent outcomes for elderly patients with severe proximal humeral fractures treated with RSA have been good to excellent. Complications following RSA can be significant, including dislocation, infection, and scapular fracture. Failure following hemiarthroplasty usually revolves around tuberosity resorption, nonunion and malunion, or rotator cuff failure. Further research is necessary to determine which patients should be treated with hemiarthroplasty, locked plating, percutaneous fixation, and RSA.
Treatment choice affects inpatient adverse events and mortality in older aged inpatients with an isolated fracture of the proximal humerus
2014, Journal of Shoulder and Elbow Surgery
This study tests the null hypothesis that, among patients aged 65 and older admitted to a United States hospital with an isolated fracture of the proximal humerus (no other injuries or fractures), there are no differences between operative (fixation or arthroplasty) and nonoperative treatments with respect to inpatient adverse events, inpatient mortality, and discharge to a long-term care facility rates accounting for comorbidities.
Using a large national database representing an estimated 132,005 patients aged 65 and older admitted to a US hospital with an isolated proximal humerus fracture between 2003 and 2007. Sixty-one percent did not have surgery, 22% were treated with open reduction and internal fixation (ORIF), and 17% were treated with arthroplasty.
The risk of an in hospital adverse event was 21% overall and was 4.4 times greater with arthroplasty and 2.7 times greater with ORIF compared to nonoperative treatment. The risk of in hospital death was 1.8% overall and was 2.8 times greater with ORIF compared to nonoperative treatment. Patients treated operatively were less likely to be discharged to a long-term facility compared to patients treated nonoperatively.
In spite of a tendency to treat the most infirm patients (those that are not discharged to home) nonoperatively, operative treatment (open reduction and internal fixation in particular) is an independent risk factor for inpatient adverse events and mortality in older-aged patients admitted to the hospital with an isolated fracture of the proximal humerus and should perhaps be offered more judiciously.

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Classification and Imaging of Proximal Humerus Fractures

Section snippets

Neer classification

Bone density assessment

Summary

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Clin Radiol

The epidemiology of peripheral fractures

Bone

The shoulder: rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa

Displaced proximal humeral fractures. Part I: classification and evaluation

J Bone Joint Surg Am

Fracture and dislocation classification compendium—2007

J Orthop Trauma

A three-dimensional classification for fractures of the proximal humerus

J Bone Joint Surg Br

Fractures at the upper end of the humerus: a classification based on the etiology of trauma

Surg Clin North Am

Fractures and joint injuries

The treatment of fractures

Beitrage zur kenntniss einiger praktisch wichtiger fracturenforamen

Shoulder reconstruction

The comprehensive classification of fractures of long bones

Evaluation of Neer system of classification of proximal humerus fractures with computerized tomographic scans and plain radiographs

J Bone Joint Surg Am

Improved interobserver variation after training of doctors in the Neer system

J Bone Joint Surg Br

The Neer classification of fractures of the proximal humerus. An assessment of interobserver variation

Skeletal Radiol

The Neer classification system for proximal humerus fractures. An assessment of interobserver reliability and intraobserver reproducibility

J Bone Joint Surg Am

The reproducibility of classification of fractures of the proximal end of the humerus

J Bone Joint Surg Am

Neer's classification system: a critical appraisal

J Trauma

Complex fractures of the proximal humerus: role of CT in treatment

Radiology