Fractures of the proximal humerus

Figures & data

Figure 1. The 16 categories of the Neer classification. A fracture is considered displaced if one or more of the four anatomical segments (greater tuberosity, lesser tuberosity, the humeral head, or the humeral shaft) are displaced more than 1 centimeter or angulated more than 45°. Modified from Neer (1970) ¹⁵ with permission from JBJS Am, Rockwater Inc.

Figure 2. The AO/OTA classification consists of three types, nine groups, and 27 subgroups hierarchically organized according to prognosis. Type A fractures are unifocal and extraarticular, type B are bifocal and extraarticular while type C fractures are intraarticular. Reprinted from Marsh (2007) ¹⁹ with permission from J Orthop Trauma, Copyright Clearance Center.

Figure 3. Locking plate for proximal humeral fractures (Philos). Reprinted with permission from Synthes.

Figure 4. Reverse shoulder arthroplasty (DeltaXtend). Reprinted with permission from DePuy International Limited.

Figure 5. The Edwin Smith Papyrus (copied c. 1600 BC). Column XII and XIII including three cases on humeral fractures. Reprinted from Allen (2005) ⁸¹ with permission from The New York Academy of Medicine Library.

Figure 6. Healed fracture of a left proximal humerus (posterior view). Young woman. First or middle part of New Kingdom (c. 1539–1075 BC). Reprinted with permission from Laboratory of Biological Anthropology, University of Copenhagen.

Figure 7. Reduction of a fractured humerus according to De Fracturis (c. 415 BC). Reprinted from É. Littré (1841) ¹⁵².

Figure 8. Velpeau’s bandage. Reprinted from Bergmann and Bruns (1901) ¹⁵³.

Figure 9. Leonardo da Vinci. The shoulder viewed from above (c. 1510–13)⁹¹.

Figure 10. Desault’s three-layer bandage recommended for immobilisation of fractures of the clavicle and the proximal humerus. The bandage was also used for immobilisation of glenohumeral dislocations. Reprinted from Desault (1805) ⁹⁵.

Table I. Classification of fractures of the proximal humerus. Translated and modified from Thudichum (1851)

I. Anatomical neck fractures

A. intra-capsular fracture without impaction

intra-capsular fracture

intra-capsular fracture-dislocation

B. intra-capsular fracture with impaction

intra-capsular fraction with impaction

intra-capsular fraction with impaction and complicating tuberosity fracture

II. Fractures of greater tuberosity

III. Fractures of lesser tuberosity

IV. Epiphysiolysis

A. epiphysiolysis

B. fracture involving the epiphyseal line

V. Surgicalneckfractures

A. extracapsular fractures without impaction

extracapsular fracture

extracapsular fracture-dislocation

B. extracapsular fracture with impaction

Figure 11. Unreduced fracture-dislocation of the proximal humerus. Reprinted from Thudichum (1851) ¹⁰⁰.

Figure 12. Liston’s bandage. Reprinted from Liston (1838) ^101.

Figure 13. Middledorpf’s triangle. Reprinted from Stimson (1899) ^102.

Figure 14. Adhesive plaster bandage and permanent traction. Reprinted from Hamilton (1865)¹⁵⁴.

Figure 15. Bardenheuer’s extension apparatus. Reprinted from Hoffa (1888) ¹⁰⁴.

Figure 16. Hennequin’s plaster splint. Reprinted from Stimson (1887)¹⁰².

Figure 17. Kocher’s approach to classification of fractures of the proximal humerus and the proximal femur. Reprinted from Kocher (1896) ¹⁰⁸.

Figure 18. The four anatomical segments of the proximal humerus. Reprinted from Codman (1934) ¹¹⁰ with permission from Krieger Publishing Company.

Table II. Mean kappa values (95% CI) for agreement on the Neer classification at three levels of clinical experience

Level of experience	Number	Mean kappa
All observers	24	0.27 (0.25–0.28)
Residents	9	0.26 (0.23–0.29)
Fellows	6	0.21 (0.16–0.25)
Specialists	9	0.33 (0.30–0.35)

Table III. Mean (95% CI) kappa values for classification according to Neer

	Control	Training
Baseline
Overall (n = 7)	0.28 (0.24–0.31)	0.27 (0.23–0.31)
Specialists (n = 4)	0.30 (0.23–0.37)	0.30 (0.23–0.37)
Non-specialists (n = 3)	0.19 (0.10–0.29)	0.26 (0.16–0.36)
After training
Overall (n = 7)	0.33 (0.29–0.36)	0.62 (0.57–0.67)
Specialists (n = 4)	0.31 (0.24–0.39)	0.79 (0.70–0.88)
Non-specialists (n = 3)	0.38 (0.28–0.47)	0.51 (0.39–0.62)

Table IV. Inter-observer agreement in 12 observer-studies (mean kappa and/or range of kappa)

	Study characteristics				Interobserver agreement (mean/range of kappa)		Intraobserver agreement (mean/range of kappa)
Study	Cases (n)	Observers (n)	Neer-classes (n)	Non-displaced fractures %	Radiographs only	CT or 3D-CT	Radiographs only or radiographs and CT viewed together on two occasions
Kristiansen 1988	100	4	5	27	0.30 (0.07–0.48) ^a
Siebenrock 1993	95	5	5	Ns	0.40 (0.25–0.51)1 ^a		0.60 (0.46–0.71) ^a
Sidor 1993	50	5	16	Ns	0.48 (0.43–0.58)		0.66 (0.50–0.83)
Sidor 1994	50	5	16	Ns	0.39 and 0.49
Brien 1995	28	4	13	0	0.48 (0.37–0.75)
Bernstein 1996	20	4	16	20	0.52	0.50	0.72 (0.63-0.79)
Sallay 1997	12	9	6	20	0.58 (0.41–1.00) ^b 0.35 (0.24–0.77) ^c
Sjöden 1997	26	10	16	12		0.44	0.34 (0.20–0.85)
Sjoden 1999	24	7	16	21		0.47	0.56 (0.27–0.73)
Brorson 2002a	42	24	16 2 ^d	21	0.27 0.41 ^d
Brorson 2002b	42 ^e	14	16	21	0.27 0.62 ^f
Schwartz 2003	21	11	15	Ns	0.17
Schrader 2005	113	3	16	Ns	0.42 ^g and 0.47 ^f,g 0.45 ^g,h and 0.55 ^f,g,h	0.34	0.19–0.73 ^g
Brorson 2009	21–42 ^i	4–24	2 ^j	0–21 0.16–0.48 ^g

^a Weighted kappa

^b Neck fractures

^c Tuberosity fractures

^d Displaced versus non-displaced

^e Randomized trial

^f After training

^g Including some CT-scans

^h Agreement on treatment recommendation

ⁱ Review of data on four-part fractures from five observer studies

^j Four-part versus non-four-part

Table V. Mean kappa-values (95% CI) for interobserver agreement between five shoulder surgeons

Neer classification	Treatment recommendations	Adequacy of images
First round
0.33 (0.29–0.38)	0.48 (0.43–0.54)	0.29 (0.22–0.38)
	0.59 ^a (0.52–0.66)
	0.38 ^b (0.31–0.46)
	0.42 ^c (0.35–0.49)
Second round ^d
0.36 (0.31–0.42)	0.52 (0.45–0.58)	0.24 (0.18–0.31)
	0.55 ^a (0.48–0.63)
	0.53 ^b (0.44–0.61)
	0.42 ^c (0.34–0.49)

^a Non-surgical treatment

^b Locking plate osteosynthesis

^c Hemiarthroplasty

^d Patients’ age known to observers

Table VI. Plausibility of combinations between the Neer- and the AO/OTA-classification

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