Classification Of Proximal Humeral Fractures Research Articles

Morphology and novel classification of proximal humeral fractures.

Background: The morphology of proximal humeral fractures (PHFs) is complex, and the fixation and selection of implants need to be guided by the fracture type and classification, which requires an accurate understanding of the fracture line. This study had three purposes. 1) Define and analyze the fracture lines and morphological features of all types PHFs by three-dimensional (3D) mapping technology. 2) Determine the osteotomy position of the biomechanical model of the PHFs according to the fracture heat map. 3) Based on the analysis of the pathological morphology and distribution of a large number of consecutive cases of PHFs, propose a novel classification of PHFs. Methods: We retrospectively collected 220 cases of PHFs and generated a 3D fracture map and heat map based on computed tomography (CT) imaging. Through analysis of the fracture morphology of the 220 PHFs, a novel classification was proposed. The primary criterion for staging was the continuity between the humeral head and the greater tuberosity and lesser tuberosity, and the secondary criterion was the relationship between the humeral head segment and the humeral shaft. Results: The fracture line was primarily found around the metaphyseal zone of region of the surgical neck, with the most extensive distribution being below the larger tuberosity and on the posterior medial side of the epiphysis. We suggest that the osteotomy gap should be immediately (approximately 5-10mm) below the lower edge of the articular surface. The most common type of fracture was type I3 (33 cases, 15.0%), followed by type IV3 fracture (23 cases, 10.4%), and type III2 fracture (22 cases, 10.0%). Interobserver and intraobserver reliability analysis for the fracture classification revealed a k value (95% confidence interval) of 0.639 (0.57-0.71) and 0.841, P < 0.01, respectively. Conclusion: In this study, the fracture line and morphological characteristics of PHFs were clarified in detail by 3D mapping technique. In addition, a new classification method was proposed by analysis of the morphological characteristics of 220 PHFs, A two-part fracture model for PHFs is also proposed.

New technologies for the classification of proximal humeral fractures: Comparison between Virtual Reality and 3D printed models—a randomised controlled trial

Correct classification of fractures according to their patterns is critical for developing a treatment plan in orthopaedic surgery. Unfortunately, for proximal humeral fractures (PHF), methods for proper classification have remained a jigsaw puzzle that has not yet been fully solved despite numerous proposed classifications and diagnostic methods. Recently, many studies have suggested that three-dimensional printed models (3DPM) can improve the interobserver agreement on PHF classifications. Moreover, Virtual Reality (VR) has not been properly studied for classification of shoulder injuries. The current study investigates the PHF classification accuracy relative to an expert committee when using either 3DPM or equivalent models displayed in VR among 36 orthopaedic surgery residents from different hospitals. We designed a multicentric randomised controlled trial in which we created two groups: a group exposed to a total of 34 3DPM and another exposed to VR equivalents. Association between classification accuracy and group assignment (VR/3DPM) was assessed using mixed effects logistic regression models. The results showed VR can be considered a non-inferior technology for classifying PHF when compared to 3DPM. Moreover, VR may be preferable when considering possible time and resource savings along with potential uses of VR for presurgical planning in orthopaedics.

The Reliability and Reproducibility of a New Revised Edelson Classification.

ObjectiveEdelson classification is a 3D classification of proximal humeral fractures, but there is a scarcity of application of this classification in large samples, and the accuracy of classification was also not testified. The objective of this research was to verify whether a revised Edelson classification produces satisfactory agreement for proximal humeral fracture classification in adult patients.MethodsA total of 827 proximal humeral fractures (304 male and 520 female patients, 58.0 ± 16.2 years) were found retrospectively from January 2014 to December 2019, and classified according to the traditional and newly proposed Edelson classification. The three‐dimensional CT images were processed, rotated and visualized within software. Five shoulder surgeons classified each fracture. After data collection, radiographic classifications results were compared by inter‐ and intraobserver analysis with the method of weighted kappa coefficients. Fracture classification based on Edelson and revised Edelson classification was presented and compared.ResultsThe mean k value for the interobserver reliability was 0.748 (range, 0.583 to 0.958) compared with Edelson classification (0.548, range, 0.48 to 0.635), indicating satisfactory agreement. The mean k value for intraobserver reliability was 0.906 (range, 0.823 to 0.943) compared with Edelson classification (0.762, range, 0.666 to 0.808), indicating excellent agreement when using the newly revised Edelson classification. The mechanism was categorized as the shoulder being in a position of forward flexion, abduction, and internal rotation in Edelson I‐IV and bicipital fractures. For the greater tuberosity fracture, the mechanism was classified into two mechanisms based on the presence of a combined dislocation. Bicipital groove fracture is a commonly observed fracture pattern, and included in the revised Edelson classification.ConclusionsThe revised Edelson classification proposed was more in line with the injury mechanism of the fracture, was beneficial in identifying more fracture types such as bicipital groove fracture, and verified to be a good proximal humeral fracture classification with good reliability compared with the traditional Edelson classification.

Comparison of state-of-the-art machine and deep learning algorithms to classify proximal humeral fractures using radiology text

IntroductionProximal humeral fractures account for a significant proportion of all fractures. Detailed accurate classification of the type and severity of the fracture is a key component of clinical decision making, treatment and plays an important role in orthopaedic trauma research. This research aimed to assess the performance of Machine Learning (ML) multiclass classification algorithms to classify proximal humeral fractures using radiology text data. Materials and MethodsData from adult (16 + years) patients admitted to a major trauma centre for management of their proximal humerus fracture from January 2010 to January 2019 were used (1,324). Six input text datasets were used for classification: X-ray and/or CT scan reports (primary) and concatenation of patient age and/or patient sex. One of seven Neer class labels were classified. Models were evaluated using accuracy, recall, precision, F1, and One-versus-rest scores. ResultsA number of statistical ML algorithms performed acceptably and one of the BERT models, exhibiting good accuracy of 61% and an excellent one-versus-rest score above 0.8. The highest precision, recall and F1 scores were 50%, 39% and 39% respectively, being considered reasonable scores with the sparse text data used and in the context of machine learning. ConclusionML and BERT algorithms based on routine unstructured X-ray and CT text reports, combined with the demographics of the patient, show promise in Neer classification of proximal humeral fractures to aid research. Use of these algorithms shows potential to speed up the classification task and assist radiologist, surgeons and researchers.

Artificial Intelligence-Based Classification Of Proximal Humeral Fractures In Plain Shoulder Radiographs, Performance Of A Convolutional Neural Network Fracture Classifier

Our aim was to train and evaluate the ability of a convolutional neural network (CNN) in classification of proximal humeral fractures (PHF) according to the AO Foundation/Orthopaedic Trauma Association (AO/OTA) classification.

Interobserver and intraobserver agreement of three-dimensionally printed models for the classification of proximal humeral fractures.

HypothesisThis study aimed to examine whether three-dimensionally printed models (3D models) could improve interobserver and intraobserver agreement when classifying proximal humeral fractures (PHFs) using the Neer system. We hypothesized that 3D models would improve interobserver and intraobserver agreement compared with x-ray, two-dimensional (2D) and three-dimensional (3D) computed tomography (CT) and that agreement using 3D models would be higher for registrars than for consultants.MethodsThirty consecutive PHF images were selected from a state-wide database and classified by fourteen observers. Each imaging modality (x-ray, 2D CT, 3D CT, 3D models) was grouped and presented in a randomly allocated sequence on two separate occasions. Interobserver and intraobserver agreements were quantified with kappa values (κ), percentage agreement, and 95% confidence intervals (CIs).ResultsSeven orthopedic registrars and seven orthopedic consultants classified 30 fractures on one occasion (interobserver). Four registrars and three consultants additionally completed classification on a second occasion (intraobserver). Interobserver agreement was greater with 3D models than with x-ray (κ = 0.47, CI: 0.44-0.50, 66.5%, CI: 64.6-68.4% and κ = 0.29, CI: 0.26-0.31, 57.2%, CI: 55.1-59.3%, respectively), 2D CT (κ = 0.30, CI: 0.27-0.33, 57.8%, CI: 55.5-60.2%), and 3D CT (κ = 0.35, CI: 0.33-0.38, 58.8%, CI: 56.7-60.9%). Intraobserver agreement appeared higher for 3D models than for other modalities; however, results were not significant. There were no differences in interobserver or intraobserver agreement between registrars and consultants.ConclusionThree-dimensionally printed models improved interobserver agreement in the classification of PHFs using the Neer system. This has potential implications for using 3D models for surgical planning and teaching.

Defining the fracture population in a pragmatic multicentre randomised controlled trial: PROFHER and the Neer classification of proximal humeral fractures.

ObjectivesAccurate characterisation of fractures is essential in fracture management trials. However, this is often hampered by poor inter-observer agreement. This article describes the practicalities of defining the fracture population, based on the Neer classification, within a pragmatic multicentre randomised controlled trial in which surgical treatment was compared with non-surgical treatment in adults with displaced fractures of the proximal humerus involving the surgical neck.MethodsThe trial manual illustrated the Neer classification of proximal humeral fractures. However, in addition to surgical neck displacement, surgeons assessing patient eligibility reported on whether either or both of the tuberosities were involved. Anonymised electronic versions of baseline radiographs were sought for all 250 trial participants. A protocol, data collection tool and training presentation were developed and tested in a pilot study. These were then used in a formal assessment and classification of the trial fractures by two independent senior orthopaedic shoulder trauma surgeons.ResultsTwo or more baseline radiographic views were obtained for each participant. The independent raters confirmed that all fractures would have been considered for surgery in contemporaneous practice. A full description of the fracture population based on the Neer classification was obtained. The agreement between the categorisation at baseline (tuberosity involvement) and Neer classification as assessed by the two raters was only fair (kappa 0.29). However, this disparity did not appear to affect trial findings, specifically in terms of influencing the effect of treatment on the primary outcome of the trial.ConclusionsA key reporting requirement, namely the description of the fracture population, was achieved within the context of a pragmatic multicentre randomised clinical trial. This article provides important guidance for researchers designing similar trials on fracture management.Cite this article: H. H. G. Handoll, S. D. Brealey, L. Jefferson, A. Keding, A. J. Brooksbank, A. J. Johnstone, J. J. Candal-Couto, A. Rangan. Defining the fracture population in a pragmatic multicentre randomised controlled trial: PROFHER and the Neer classification of proximal humeral fractures.Bone Joint Res 2016;5:481–489. DOI: 10.1302/2046-3758.510.BJR-2016-0132.R1.

Interobserver agreement of Neer and AO classifications for proximal humeral fractures

The classification of proximal humeral fractures remains challenging. The two main classification systems used, the Neer and the AO classification, have both been shown to have less than ideal interobserver agreement. Agreement in classification is required, however, to guide fracture management. Data from the Victorian Orthopaedic Trauma Outcomes Registry were collected and the X-rays of 104 proximal humeral fractures were reviewed by three orthopaedic consultants. They classified the fractures according to the Neer and AO classifications, as well as their simplified versions. Interobserver agreement was then assessed using kappa statistics. Interobserver agreement was better overall in the Neer classification, which was moderate (kappa = 0.40-0.58), than the AO classification, which was fair to moderate (kappa = 0.31-0.54). When simplified, the Neer and AO classification interobserver agreement remained similar. The classification of proximal humeral fractures with both the Neer and the AO systems remains difficult with minimal improvements seen when reducing the number of categories in each classification system. From these results, the Neer classification system would appear slightly more useful in clinical practice to guide treatment.

Classification of proximal humeral fractures based on a pathomorphologic analysis

The purpose of this study was to analyze the pathomorphology of proximal humeral fractures to determine relevant and reliable parameters for fracture classification. A total of 100 consecutive acute proximal humeral fractures in adult patients were analyzed by 2 non-independent observers from a single shoulder department using a standardized protocol based on biplane radiographs and 3-dimensional computed tomography scans. A fracture classification system based on the most reliable key features of the pathomorphologic analysis was created, and its reliability was tested by 6 independent shoulder experts analyzing another 100 consecutive proximal humeral fractures. The head position in relation to the shaft (varus, valgus, sagittal deformity) and the presence of tuberosity fractures showed a higher interobserver reliability (κ > 0.8) than measurements for medial hinge, shaft, and tuberosity displacement, metaphyseal extension, fracture impaction, as well as head-split component identification (κ < 0.7). These findings were used to classify nondisplaced proximal humeral fractures as type 1, fractures with normal coronal head position but sagittal deformity as type 2, valgus fractures as type 3, varus fractures as type 4, and fracture dislocations as type 5. The fracture type was further combined with the fractured main fragments (G for greater tuberosity, L for lesser). Interobserver and intraobserver reliability analysis for the fracture classification revealed a κ value (95% confidence interval) of 0.700 (0.631-0.767) and 0.917 (0.879-0.943), respectively. The new classification system with emphasis on the qualitative aspects of proximal humeral fractures showed high reliability when based on a standardized imaging protocol including computed tomography scans.

Not the Last Word: Codman Was Right--Spread The Word.

Second only to the discovery of insulin by Sir Frederick G. Banting, the development of an “End Result System” by Ernest A. Codman MD was the greatest contribution to general medicine by an orthopaedic surgeon. You may know Codman more for his eponymous Codman’s Triangle (made by the elevated periosteum adjacent to a long bone tumor) or for his classification of proximal humeral fractures (which is the basis of the current practice of defining such fractures in terms of “parts”), but the End Result System outweighs them both, by far.

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.

Interobserver Reliability of Classification and Characterization of Proximal Humeral Fractures

Interobserver reliability for the classification of proximal humeral fractures is limited. The aim of this study was to test the null hypothesis that interobserver reliability of the AO classification of proximal humeral fractures, the preferred treatment, and fracture characteristics is the same for two-dimensional (2-D) and three-dimensional (3-D) computed tomography (CT). Members of the Science of Variation Group--fully trained practicing orthopaedic and trauma surgeons from around the world--were randomized to evaluate radiographs and either 2-D CT or 3-D CT images of fifteen proximal humeral fractures via a web-based survey and respond to the following four questions: (1) Is the greater tuberosity displaced? (2) Is the humeral head split? (3) Is the arterial supply compromised? (4) Is the glenohumeral joint dislocated? They also classified the fracture according to the AO system and indicated their preferred treatment of the fracture (operative or nonoperative). Agreement among observers was assessed with use of the multirater kappa (κ) measure. Interobserver reliability of the AO classification, fracture characteristics, and preferred treatment generally ranged from "slight" to "fair." A few small but statistically significant differences were found. Observers randomized to the 2-D CT group had slightly but significantly better agreement on displacement of the greater tuberosity (κ = 0.35 compared with 0.30, p < 0.001) and on the AO classification (κ = 0.18 compared with 0.17, p = 0.018). A subgroup analysis of the AO classification results revealed that shoulder and elbow surgeons, orthopaedic trauma surgeons, and surgeons in the United States had slightly greater reliability on 2-D CT, whereas surgeons in practice for ten years or less and surgeons from other subspecialties had slightly greater reliability on 3-D CT. Proximal humeral fracture classifications may be helpful conceptually, but they have poor interobserver reliability even when 3-D rather than 2-D CT is utilized. This may contribute to the similarly poor interobserver reliability that was observed for selection of the treatment for proximal humeral fractures. The lack of a reliable classification confounds efforts to compare the outcomes of treatment methods among different clinical trials and reports.

Erratum to: AST classification of proximal humeral fractures: introduction and interobserver reliability assessment

Erratum to: AST classification of proximal humeral fractures: introduction and interobserver reliability assessment

上腕骨近位端骨折の分類法について(Book Review)

上腕骨近位端骨折の分類法について(Book Review)

Surgeons agree more on treatment recommendations than on classification of proximal humeral fractures

BackgroundOrthopaedic surgeons disagree considerably when classifying fractures of the proximal humerus. However, the clinical implications of low observer agreement remain unclear. The purpose of the study was to compare the agreement on Neer classification with the agreement on treatment recommendations.MethodsWe conducted a multi-centre observer-study. Five experienced shoulder surgeons independently assessed a consecutive series of 193 radiographs at two occasions three months apart. All pairs of radiographs were classified according to Neer. Subsequently, the observers were asked to recommend one of three treatment modalities for each case: non-operative treatment, locking plate osteosynthesis, or hemiarthroplasty.ResultsAt both classification rounds mean kappa-values for inter-observer agreement on treatment recommendations (0.48 and 0.52) were significantly higher than the agreement on Neer classification (0.33 and 0.36) (p < 0.001 at both rounds). The highest mean kappa-values were found for inter-observer agreement on non-surgical treatment (0.59 and 0.55). In 36% (345 out of 965) of observations an observer changed Neer category between first and second classification round. However, in only 34% of these cases (116 out of 345) the observers changed their treatment recommendations.ConclusionsWe found a significantly higher agreement on treatment recommendations compared to agreement on fracture classification. The low observer agreement on the Neer classification reported in several observer studies may have less clinical importance than previously assumed. However, inter-observer agreement did not exceed moderate levels.

AST classification of proximal humeral fractures: introduction and interobserver reliability assessment

This article introduces an alphanumeric AST (Articular, Surgical neck, Tuberosities) classification of proximal humeral fractures, based on the number, localization, and displacement of articular and extra-articular fragments. All possible cases of proximal humeral fractures can be assessed from a single figure using this classification. The aim of the study was thus to describe the AST classification and to assess interobserver reliability. This classification is based on a single figure, allowing an easy description of the anatomic variants of different proximal humeral fractures. The severity of the fracture is determined by the fragment displacement in angular degrees and the major linear displacement in millimeters. AST reproducibility was assessed and compared with Neer, AO, and Duparc classifications, commonly used in clinical practice. The interobserver agreement was measured with Cohen's kappa coefficients and their 95% confidence intervals. Thirteen independent observers analyzed a total of 64 X-rays. Overall kappa coefficients were 0.34, 0.29, 0.24, and 0.25 for AST, Neer, AO, and Duparc classifications, respectively. The AST classification, which is easier to use because it is based on only one figure, is at least as reproducible as other proximal humeral fracture classifications.

The reliability and reproducibility of the Neer classification system – Digital radiography (PACS) improves agreement

Introduction We investigated if the introduction of digital radiography, with its software permitting enhancement of plain radiographs, improved inter- and intra-observer agreement in the Neer classification. Methods Five observers participated in classifying 50 randomly selected radiographs with a confirmed proximal humeral fracture. The observers included a junior registrar, an upper-limb fellow, a lower-limb orthopaedic consultant and two orthopaedic shoulder consultants. Agreement was quantified via kappa values. Results In general, good (0.61–0.80) results were obtained using kappa value for inter-observer reliability throughout all grades. On further analysis, however, discrepancies persist in the classification between Neer type 1/2 and Neer type 5 categories. The latter was not restricted to more inexperienced surgeons. Intra-observer agreement (>0.81) was excellent throughout all grades. Conclusion The introduction of digital radiography aids the improvement of Neer classification of proximal humeral fractures across all grades. With superior agreement in displacement and fracture patterns, improved communication and discussion of these injuries and similar treatment plans can be expected. This may help negate one aspect of the variability in outcome of proximal humeral shaft fractures. More complex fracture configurations continue to have difficulty in interpretation and may require further imaging analysis to conclude definitively.

Current Concepts in the Treatment of Proximal Humeral Fractures

Preoperative classification of proximal humeral fractures in addition to thorough knowledge of the specific anatomy and vascular blood supply is more important for successful treatment than the choice of implant. If reduction and fixation is necessary, aggressive reduction maneuvers can compromise humeral head perfusion with subsequent humeral head necrosis regardless of the implant used. Modern implants such as intramedullary proximal humeral nails and anatomically designed proximal humeral angular stable plates offer high primary stability even in osteoporotic bone with preservation of periosteal blood supply to the humeral head. These implants allow early functional exercises and showed good to excellent results in the majority of patients with an acceptable complication rate. Increasing experience with these relatively new implants and further technical development might improve clinical results and reduce complications. Minimally invasive, percutaneous techniques also demonstrate favorable results comparable to those mentioned above, although mean patient age tends to be younger in these studies and complications requiring reoperation tend to be more pronounced in elderly patients due to poor bone quality. Alternatively, nonoperative treatment of displaced two- and three-part fractures in elderly patients with severe morbidity and high perioperative risks should be considered. In elderly patients with selected displaced four-part fractures or fracture dislocations and head-split fractures, hemiarthroplasty offers high subjective patient satisfaction despite moderate function with most of the patients being pain free.

The Classification of Proximal Humeral Fractures

The Classification of Proximal Humeral Fractures