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Interobserver Reliability of Classification and Characterization of Proximal Humeral FracturesA Comparison of Two and Three-Dimensional CT
Wendy E. Bruinsma, MD1; Thierry G. Guitton, MD, PhD1; Jon J.P. Warner, MD1; David Ring, MD, PhD1; the Science of Variation Group
1 Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114. E-mail address for D. Ring: dring@partners.org
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The Science of Variation Group: Parag Melvanki, Rudolf W. Poolman, Brett D. Crist, Lars C. Borris, Vishwanath M. Iyer, Reto H. Babst, Robert D. Zura, Huub van der Heide, Frede Frihagen, Iain McGraw, Eckart Schwab, George Thomas, Axel Jubel, James Kellam, Andrew Schmidt, Philipp Lenzlinger, Fred Baumgaertel, Elena Grosso, Matt Mormino, Marc Swiontkowski, Kyle Jeray, Daphne Beingessner, Neeraj Bijlani, Michael Prayson, Ladislav Mica, David Sonnabend, Darren Drosdowech, Francisco Lopez-Gonzalez, W. Jaap Willems, Frank Walter, Charalampos Zalavras, Richard S. Page, Thomas Wright, Scott Duncan, Taco Gosens, George S.M. Dyer, Grant Garrigues, German Ricardo Hernandez, Jeffrey A. Greenberg, Phani Dantuluri, Jose A. Ortiz Jr., Charles Cassidy, Alberto Pérez Castillo, Rick Papandrea, Sanjeev Kakar, Steve Kronlage, Leon Benson, Julie Adams, Lawrence Weiss, Gustavo Mantovani Ruggiero, Jay Pomerance, Ramon de Bedout, Eric Hofmeister, Marc J. Richard, Fabio Suarez, Theresa Wyrick, Michael Baskies, Thomas Hughes, Neil Wilson, J.C. Goslings, Thakkar Navin, Kevin Eng, Qiugen Wang, Pradeep Choudhari, Henry Broekhuyse, Richard Jenkinson, K.J. Ponsen, Arie B. van Vugt, Leon Elmans, Steven J. Rhemrev, Peter Kloen, Andreas Platz, Peter R.G. Brink, Rajat Varma, Alan Kawaguchi, James V. Nepola, Thomas DeCoster, Raymond Malcolm Smith, Kenneth Egol, Joseph M. Conflitti, Antonio Barquet, Rodrigo Pesantez, Jin-Young Park, Chunyan Jiang, Martin Richardson, Jeremy Hall, George Kontakis, Denise Eygendaal, Augustus D. Mazzocca, Xavier A. Duralde, Gerald Williams Jr., Donald Endrizzi, Steven J. Hattrup, Steve Petersen, Sergio L. Checchia, Sander Spruijt, Jason C. Fanuele, Taizoon Baxamusa, Chris Wilson, Francisco Javier Aguilar Sierra, Jorge Boretto, Karel Chivers, Jorge Rubio, Peter Schandelmaier, John L. Marsh, and Giuseppe Porcellini.

Investigation performed at the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Sep 04;95(17):1600-1604. doi: 10.2106/JBJS.L.00586
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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.

Level of Evidence: 

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

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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