Understanding proximal humerus fractures: Image analysis, classification, and treatment

Proximal humerus fractures are difficult to define because of their extreme variability and potential for complexity. We designed a study to evaluate further why this is true. Radiographs of 113 proximal humeral fractures were assessed by 3 knowledgeable observers. The observers were asked to answer independently 9 questions about the fracture, to classify the fracture according to the Neer classification, and to recommend treatment. Two months later, a learning session was held to discuss discrepancies among the observers and to develop learning points to improve analysis of the images. Two months later, the radiographs were reassessed. Developing 10 learning points enhanced the ability to interpret images at the second review and provide more consistent fracture classification with statistically significant improvements. The problem is understanding the images of complex fractures—not the classification system. To enhance consistency in understanding these fractures, imaging of complex fractures must be enhanced.