Agreement in the neer classification of proximal humerus fracture
Keywords:Orthopedics, Traumatology, Proximal humerus, Fractures, Neer
Background: Proximal humerus fractures account for approximately 4 to 5% of all fractures, affecting more elderly females. As a treatment method, whether surgical or conservative, it is necessary to classify it to know the prognosis of the fracture. Despite being widely used, there are dissociations of evaluation and radiographic reproducibility among examiners.
Aim: To assess the inter- and intra-observational agreement of Neer's classification for fractures of the proximal humerus in adults.
Method: Radiographs of 20 cases of proximal humerus fracture were selected and made available to 35 examiners (Orthopedists, including specialists in shoulder and elbow surgery), who classified them according to Neer's classification, over a period of 60 days. Results: Initially evaluating the 35 evaluators with different levels of experience, at two different times, with a common interval of 60 days between one evaluation and another, the intra-evaluator reliability, considering the median, was excellent 0.923 (95% CI [0.610 - 1.237]), as well as the mode 0.925 (95% CI [0.626 – 1.224]). In the evaluation of the 20 evaluators with the highest intra-evaluator reliability (k>0.5), the intra-evaluator reliability, considering the median among the 20 evaluators, was excellent 0.923 (95% CI [0.610 - 1.237]), as well as considering the mode 0.855 (95% CI [0.569 - 1.141]). Finally, considering the 20 evaluators with the highest individual intra-evaluator reliability, the inter-evaluator reliability in the first evaluation (test) was light 0.259 (95% CI [0.239 - 0.280]), as well as in the second evaluation (retest) 0.289 (95% CI [ 0.269 - 0.310]).
Conclusion: This study evidences that the classification system proposed by Neer, following the Kappa index, presents as a final result a poor categorization of agreement, both intraobservational and interobservational, of fractures of the proximal humerus extremity. A lower reliability (mild to negligible) was also observed in the interobserver analysis. Thus, it is evident the importance of using other classification systems and complementary diagnostic methods, such as computed tomography, for better assessment and management of patients with fractures of the proximal humerus, aiming at optimizing the treatment and rehabilitation of these cases.
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