Analysis of the subcapital two-part humerus fracture by fluoroscopy: objective criteria for classification and decision making

Nicolas Bless; Nicola Keller; Amir Steinitz; Thibaut Klein; Daniel Rikli

doi:10.1007/s00402-021-03940-x

Analysis of the subcapital two-part humerus fracture by fluoroscopy: objective criteria for classification and decision making

Arch Orthop Trauma Surg. 2022 Sep;142(9):2253-2262. doi: 10.1007/s00402-021-03940-x. Epub 2021 Jun 2.

Authors

Nicolas Bless^#¹, Nicola Keller^#², Amir Steinitz³, Thibaut Klein⁴, Daniel Rikli⁵

Affiliations

¹ Department of Orthopedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland. Nicolas.Bless@usb.ch.
² University of Basel, Basel, Switzerland.
³ Clinic for Orthopedics and Surgery, Merian Iselin, Basel, Switzerland.
⁴ Department of Biomedicine, University of Basel, Basel, Switzerland.
⁵ Department of Orthopedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland.

^# Contributed equally.

Abstract

Background: Surgical decision making in the treatment of proximal humerus fractures (PHFx) is primarily based on fracture classification using standard radiographs. Due to the lack of objective criteria, this classification process is associated with high interobserver variation. In this study, we investigate the fluoroscopic analysis of humerus fractures through the surgical neck using a semi-quantitative determination of distinct angulation patterns of the proximal humerus as they appear in the image intensifier.

Methods: Using a saw bone model, defined subcapital 2-part fracture configurations were generated and assessed radiographically. Anatomical landmarks-including the greater and lesser tuberosity as well as anatomical neck-were identified using an image converter, and the exact degree of fracture displacement with 10° up to 70° (in 10° increments) of posterior, varus or combined posterior-varus angulation was compared to nondisplaced controls. From the resultant series of radiographs, the appearance of these angulations in anteroposterior (AP) and scapular Y-views were also visualized and defined.

Results: An angulation of 50° or more of any given 2-part fracture through the surgical neck is present when the greater tuberosity becomes the most proximal point in AP view (varus and combined posterior-varus angulation) or a bimodal form is found for the superior contour of the head with the lesser tuberosity being the most proximal point in the Y-view (posterior angulation).

Conclusion: The radiological appearance of various PHFx constellations can be well visualized using the saw bone shoulder model. The presence of angulation in accordance with the Neer classification for group III fractures can be adequately determined by analyzing the relative position of the greater or lesser tuberosity to the humeral head calotte. This can assist the surgeon's decision on whether to operate or opt for a conservative approach.

Level of evidence: Basic Science, Anatomy Study, Imaging.

Keywords: Angulation; Classification; Fluoroscopy; Proximal humerus fracture; Shoulder; Surgical neck.

MeSH terms

Decision Making
Fluoroscopy
Fracture Fixation, Internal / methods
Humans
Humeral Fractures* / diagnostic imaging
Humeral Fractures* / surgery
Humerus / diagnostic imaging
Humerus / surgery
Shoulder Fractures* / diagnostic imaging
Shoulder Fractures* / surgery