Treatment of displaced proximal humeral fractures in elderly patients

Treatment of displaced proximal humeral fractures in elderly patients / Author’s replay

Karladani, H A


I read with interest the paper in the May 1997 issue by Zyto et al1 entitled `Treatment of displaced proximal humeral fractures in elderly patients’. It had the selection criteria of `three- or four– part fractures of the humerus’, a phrase that specifically identifies the use of Neer’s classification system, and ended with the strong assumption that there was no significant difference in shoulder function with regard to the type of treatment. This statement could prove to be misleading. It is well established that loose application of Neer’s classification system such as with two radiographs per patient cannot hope to achieve accurate radiological analysis of proximal humeral fractures.2-4 Furthermore, it appeared that the authors did not adjust for unknown confounding factors.

To this end, the blanket statement that “…the outcome of surgical and conservative treatment of three-part fractures of the proximal humerus in elderly patients is similar…” is only true for the modified method used by the authors and may not be true at all if Neer’s classification system is strictly applied.


Gothenburg University


1. Zyto K, Ahrengart L, Sperber A, Tornkvist H. Treatment of displaced proximal humeral fractures in elderly patients. J Bone Joint Surg [Br] 1997;79-B:412-7.

2. Pavlov H, Warren RF, Weiss CB Jr, Dines DM. The roentgenographic evaluation of anterior shoulder instability. Clin Orthop 1985; 194:153-8.

3. Flatow EL, Ulrich C. Humerus. Oxford: Butterworth-Heinemann, 1995;58.

4. Neer CS II. Displaced proximal humeral fractures Part I: classification and evaluation. J Bone Joint Surg [Am] 1970;52-A:1077-89.

Author’s reply:


I thank Dr Karladani for his comments. Before the start of any treatment the fracture pattern should be analysed and a valid classification system can be a useful tool for selecting the optimal treatment. Neer’s classification system is commonly used. It is based on four different anatomical fragments of the fractured proximal humerus.1 Recently, the reliability and reproducibility of the Neer classification system have been questioned.2-4 Sidor et al5 have shown that five different observers agreed on the final classification for only one-third of the fractures, indicating that the Neer classification system is of little value for interpreting comminuted fractures of the proximal humerus. Newer techniques for accurate radiological evaluation, such as CT and three-dimensional analysis, have not improved the accuracy of classification of the fracture pattern. Unfortunately, we do not have a better one.

For the radiological assessment of the fractured arm, we used the AP and lateral views. We agree that there is perhaps some inaccuracy in how we classified the fracture pattern, but this is strictly theoretical because clinically we had to use the available system with all its limitations. It is doubtful if we would have achieved improved accuracy of analysis of the fracture pattern with more radiological views or more sophisticated techniques.

Our rationale for using limited internal fixation is explained in the text. Surgery improved the position of the fracture which was maintained during the healing process.

We believe that our results do not reflect the classification system but that there are other factors to be considered such as the osteoporotic bone, the degenerative cuff and the low patient compliance.


Soder Hospital

Stockholm, Sweden.

1. Neer CS II. Displaced proximal humeral fractures. Part II. Treatment of three part and four part displacement. J Bone Joint Surg[Am] 1970; 52-A: 1090-103.

2. Kristiansen B, et al. The Neer classification of fractures of the proximal humerus: an assessment of interobserver variation. Skeletal Radiol 1988;17:420-2.

3. Siebenrock AA, Gerber C. The reproducibility of classification of fractures of the proximal end of the humerus. J Bone Joint Surg [Am 1993;75-A:1751-5.

4. Bernstein J, et al. Evaluation of the Neer system of classification of proximal humeral fractures with computerized tomographic scans and plain radiographs. J Bone Joint Surg [Am] 1996;78-A:1371-5.

5. Sidor ML, Zuckerman JD, Lyon T, et al. The Neer classification system for proximal humeral fractures: an assessment of interobserver reliability and intraobserver reproducibility. J Bone Joint Surg [Am] 1993;75-A: 1745-50.

6. Sjoden, et al. 3D-radiographic analysis does not improve the reproducibility of fracture classification in the proximal humerus. Presented at the lOth Congress of the European Society for Surgery of the Shoulder and the Elbow, Salzburg, 1997.

Copyright British Editorial Society of Bone & Joint Surgery Jan 1999

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