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The Journal of Bone and Joint Surgery, Vol 75, Issue 12 1745-1750, Copyright © 1993 by Journal of Bone and Joint Surgery, Inc
The Neer classification system for proximal humeral fractures. An assessment of interobserver reliability and intraobserver reproducibility
ML Sidor, JD Zuckerman, T Lyon, K Koval, F Cuomo and N Schoenberg
Shoulder Service, Hospital for Joint Diseases Orthopaedic Institute, New York, N.Y. 10003.
The radiographs of fifty fractures of the proximal part of the humerus were
used to assess the interobserver reliability and intraobserver
reproducibility of the Neer classification system. A trauma series
consisting of scapular anteroposterior, scapular lateral, and axillary
radiographs was available for each fracture. The radiographs were reviewed
by an orthopaedic shoulder specialist, an orthopaedic traumatologist, a
skeletal radiologist, and two orthopaedic residents, in their fifth and
second years of postgraduate training. The radiographs were reviewed on two
different occasions, six months apart. Interobserver reliability was
assessed by comparison of the fracture classifications determined by the
five observers. Intraobserver reproducibility was evaluated by comparison
of the classifications determined by each observer on the first and second
viewings. Kappa (kappa) reliability coefficients were used. All five
observers agreed on the final classification for 32 and 30 per cent of the
fractures on the first and second viewings, respectively. Paired
comparisons between the five observers showed a mean reliability
coefficient of 0.48 (range, 0.43 to 0.58) for the first viewing and 0.52
(range, 0.37 to 0.62) for the second viewing. The attending physicians
obtained a slightly higher kappa value than the orthopaedic residents (0.52
compared with 0.48). Reproducibility ranged from 0.83 (the shoulder
specialist) to 0.50 (the skeletal radiologist), with a mean of 0.66.
Simplification of the Neer classification system, from sixteen categories
to six more general categories based on fracture type, did not
significantly improve either interobserver reliability or intraobserver
reproducibility.
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