Effect of humeral rotation on the reliability of radiographic measurements for proximal humerus fractures

Background: There are concerns as to the reliability of proximal humerus radiographic measurements, particularly regarding the rotational position of the humerus when obtaining radiographs. Methods: Twenty-four patients with proximal humerus fractures fixed surgically with locked plates received postoperative anteroposterior radiographs with the humerus in neutral rotation and in 30 degrees of internal and external rotation. Radiographic measurements for head shaft angle, humeral offset and humeral head height were performed in each humeral rotation position. Intra-class correlation coefficient was used to assess inter-rater and intra-rater reliability. Mean differences (md) in measurements between humeral positions was evaluated using one-way ANOVA. Results: Head shaft angle demonstrated good-to-excellent reliability; the highest estimates for interrater reliability (ICC: 0.85; 95% CI: 0.76, 0.94) and intra-rater reliability (ICC: 0.96; 95% CI: 0.93, 0.98) were achieved in neutral rotation. There were significant differences in measurement values between each rotational position, with mean head shaft angle of 133.1 degrees in external rotation, and increasingly valgus measurements in neutral (md: 7.6 degrees; 95% CI: 5.0, 10.3 degrees; p < 0.001) and internal rotation (md: 26.4 degrees; 95% CI: 21.8, 30.9 degrees; p < 0.001). Humeral head height and humeral offset showed good-to-excellent reliability in neutral and external rotation, but poor inter-rater reliability in internal rotation. Humeral head height was significantly greater using internal compared to external rotation (md: 4.5 mm; 95% CI: 1.7, 7.3 mm; p = 0.002). Humeral offset was significantly greater in external compared to internal rotation (md: 4.6 mm; 95% CI: 2.6, 6.6 mm; p < 0.001). Conclusions: Views of the humerus in neutral rotation and 30 degrees of external rotation displayed superior reliability. Differences in radiographic measurement values, depending on humeral rotation views, can make for problematic correlations with patient outcome measures. Studies assessing radiographic outcomes following proximal humerus fractures should ensure standardized humeral rotation for obtaining anteroposterior shoulder radiographs, with neutral rotation and external rotation views likely yielding the most reliable results. Level of Evidence: Level IV (c) 2023 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.