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

There are concerns as to the reliability of proximal humerus radiographic measurements, particularly regarding the rotational position of the humerus when obtaining radiographs. 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° 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. Head shaft angle demonstrated good-to-excellent reliability; the highest estimates for inter-rater 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° in external rotation, and increasingly valgus measurements in neutral (md: 7.6°; 95% CI: 5.0, 10.3°; p