Radiographs Versus Radiographic Measurements in Distal Radius Fractures

Abstract

Surgeons use radiographic measures of deformity to help make treatment decisions in distal radius fractures. Precise threshold values are sometimes offered as a guide to treatment. The purpose was to evaluate if agreement on treatment recommendations would improve if surgeons were provided with radiographs rather than precise numeric radiographic measurements. We randomized 259 surgeons to review the scenarios of 30 consecutive adult patients with a distal radius fracture treated at our emergency department either with radiographs (135 surgeons) or with radiographic measurements (124 surgeons). Interrater reliability was measured with the Fleiss’ generalized Kappa. Factors associated with a recommendation for operative treatment were sought in bivariate and multivariable analyses. Surgeons that received measurements only recommended operative treatment significantly more often, but were less likely to agree than surgeons evaluating actual radiographs. Patient factors - radiographic factors in particular - had a greater influence on treatment recommendation than surgeon factors. Agreement on treatment recommendations improved if surgeons were provided with radiographs instead of just measurements. There may be radiographic factors other than measures of deformity that some surgeons use to determine recommendations for surgery.

Keywords

Distal radius fracture - Interobserver agreement - Patient characteristics - Radiographic measurements - Radiographs - Surgeon characteristics

• References

• 1 Ilyas AM, Jupiter JB. Distal radius fractures-classification of treatment and indications for surgery. Orthop Clin North Am 2007; 38 (2) 167-173 doi: 10.1016/j.ocl.2007.01.002
• 2 Diaz-Garcia RJ, Oda T, Shauver MJ, Chung KC. A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly. J Hand Surg Am 2011; 36 (5) 824-835 doi: 10.1016/j.jhsa.2011.02.005, e822
• 3 Guitton TG, Ring D, Science of Variation G. Interobserver reliability of radial head fracture classification: two-dimensional compared with three-dimensional CT. J Bone Joint Surg Am 2011; 93 (21) 2015-2021 doi:10.2106/JBJS.J.00711
• 4 Andersen DJ, Blair WF, Steyers Jr CM, Adams BD, el-Khouri GY, Brandser EA. Classification of distal radius fractures: an analysis of interobserver reliability and intraobserver reproducibility. J Hand Surg Am 1996; 21 (4) 574-582
• 5 Neuhaus V, Bot AG, Guitton TG, Ring DC, Science of Variation G. Scapula fractures: interobserver reliability of classification and treatment. J Orthop Trauma 2014; 28 (3) 124-129 doi:10.1097/BOT. 0b013e31829673e2
• 6 Thomason K, Smith KL. The reliability of measurements taken from computer-stored digitalised x-rays of acute distal radius fractures. J Hand Surg Eur 2008; 33 (3) 369-372 doi:10.1177/1753193407087509
• 7 Guitton TG, Ring D. Interobserver reliability of radial head fracture classification: two-dimensional compared with threedimensional CT. J Bone Joint Surg Am 2011; 93 (21) 2015-2021 doi:10.2106/JBJS.J.00711
• 8 Venkataraman G, Ananthanarayanan V, Paner GP. Accessible calculation of multirater kappa statistics for pathologists. Virchows Arch 2006; 449 (2) 272 doi:10.1007/s00428-006-0209-2
• 9 King JE Generalized Kappa & Other Indices of Interrater Reliability. http://www.ccitonline.org/jking/homepage/interrater.html. Accessed November 1st, 2012
• 10 Hallgren KA. Computing inter-rater reliability for observational data: an overview and tutorial. Tutor Quant Methods Psychol 2012; 8 (1) 23-34
• 11 Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33 (1) 159-174
• 12 Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987; 40 (5) 373-383
• 13 Kirkland LL, Kashiwagi DT, Burton MC, Cha S, Varkey P. The Charlson Comorbidity Index Score as a predictor of 30-day mortality after hip fracture surgery. Am J Med Qual 2011; 26 (6) 461-467 doi:10.1177/1062860611402188
• 14 Robertson GA, Robertson BF, Thomas B, McEachan J, Davidson DM. Assessing angulation on digital images of radiographs of fractures of the distal radius: visual estimation versus computer software measurement. J Hand Surg Eur 2011; 36 (3) 230-235 doi: 10.1177/1753193410391361
• 15 Gaskin JS, Pimple MK, Wharton R, Fernandez C, Gaskin D, Ricketts DM. How accurate and reliable are doctors in estimating fracture angulation?. Injury 2007; 38 (2) 160-162 doi:10. 1016/j.injury.2006.09.008
• 16 Wigderowitz CA, Sadaiyappan V, McGurty DM, Rowley DI. Computerized analysis of radiographs in Colles’ fractures. Clin Orthop Relat Res 2001; 387: 217-224
• 17 Grainger AJ, Duryea J, Elliott JM, Genant HK. The evaluation of a new digital semi-automated system for the radiological assessment of distal radial fractures. Skeletal Radiol 2002; 31 (8) 457-463 doi:10.1007/s00256-002-0526-8
• 18 Ilyas AM, Jupiter JB. Distal radius fractures-classification of treatment and indications for surgery. Hand Clin 2010; 26 (1) 37-42 doi:10.1016/j.hcl.2009.08.003
• 19 Rajabi B, Roed O, Roed K, Alm-Paulsen PS, Russwurm H, Finsen V. Accurate radiographic measurement of the distal radial tilt. Hand Surg 2011; 16 (3) 259-262
• 20 Kreder HJ, Hanel DP, McKee M, Jupiter J, McGillivary G, Swiontkowski MF. X-ray film measurements for healed distal radius fractures. J Hand Surg Am 1996; 21 (1) 31-39 doi:10.1016/S0363-5023(96)80151-1
• 21 Medoff RJ. Essential radiographic evaluation for distal radius fractures. Hand Clin 2005; 21 (3) 279-288 doi:10.1016/j.hcl.2005.02.008
• 22 Chung KC, Shauver MJ, Birkmeyer JD. Trends in the United States in the treatment of distal radial fractures in the elderly. J Bone Joint Surg Am 2009; 91 (8) 1868-1873 doi:10.2106/JBJS.H.01297
• 23 Chung KC, Shauver MJ, Yin H. The relationship between ASSH membership and the treatment of distal radius fracture in the United States Medicare population. J Hand Surg Am 2011; 36 (8) 1288-1293 doi:10.1016/j.jhsa.2011.05.028
• 24 Koval KJ, Harrast JJ, Anglen JO, Weinstein JN. Fractures of the distal part of the radius. The evolution of practice over time. Where’s the evidence?. J Bone Joint Surg Am 2008; 90 (9) 1855-1861 doi: 10.2106/JBJS.G.01569
• 25 Kodama N, Takemura Y, Ueba H, Imai S, Matsusue Y. Acceptable parameters for alignment of distal radius fracture with conservative treatment in elderly patients. J Orthop Sci 2014; 19 (2) 292-297 doi:10.1007/s00776-013-0514-y
• 26 Mackenney PJ, McQueen MM, Elton R. Prediction of instability in distal radial fractures. J Bone Joint Surg Am 2006; 88 (9) 1944-1951 doi:10.2106/JBJS.D.02520