Intramedullary nailing versus sliding hip screw for A1 and A2 trochanteric hip fractures.

AIMS: This study evaluated variation in the surgical treatment of stable (A1) and unstable (A2) trochanteric hip fractures among an international group of orthopaedic surgeons, and determined the influence of patient, fracture, and surgeon characteristics on choice of implant (intramedullary nailing (IMN) versus sliding hip screw (SHS)). METHODS: A total of 128 orthopaedic surgeons in the Science of Variation Group evaluated radiographs of 30 patients with Type A1 and A2 trochanteric hip fractures and indicated their preferred treatment: IMN or SHS. The management of Type A3 (reverse obliquity) trochanteric fractures was not evaluated. Agreement between surgeons was calculated using multirater kappa. Multivariate logistic regression models were used to assess whether patient, fracture, and surgeon characteristics were independently associated with choice of implant. RESULTS: The overall agreement between surgeons on implant choice was fair (kappa = 0.27 (95% confidence interval (CI) 0.25 to 0.28)). Factors associated with preference for IMN included USA compared to Europe or the UK (Europe odds ratio (OR) 0.56 (95% CI 0.47 to 0.67); UK OR 0.16 (95% CI 0.12 to 0.22); p < 0.001); exposure to IMN only during training compared to surgeons that were exposed to both (only IMN during training OR 2.6 (95% CI 2.0 to 3.4); p < 0.001); and A2 compared to A1 fractures (Type A2 OR 10 (95% CI 8.4 to 12); p < 0.001). CONCLUSION: In an international cohort of orthopaedic surgeons, there was a large variation in implant preference for patients with A1 and A2 trochanteric fractures. This is due to surgeon bias (country of practice and aspects of training). The observation that surgeons favoured the more expensive implant (IMN) in the absence of convincing evidence of its superiority suggests that surgeon de-biasing strategies may be a useful focus for optimizing patient outcomes and promoting value-based healthcare. Cite this article: Bone Joint J 2021;103-B(4):775-781.

Classification of tibial plateau fractures using 3DCT with and without subtraction of unfractured bones.

BACKGROUND: The addition of 3D CT scans for observers evaluating tibial plateau fractures decreases agreement and diagnostic accuracy, possibly due to obstruction of the view by unfractured bones (i.e., patella, fibula, and femur) in 3D reconstructions. QUESTIONS/PURPOSES: This study compared (1) the interobserver agreement between (subgroups of) observers classifying 3DCT reconstructions of tibial plateau fractures according to Schatzker, Luo, and AO/OTA, (2) recognition of different fracture characteristics, and (3) the level of confidence on a scale from 0 to 10 with and without subtraction of the unfractured bones. METHODS: We selected twenty consecutive 3DCT reconstructions of tibial plateau fractures treated in a level I trauma center between 2013 and 2014. Members of the Science of Variation Group were randomized (1:1) to evaluate reconstructions with or without subtraction of the unfractured bone. Forty-nine surgeons completed the survey. The interobserver agreement was determined using Fleiss' kappa, and bootstrapping (resamples = 1000) was used to calculate the standard error, z statistic, and confidence intervals. RESULTS: Overall, subtraction of unfractured bones did not affect interobserver agreement in Schatzker, Luo, and AO/OTA classification systems, agreement on the presence of fracture characteristics, and level of confidence. In subgroup analysis, non-trauma surgeons had significantly higher agreement in the three classification systems with subtraction. For fracture characteristics, some subgroups had higher agreement while others had lower agreement with subtraction. DISCUSSION: The finding that agreement on classification of tibial plateau fractures is limited on 3DCT scan and is not improved by subtraction of unfractured bones suggests that disagreement may be based on variations in understanding and bias. Reliability of these classification systems might benefit from a focus on accounting for these pre-existing conceptualizations rather than further emphasis on imaging detail. LEVEL OF EVIDENCE: Diagnostic, level 1.

Does Mindfulness Correlate With Physical Function and Pain Intensity in Patients With Upper Extremity Illness?

BACKGROUND: Mindfulness skills training interventions seem efficacious in increasing physical function and decreasing pain intensity in patients with chronic pain. The relationship of mindfulness and upper extremity complaints in patients presenting to orthopedic surgical practices is not known. The aim of this study was to assess if mindfulness has a relationship to physical function and pain intensity in patients with upper extremity illness. METHODS: In this cross-sectional study, a total of 126 patients with a nontraumatic upper extremity condition were asked to fill out questionnaires assessing the 5 facets of mindfulness, pain intensity, and upper extremity physical function, along with clinical and demographic variables prior to their visit with the surgeon. RESULTS: Nonreactivity to inner experiences was the only facet of mindfulness that was correlated with upper extremity physical function and pain intensity. The overall mindfulness score was correlated with pain intensity only. In multivariable analyses, mindfulness was not associated with either physical function or with pain intensity. Pain interference was the most important predictor of both pain intensity and physical function. CONCLUSIONS: Greater overall mindfulness was associated with lower pain intensity, and greater ability to be nonreactive to inner experiences was associated with both pain intensity and upper extremity physical function in bivariate but not multivariable analyses. Pain interference was the most important predictor of both pain intensity and upper extremity physical function. Psychosocial interventions focused on improving physical function and decreasing pain intensity in this population should focus primarily on reducing pain interference, and secondarily on teaching patients mindfulness skills.

The PROMIS Global Health Questionnaire Correlates With the QuickDASH in Patients With Upper Extremity Illness.

BACKGROUND: The objective of this study is to evaluate the construct validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health instrument by establishing its correlation to the Quick-Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire in patients with upper extremity illness. METHODS: A cohort of 112 patients completed a sociodemographic survey and the PROMIS Global Health and QuickDASH questionnaires. Pearson correlation coefficients were used to evaluate the association of the QuickDASH with the PROMIS Global Health items and subscales. RESULTS: Six of the 10 PROMIS Global Health items were associated with the QuickDASH. The PROMIS Global Physical Health subscale showed moderate correlation with QuickDASH and the Mental Health subscale. There was no significant relationship between the PROMIS Global Mental Health subscale and QuickDASH. CONCLUSIONS: The consistent finding that general patient-reported outcomes correlate moderately with regional patient-reported outcomes suggests that a small number of relatively nonspecific patient-reported outcome measures might be used to assess a variety of illnesses. In our opinion, the blending of physical and mental health questions in the PROMIS Global Health makes this instrument less useful for research or patient care.

Interobserver Variability of Radiographic Assessment Using a Mobile Messaging Application as a Teleconsultation Tool.

BACKGROUND: To examine whether interobserver reliability, decision-making, and confidence in decision-making in the treatment of distal radius fractures changes if radiographs are viewed on a messenger application on a mobile phone compared to a standard DICOM viewer. METHODS: Radiographs of distal radius fractures were presented to surgeons on either a smart phone using a mobile messenger application or a laptop using a DICOM viewer application. Twenty observers participated: 10 (50%) were randomly assigned to the DICOM viewer group and 10 (50%) to the mobile messenger group. Each observer was asked to evaluate the cases and (1) classify the fracture type according to the AO classification, (2) recommend operative or conservative treatment and (3) rate their confidence about this decision. RESULTS: There was no significant difference in interobserver reliability for AO classification and recommendation for surgery for distal radius fractures in both groups. The percentage of recommendation for surgery was significantly higher in the messenger application group compared to the DICOM viewer group (89% versus 78%, P=0.019) and the confidence for treatment decision was significantly higher in the mobile messenger group compared to the DICOM viewer group (8.9 versus 7.9, P=0.026). CONCLUSION: Messenger applications on mobile phones could facilitate remote decision-making for patients with distal radius fractures, but should be used with caution.

Unplanned Reoperation After Trapeziometacarpal Arthroplasty: Rate, Reasons, and Risk Factors.

BACKGROUND: Trapeziometacarpal (TMC) arthritis is an expected part of ageing to which most patients adapt well. Patients who do not adapt to TMC arthritis may be offered operative treatment. The factors associated with reoperation after TMC arthroplasty are incompletely understood. The purpose of this study was to determine the rate of, the underlying reasons for, and the factors associated with unplanned reoperation after TMC arthroplasty. METHODS: In this retrospective study, we included all adult patients who had TMC arthroplasty for TMC arthritis at 1 of 3 large urban area hospitals between January 2000 and December 2009. Variables were inserted into a multivariable Cox proportional hazards model to determine factors associated with unplanned reoperation, and the Kaplan-Meier curve was used to estimate and describe the probability of unplanned reoperation over time. RESULTS: Among 458 TMC arthroplasties, 19 (4%) had an unplanned reoperation; 16 of 19 (84%) for persistent pain and two-thirds within the first year. The multivariate Cox regression analysis showed that unplanned reoperation was independently associated with younger age, surgeon inexperience, and index procedure type. CONCLUSIONS: Surgeons should be aware as well as patients should be informed that as many as 4% are offered or request a second surgery, usually for persistent pain and often within the 1-year window when additional improvement is anticipated.

Axillary Artery Injury Associated with Proximal Humerus Fracture: A Report of 6 Cases.

Proximal humerus fractures are common, but associated injury of the axillary artery is uncommon. The majority of published blunt traumatic axillary artery injuries are associated with anterior glenohumeral dislocation; a few are associated with isolated proximal humerus fractures or fracture-dislocation. Experience within our institution demonstrates that axillary artery injury is often unrecognized on initial presentation owing to palpable peripheral pulses and the absence of ischemia and places the hand at risk of necrosis and amputation if there is prolonged ischemia and the forearm at risk of compartment syndrome after revascularization. Accurate physical examination in combination with a low threshold for Doppler examination or angiography can establish the diagnosis of axillary artery injury. We present 6 cases of axillary artery injury associated with proximal humerus fractures in order to highlight the potential for this vascular injury in the setting of a proximal humerus fracture.

Online Studies on Variation in Orthopedic Surgery: Computed Tomography in MPEG4 Versus DICOM Format.

The purpose of this study was to compare the observer participation and satisfaction as well as interobserver reliability between two online platforms, Science of Variation Group (SOVG) and Traumaplatform Study Collaborative, for the evaluation of complex tibial plateau fractures using computed tomography in MPEG4 and DICOM format. A total of 143 observers started with the online evaluation of 15 complex tibial plateau fractures via either the SOVG or Traumaplatform Study Collaborative websites using MPEG4 videos or a DICOM viewer, respectively. Observers were asked to indicate the absence or presence of four tibial plateau fracture characteristics and to rate their satisfaction with the evaluation as provided by the respective online platforms. The observer participation rate was significantly higher in the SOVG (MPEG4 video) group compared to that in the Traumaplatform Study Collaborative (DICOM viewer) group (75 and 43%, respectively; P < 0.001). The median observer satisfaction with the online evaluation was seven (range, 0-10) using MPEG4 video compared to six (range, 1-9) using DICOM viewer (P = 0.11). The interobserver reliability for recognition of fracture characteristics in complex tibial plateau fractures was higher for the evaluation using MPEG4 video. In conclusion, observer participation and interobserver reliability for the characterization of tibial plateau fractures was greater with MPEG4 videos than with a standard DICOM viewer, while there was no difference in observer satisfaction. Future reliability studies should account for the method of delivering images.

The Effect of Two Factors on Interobserver Reliability for Proximal Humeral Fractures.

INTRODUCTION: The purpose of this study was to assess whether training observers and simplifying proximal humeral fracture classifications improve interobserver reliability among a large number of orthopaedic surgeons. METHODS: One hundred eighty-five observers were randomized to receive training or no training in a simple classification for proximal humeral fractures before evaluating preoperative radiographs of a consecutive series of 30 patients who were treated with open reduction and internal fixation. RESULTS: The overall interobserver reliability of the simple proximal humeral fracture classification system was low and not significantly different between the training and the no training group (κ = 0.20 and κ = 0.18, respectively; P = 0.10). Subgroup analyses showed that training improved the agreement among surgeons who have been in independent practice ≤5 years (κ = 0.23 versus κ = 0.14; P < 0.001), surgeons from the United States (κ = 0.23 versus κ = 0.16; P = 0.002), and general orthopaedic surgeons (κ = 0.42 versus κ = 0.15; P = 0.021). DISCUSSION: Simplifying classifications and training observers did not improve the interobserver reliability for the diagnosis of proximal humeral fractures. However, training observers improved interobserver reliability of a simple proximal humeral fracture classification system among surgeons from the United States and, in particular, younger and less specialized surgeons. This finding may suggest that our interpretations of radiographic information might become more fixed and immutable with experience.

The relationship between therapist-rated function and patient-reported outcome measures.

STUDY DESIGN: Prospective cohort study. INTRODUCTION: Some third-party payers require hand therapists to rate patient's functional disability based on patient self-rating using patient-reported outcome measures (PROMs), objective measurements of impairment, and observation of functional tasks-hand therapist-rated function (HTRF). PURPOSE OF THE STUDY: To test the correlation between HTRF and PROMs (upper limb functional index [ULFI] and Patient-Reported Outcomes Measurement Information System upper extremity [PROMIS UE]) and its association with psychological factors. METHODS: In 2014, 100 new patients with upper extremity illness presenting to hand therapists were asked to participate in an observational cross-sectional study. Demographic-, condition-related, and psychological factors were obtained in addition to PROMs and HTRF. RESULTS: HTRF correlated moderately with PROMIS UE (r = -0.49, P < .001) and ULFI (r = -0.56, P < .001). Correlation between PROMIS UE and ULFI was strong (r = 0.78, P < .001). Psychological factors explained most of the variations in both HTRF and PROMs. CONCLUSIONS: Hand therapists' ratings of patient function correlate less strongly with PROMs than PROMs correlate with one other. The discrepancy between HTRF and PROMs may offer an opportunity to address stress, distress, or ineffective coping strategies that can interfere with recovery-an opportunity for therapists and patients to collaborate and develop goals and for future research to develop effective and feasible strategies for hand therapists. LEVEL OF EVIDENCE: Level II, diagnostic study.

Fracture line distribution of olecranon fractures.

PURPOSE: The association between specific olecranon fracture characteristics (e.g., displacement, fragmentation, subluxation) and fracture line distribution might help surgeons predict intra-articular fracture location based on fracture characteristics that can be determined on radiographs. We hypothesized that fracture mapping techniques would reveal different fracture patterns for minimally displaced fractures, displaced fractures, and fracture-dislocations of the olecranon. METHODS: A consecutive series of 78 patients with olecranon fractures were evaluated using initial radiographs and computed tomography scans and characterized according to the Mayo classification. Fracture lines were identified based on reduced three-dimensional computed tomography reconstructions and graphically superimposed onto a standard template to create two-dimensional fracture maps. The fracture maps were then converted into fracture heat maps. Based on fracture and heat maps, fracture line location and patterns were determined. RESULTS: Six (7.7%) patients had a non- or minimally displaced fracture, 22 (28%) a displaced fracture, and 50 (64%) a fracture-dislocation of the olecranon. There were 27 (54%) anterior and 23 (46%) posterior olecranon fracture-dislocations. Fracture lines of non- or minimally displaced fractures and posterior fracture-dislocations enter and exit the trochlear notch at the base of the coronoid, while fracture lines of displaced fractures and anterior fracture-dislocations were spread more broadly over the depths of the trochlear notch. CONCLUSIONS: Based on fracture characteristics depicted on radiographs, one can anticipate the amount of the olecranon involved (how close is the fracture line to the coronoid) and the orientation of the fracture line. Computer tomography could be reserved for when more specific knowledge of the fracture line might affect treatment. LEVEL OF EVIDENCE: III.

Lifetime prevalence of and factors associated with non-traumatic musculoskeletal pains amongst surgeons and patients.

PURPOSE: There is evidence that surgeons make different recommendations for people seeking their care than they make for themselves. There may also be differences in pain episodes and management strategies between surgeons and people seeking care, knowledge of which might improve care. We aimed to assess whether the prevalence of non-traumatic pains, treatments and other factors differed between patients and surgeons. MATERIALS AND METHODS: Two-hundred and twenty surgeons, members of the Science of Variation Group (SOVG), and 248 patients seeking care at the Hand Service at a large academic hospital completed a survey regarding the lifetime incidence of non-traumatic pains lasting > one month using short versions of the Pain Catastrophising Scale (PCS-4); Patient Health Questionnaire (PHQ-2); and Short Health Anxiety Inventory (SHAI-5). RESULTS: Surgeons had a higher prevalence of at least one non-traumatic pain than patients and were more likely to report pain at more than one anatomical site. Patients were more likely to receive any treatment: surgery; injection; non-opioid medication; opioid medication; physical or occupational therapy. Patients missed work more often than surgeons. Age was the only factor independently associated with patient pain. Practicing in the United States was the only factor independently associated with surgeon pain. CONCLUSIONS: Non-traumatic pains are extremely common. Surgeons have particularly effective coping strategies, allowing them to maintain their life roles with limited medical care when in pain. Increasing the appeal and availability of methods for optimising coping strategies might help to narrow the gap between surgeon and patient health.

Proximity of Vital Structures to the Clavicle: Comparison of Fractured and Non-fractured Side.

BACKGROUND: Previous anatomic and radiological studies have described the relationship of the clavicle to major neurovascular structures in healthy subjects. We were curious about this relationship in patients with a clavicle fracture and if it is different from non-fractured clavicles. METHODS: We retrospectively identified all patients with a clavicle fracture between July 2001 and October 2013 in two level 1 trauma centers. Patients aged 18 years or greater with an acute unilateral clavicle fracture and a chest CT scan in the supine position displaying both clavicles and the complete fracture were included. Seventy patients were available for study. The distance was measured from the fracture site and from the closest clavicular cortex to the closest major artery, major vein, and inner surface of the thoracic cavity. CT data was evaluated in OsiriX DICOM viewer software with the use of three-dimensional Multiplanar Reconstruction. RESULTS: Compared to the fractured side, the clavicle was significantly closer to the artery and vein on the non-fractured side (P<0.001 and p=0.0025 respectively). There was a significant difference in the median distance of the fracture site to the artery, vein, and inner surface of thoracic cavity between the different types of fractures (P<0.001). A post-hoc comparison showed significant differences in all distances between fracture types, except for the distance of proximal third compared to middle third fractures to the closest artery (P=0.41). There was no significant difference in distance when the arm is up overhead compared to down by the side of the body in computed tomography (CT) scans. CONCLUSIONS: A fracture of the clavicle changes the relationship of the clavicle to major vital structures. The minimum distance of the clavicle to the closest artery and vein is significantly less on the non-fractured side, compared to the fractured side.

The direct and indirect effects of the negative affectivity trait on self reported physical function among patients with upper extremity conditions.

Negative affectivity is a personality trait that predisposes people to psychological distress and low life satisfaction. Negative affectivity may also affect pain intensity and physical function in patients with musculoskeletal conditions. We explored the association of negative affectivity to pain intensity and self-reported physical function, and tested whether pain intensity mediates the effect of negative affectivity on physical function. In a cross-sectional study, 102 patients with upper extremity musculoskeletal conditions presenting to an orthopedic surgeon completed self-report measures of negative affectivity, pain intensity, and physical function in addition to demographic and injury information. We used the Preacher and Hayes' bootstrapping approach to quantify the indirect effect of negative affectivity on physical function through pain intensity. Negative affectivity correlated with greater pain intensity and lower self-reported physical function significantly. Also, pain intensity mediated the association of negative affectivity with physical function. The indirect effect accounted for one-third of the total effect. To conclude, negative affectivity is associated with decreased engagement in daily life activities both directly, but also indirectly through increased pain intensity. Treatments targeting negative affectivity may be more economical and efficient for alleviation of pain and limitations associated with musculoskeletal illness than those addressing coping strategies or psychological distress.

Online Health Information Seeking in Hand and Upper Extremity Surgery.

PURPOSE: Information gathering is a key component of shared decision making and has a measurable effect on treatment decisions. Access to health information might improve quality of care in hand surgery. Our purpose was to identify socio-demographic, condition-related, and psychosocial factors associated with online information-seeking behavior in patients with hand and upper-extremity conditions. METHODS: From June 2015 to February 2016, we enrolled 134 patients with an upper-extremity condition who presented to an outpatient hand surgery office at an urban level I trauma center in this cross-sectional study. Participants provided socio-demographic information and completed online questionnaires assessing their online information-seeking behavior, pain intensity, symptoms of depression, and pain interference, and an upper extremity-specific, patient-reported outcome measure. RESULTS: A total of 57 patients (43%) sought information regarding their condition online before their visit. Compared with patients with no online information-seeking behavior, patients who sought information online were more educated. Psychosocial and condition-related factors were not associated with online information seeking. In multivariable analysis, education in years and involvement of the dominant upper limb were independently associated with online information-seeking behavior. CONCLUSIONS: Education in years and involvement of the dominant upper limb were independently associated with online information-seeking behavior but psychosocial and condition-related factors were not. CLINICAL RELEVANCE: As health information seeking is becoming an integral part of the modern day clinical experience, efforts to make online information more appealing and useful to people of all education levels are merited.

The yield of subsequent radiographs during nonoperative treatment of radial head and neck fractures.

OBJECTIVES: After diagnosis of an isolated radial head or neck fracture and selection of nonoperative treatment, the value of subsequent radiographs is uncertain. This study tested the null hypothesis that there are no patient, surgeon, or injury factors associated with alteration in patient management based on subsequent radiographs. Secondarily, we tested the null hypothesis that the use of subsequent radiographs is not associated with patient, surgeon, and fracture characteristics. METHODS: We identified 415 adult patients with nonoperative treatment for isolated Broberg and Morrey modified Mason type 1 or 2 fractures at a large urban hospital system during years 2013 and 2014. Patient demographics, fracture characteristics, provider characteristics, and treatment details were obtained from a hospital database. Bivariate analysis and multivariable logistic regression modeling were performed. RESULTS: One of 255 patients with 262 fractures that had subsequent radiographs (0.4%) was offered surgery but declined. In multivariable analysis, displaced fractures were more likely to have subsequent radiographs, but surgeon-to-surgeon variation was a far more influential factor. CONCLUSIONS: Radiographs subsequent to diagnosis do not alter treatment of radial head fractures with no associated ligament injuries or fractures. The substantial surgeon-to-surgeon variation in the use of subsequent radiographs suggests that this may be a good focus for quality improvement initiatives.

Involvement of the lesser sigmoid notch in elbow fracture dislocations.

BACKGROUND: This study addressed the primary null hypothesis that there is no difference in the articular surface area of the lesser sigmoid notch involved among Mayo classes. Secondarily, we analyzed the fracture line location and the pattern of lesser sigmoid notch articular surface involvement among Mayo classes. METHODS: Using quantitative 3-dimensional computed tomography, we reconstructed and analyzed fractures involving the lesser sigmoid notch articular surface in 52 patients. Further, we assessed the surface area involved in the fracture, the number of fracture fragments, and the location and direction of the fracture lines. Coronoid fractures were classified according to Mayo types. RESULTS: There was no significant difference between Mayo types 1 and 2 in any characteristic of the involvement of the lesser sigmoid notch articular surface, whereas Mayo type 3 was significantly different from both Mayo types 1 and 2 in the area involved in the fracture (42% in Mayo type 3 vs. 9% in Mayo types 1 and 2), the number of articular fragments (>3 fragments in type 3 vs. 2 fragments in types 1 and 2), and the direction of fracture line (both horizontal and vertical lines in type 3 vs. only horizontal line in types 1 and 2). CONCLUSION: Mayo type III results in a more complex fracture, which might need to be addressed directly or indirectly during open reduction with internal fixation of olecranon fracture dislocations because changes in the geometry of lesser sigmoid notch may affect the radioulnar joint if it remains incongruent.

Fracture mapping of displaced partial articular fractures of the radial head.

BACKGROUND: Recognition of patterns of traumatic elbow instability helps anticipate specific fracture characteristics and associated injuries. The objective of this study was to assess the association of fracture line distribution and location of displaced partial articular radial head fractures with specific patterns of traumatic elbow instability using fracture mapping techniques. METHODS: Fracture line distribution and location of 66 acute displaced partial articular radial head fractures were identified using quantitative 3-dimensional computed tomography reconstructions that allowed reduction of fracture fragments and a standardized method to divide the radial head into quadrants with forearm in neutral position. Based on qualitative and quantitative assessment of fracture maps, the association between fracture characteristics of displaced partial articular radial head fractures and specific elbow fracture patterns was determined. RESULTS: In partial articular radial head fractures, the highest fracture line intensity was located in the anterolateral quadrant near the center of the radial head. Fracture location corresponded with fracture line distribution; most fractures involved the anterolateral quadrant (n = 65; 98%), whereas parts of the posteromedial quadrant were involved in a minority of the fractures (n = 10; 15%). The association of fracture line distribution and location with overall fracture patterns of the elbow, as depicted on fracture maps, was not statistically significant. CONCLUSION: Fracture maps demonstrated no association between fracture line distribution and location of displaced partial articular fractures of the radial head and overall specific patterns of traumatic elbow instability, suggesting a common fracture mechanism that involves the anterolateral part of the radial head in most patients.

Tibial Plateau Fracture Characteristics: Reliability and Diagnostic Accuracy.

OBJECTIVES: The purpose of this study was to assess the interobserver reliability and diagnostic accuracy for 2-dimensional (2D) and 3-dimensional (3D) computed tomography (CT)-based evaluation of tibial plateau fracture characteristics. We hypothesized that recognition of specific tibial plateau fracture characteristics is equally reliable and accurate in 2DCT and 2D- and 3DCT. METHODS: Eighty-one orthopedic trauma surgeons and residents were randomized to either 2DCT or 2D- and 3DCT evaluation of 15 complex tibial plateau fractures using web-based platforms to recognize 4 tibial plateau fracture characteristics: (1) a posteromedial component, (2) a lateral component, (3) a tibial tubercle component, and (4) a tibial spine (central) component. Interobserver reliability was evaluated by Siegel and Castellan's multirater kappa measure and kappa values were interpreted according to the categorical rating by Landis and Koch. Diagnostic accuracy was calculated according to standard formulas. RESULTS: Interobserver reliability of tibial plateau fracture characteristics ranged from "fair" to "substantial". The addition of 3DCT reconstructions did not improve agreement between observers or diagnostic accuracy, because kappa values and diagnostic accuracy were significantly better for evaluation of tibial plateau fractures using 2DCT alone. Diagnostic accuracy of fracture characteristics ranged from 70% to 89% and was better for more frequently encountered components (ie, the posteromedial and lateral component). CONCLUSIONS: The recognition of tibial plateau fracture characteristics prove accurate and reliable on CT-based evaluation in this study and may be useful besides current classification systems, which do not account for all fracture components, in daily practice to help clinical decision making. Further research is needed to evaluate whether the use of distinct fracture components helps preoperative planning of surgical approach and specific fixation techniques.