Interobserver reliability of classification and characterization of proximal humeral fractures: a comparison of two and three-dimensional CT

Interobserver reliability for the classification of proximal humeral fractures is limited. The aim of this study was to test the null hypothesis that interobserver reliability of the AO classification of proximal humeral fractures, the preferred treatment, and fracture characteristics is the same for two-dimensional (2-D) and three-dimensional (3-D) computed tomography (CT). Members of the Science of Variation Group--fully trained practicing orthopaedic and trauma surgeons from around the world--were randomized to evaluate radiographs and either 2-D CT or 3-D CT images of fifteen proximal humeral fractures via a web-based survey and respond to the following four questions: (1) Is the greater tuberosity displaced? (2) Is the humeral head split? (3) Is the arterial supply compromised? (4) Is the glenohumeral joint dislocated? They also classified the fracture according to the AO system and indicated their preferred treatment of the fracture (operative or nonoperative). Agreement among observers was assessed with use of the multirater kappa (κ) measure. Interobserver reliability of the AO classification, fracture characteristics, and preferred treatment generally ranged from "slight" to "fair." A few small but statistically significant differences were found. Observers randomized to the 2-D CT group had slightly but significantly better agreement on displacement of the greater tuberosity (κ = 0.35 compared with 0.30, p < 0.001) and on the AO classification (κ = 0.18 compared with 0.17, p = 0.018). A subgroup analysis of the AO classification results revealed that shoulder and elbow surgeons, orthopaedic trauma surgeons, and surgeons in the United States had slightly greater reliability on 2-D CT, whereas surgeons in practice for ten years or less and surgeons from other subspecialties had slightly greater reliability on 3-D CT. Proximal humeral fracture classifications may be helpful conceptually, but they have poor interobserver reliability even when 3-D rather than 2-D CT is utilized. This may contribute to the similarly poor interobserver reliability that was observed for selection of the treatment for proximal humeral fractures. The lack of a reliable classification confounds efforts to compare the outcomes of treatment methods among different clinical trials and reports

Interobserver reliability of coronoid fracture classification : two-dimensional versus three-dimensional computed tomography

Purpose : This study tests the hypothesis that 3-dimensional computed tomography (CT) reconstructions improve interobserver agreement on classification and treatment of coronoid fractures compared with 2-dimensional CT.Methods : A total of 29 orthopedic surgeons evaluated 10 coronoid fractures on 2 occasions (first with radiographs and 2-dimensional CT and then with radiographs and 3-dimensional CT), separated by a minimum of 2 weeks. Surgeons classified fractures according to the classifications of Regan and Morrey and of O\u27Driscoll et al., identified specific characteristics, recommended the most appropriate treatment approach, and made treatment recommendations. The kappa multirater measure (&kappa;) was calculated to estimate agreement between observers.Results : Regardless of the imaging modality used, there was fair to moderate agreement for most of the observations. Three-dimensional CT improved interobserver agreement in Regan and Morrey\u27s classsication (&kappa;3-dimensional = 0.51 vs &kappa;2-dimensional = 0.40; p &lt; .001) and O\u27Driscoll et al.\u27s classifications (&kappa;3-dimensional = 0.48 vs &kappa;2-dimensional = 0.42; p = .009). There were trends toward better reliability for 3-dimensional reconstruction in recognition of coronoid tip fractures (&kappa;3-dimensional = 0.19, &kappa;2-dimensional = 0.03; p = .268), comminution (&kappa;3-dimensional = 0.41 vs &kappa;2-dimensional = 0.29; p = .133), and impacted fragments (&kappa;3-dimensional = 0.39 vs &kappa;2-dimensional = 0.27; p = .094), and in surgeons\u27 opinions on the need for something other than screws or plate for surgical fixation (&kappa;3-dimensional = 0.31 vs &kappa;2-dimensional = 0.15; p = .138). Interobserver agreement on treatment approach was better with 2-dimensional CT (&kappa;3-dimensional = 0.27, &kappa;2-dimensional = 0.32; p = .015).Conclusions : Three-dimensional CT reconstructions improve interobserver agreement with respect to fracture classification compared with 2-dimensional CT.<br /

Training improves interobserver reliability for the diagnosis of scaphoid fracture displacement

Background The diagnosis of displacement in scaphoid fractures is notorious for poor interobserver reliability.Questions/purposes We tested whether training can improve interobserver reliability and sensitivity, specificity, and accuracy for the diagnosis of scaphoid fracture displacement on radiographs and CT scans.Methods Sixty-four orthopaedic surgeons rated a set of radiographs and CT scans of 10 displaced and 10 nondisplaced scaphoid fractures for the presence of displacement, using a web-based rating application. Before rating, observers were randomized to a training group (34 observers) and a nontraining group (30 observers). The training group received an online training module before the rating session, and the nontraining group did not. Interobserver reliability for training and nontraining was assessed by Siegel&rsquo;s multirater kappa and the Z-test was used to test for significance.Results There was a small, but significant difference in the interobserver reliability for displacement ratings in favor of the training group compared with the nontraining group. Ratings of radiographs and CT scans combined resulted in moderate agreement for both groups. The average sensitivity, specificity, and accuracy of diagnosing displacement of scaphoid fractures were, respectively, 83%, 85%, and 84% for the nontraining group and 87%, 86%, and 87% for the training group. Assuming a 5% prevalence of fracture displacement, the positive predictive value was 0.23 in the nontraining group and 0.25 in the training group. The negative predictive value was 0.99 in both groups.Conclusions Our results suggest training can improve interobserver reliability and sensitivity, specificity and accuracy for the diagnosis of scaphoid fracture displacement, but the improvements are slight. These findings are encouraging for future research regarding interobserver variation and how to reduce it further.<br /

Diagnosis of elbow fracture patterns on radiographs: interobserver reliability and diagnostic accuracy

Item does not contain fulltextBACKGROUND: Studies of traumatic elbow instability suggest that recognition of a pattern in the combination and character of the fractures and joint displacements helps predict soft tissue injury and guide the treatment of traumatic elbow instability, but there is no evidence that patterns can be identified reliably. QUESTIONS/PURPOSES: We therefore determined (1) the interobserver reliability of identifying specific patterns of traumatic elbow instability on radiographs for subgroups of orthopaedic surgeons; and (2) the diagnostic accuracy of radiographic diagnosis. METHODS: Seventy-three orthopaedic surgeons evaluated 53 sets of radiographs and diagnosed one of five common patterns of traumatic elbow instability by using a web-based survey. The interobserver reliability was analyzed using Cohen's multirater kappa. Intraoperative diagnosis was the reference for fracture pattern in calculations of the sensitivity, specificity, accuracy, and positive predictive and negative predictive values of radiographic diagnosis. RESULTS: The overall interobserver reliability for patterns of traumatic elbow instability on radiographs was kappa=0.41. Treatment of greater than five such injuries a year was associated with greater interobserver agreement, but years in practice were not. Diagnostic accuracy ranged from 76% to 93% and was lowest for the terrible triad pattern of injury. CONCLUSIONS: Specific patterns of traumatic elbow instability can be diagnosed with moderate interobserver reliability and reasonable accuracy on radiographs. LEVEL OF EVIDENCE: Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence

Scapula fractures: interobserver reliability of classification and treatment

OBJECTIVES:There is substantial variation in the classification and the management of scapula fractures. The first purpose of this study was to analyze the interobserver reliability of the OTA/AO and the New International Classification of scapula fractures. The second purpose was to assess the proportion of agreement among orthopaedic surgeons on operative or nonoperative treatment. DESIGN:: Web-based reliability study SETTING:: Independent orthopaedic surgeons from several countries were invited to classify scapular fractures in an online survey. PARTICIPANTS:One-hundred and three orthopaedic surgeons evaluated 35 movies of 3DCT-reconstruction of selected scapular fractures, representing a full spectrum of fracture patterns. MAIN OUTCOME MEASUREMENTS:Fleiss' kappa (κ) was used to assess the reliability of agreement between the surgeons. RESULTS:: The overall agreement on the OTA/AO Classification was moderate for the types (A, B, and C, κ = 0.54) with a 71% proportion of rater agreement (PA) as well as for the nine groups (A1 to C3, κ = 0.47) with a 57% PA. For the New International Classification, the agreement about the intra-articular extension of the fracture (Fossa (F), κ = 0.79) was substantial, the agreement about a fractured body (Body (B), κ = 0.57) or process was moderate (Process (P), κ = 0.53), however PAs were more than 81%. The agreement on the treatment recommendation was moderate (κ = 0.57) with a 73% PA. CONCLUSIONS:The New International Classification was more reliable. Body and process fractures generated more disagreement than intra-articular fractures and need further clear definitions