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

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Impact of Clavicular Shortening after Midclavicular Fracture: A Retrospective Series

Background: Clavicular shortening often occurs after midclavicular fractures and its impact on functional outcomes has thus far been evaluated solely by radiographic and surgeon-based measures, with divergent findings. The goal of this study was to evaluate shoulder function and disability after midclavicular fractures in relation to shortening and compare it with that of healthy individuals and individuals with nonunion.Methods: Seventy-one adult patients (38±14 years) with midclavicular fractures that had been treated nonoperatively were reviewed retrospectively after a mean follow up of 28±15 months.The primary outcome variables were Disabilities of the Arm, Shoulder, and Hand, Constant–Murley, and Cologne clavicle scores. Range of motion was calculated as the difference in degrees between the injured and uninjured sides. Control cohorts of 35 healthy adults and 28 persons with nonunion were assembled. Results: Average shortening was 1.2±0.75 cm. Patients with clavicular shortening of &gt;2 cm (Group 3) had signifi cantly more pain, greater loss of mobility and lower Constant–Murley scores than patients with shortening &lt; 1 cm (Group 1) and healthy controls. Shortening deformity of more than 2 cm associated&nbsp; with Disabilities of the Arm, Shoulder, and Hand, Constant–Murley, and Cologne clavicle equivalent to those of subjects with nonunion. Shortening deformity of more than 2 cm is functionally equivalent to nonunion.Conclusions: Shortening deformities after clavicular fractures in adults greatly impact functional outcomes. Patients perceive a shortening deformity of ≥ 2cm as conferring significant disability. These findings&nbsp; suggest that the goal of therapy for diaphyseal clavicular fractures should be restoration of anatomical&nbsp; length of the clavicle.</p

A Critique of ‘Neoliberal Autonomy’: The Rhetoric of Ownership Society

Ownership Society, Neoliberal(ism), Autonomy, Social Security privatization,