Kappa statistics in the assessment of observer variation: the significance of multiple observers classifying ankle fractures

Studies using kappa statistics have been conducted with a varied but limited number of observers. The aim of this study was to evaluate the significance of multiple observers on kappa as a measure of observer variation. One hundred orthopedic specialists were asked to assess a random sample of ten sets of standard radiographs of 94 consecutive patients with ankle fractures. The observers were randomly allocated into four groups, which again were divided into subgroups with an increasing number of observers. Random subgroups of three observers revealed kappa values from 0.20 to 0.64 in the Lauge-Hansen and 0.27 to 0.90 in the Weber classification system. With an increasing number of observers in the subgroups, kappa stabilizes around a mean value, indicating that the sampling variation and standard error decrease. The standard error found in this study makes kappa questionable as a measure for agreement among a small number of observers. Thus, kappa values obtained for a given diagnostic tool at one department are not directly comparable with results from other departments. We conclude that kappa cannot stand alone as a simple measure of observer variation.

Anterior tibiofibular ligament avulsion fracture in weber type B lateral malleolar fracture

BACKGROUND

The purpose of this study was to determine the incidence, relationship with the ankle diastasis, and effect of treatment of the anterior tibiofibular ligament avulsion fracture (Wagstaffe fracture) combined with the Weber type B lateral malleolar fracture.

METHODS

This study reviewed 94 cases of ankle fractures treated with operative methods.

RESULTS

There were 52 cases of Weber type B lateral malleolar fractures and 13 cases of Wagstaffe fractures combined with them (25%). Ankle diastases were diagnosed in 20 cases (38.5%) in all Weber type B fractures and 11 (84.6%) of the 13 Wagstaffe fractures.

CONCLUSION

The Wagstaffe fracture can be a good diagnostic clue of ankle diastasis in Weber type B lateral malleolar fracture. The accurate reduction and fixation of the avulsed fragment is important for restoration of the stable distal tibiofibular joint and to prevent the chronic ankle joint pain caused by impingement of the avulsed fragment.

The relationship between self-reported and clinical measures and the number of days to return to sport following acute lateral ankle sprains

STUDY DESIGN

This is a prospective observational study.

OBJECTIVE

To determine the relationship of self-reported and clinical measures to the number of days to return to sport following acute lateral ankle sprains.

BACKGROUND

In order to direct rehabilitation, injury classification schemes should include self-reported and clinical measures that help prognosticate the number of days to return to sport (DAYS).

METHODS AND MEASURES

Twenty Division II college athletes (7 men, 13 women; mean age = 19.2 +/- 1.1 years) were assessed following an acute lateral ankle sprain and upon return to sport. Athletes were assessed by three self-reported measures: global function question, Short Form-36 Physical Function scale (SF36PF), visual analog pain scale, and four clinical measures: ankle active range of motion (AROM), ankle dorsiflexion strength, ankle plantar flexion strength, ambulation status. Simple regression, multiple regression, and effect sizes (ES) were used to analyze these data.

RESULTS

The simple regression revealed a statistically significant relationship between DAYS and the global function question (r2 = .22), the SF36PF (r2 = .28), and the patient's ambulation status (r2 = .27). A multiple regression using these three variables in combination was also statistically significant (P = .015) and explained approximately one-third of the variance in DAYS, (r2 = .37). All dependent variables revealed large or moderate ES.

CONCLUSION

Self-reported functional measures in conjunction with the athlete's ambulation status are important factors in predicting the number of days to return to sport following acute lateral ankle sprains. Further research using large sample sizes and other clinical and functional measures is necessary.

Telemark skiing injuries: an 11-year study

This study evaluated telemark injuries in a Swedish ski area in terms of injury ratio, location, and causes over time. During the seasons of 1989-2000 all injured telemark skiers ( n=94) who attended the medical center in Tärnaby, Sweden, within 48 h after the accident were registered and asked to fill in an injury form. A control group of noninjured telemark skiers were interviewed in the season of 1999-2000. The most common cause of injury was fall (70%) and the injury ratio was 1.2. There was a higher proportion of beginners in the injured population, and they had a fall/run ratio of 0.7, compared with 0.3 for average and advanced skiers. Ankle/foot injuries were most common (28% of injuries) followed by knee (20%) and head/neck (17%). The ankle/foot injuries decreased from 35% to 22% in the seasons 1989-1995 to 1995-2000. Beginners had more ankle/foot injuries than skilled participants. The severity of ankle/foot injuries classified as the Abbreviated Injury Scale group 2 or higher decreased from 33% to 21% during the study period. Twenty-seven percent used plastic and 73% leather boots. We found no association between boot material and ankle/foot injuries. The proportion of high boots with two or more buckles was 51%. High boots appeared to be protective against ankle/foot injuries. The proportion of high boots increased from 24% to 67% during the study period. Thus ankle/foot injuries were the most common injury location, but have decreased over time. The severity of these injuries has also decreased. A possible explanation could be the increased use of high boots.

Validation of the Ottawa ankle rules in a Hong Kong ED

The Ottawa ankle rules (OAR) have been validated in many Western countries. However, a recent study performed in an accident and emergency department in Singapore failed to validate the OAR. Therefore, the implementation of the use of OAR in accident and emergency departments in Hong Kong may be treated with skepticism. This prospective study was performed to validate the ordering of radiographs using OAR in Chinese patients with foot and ankle injuries in Hong Kong. Emergency physicians trained in the use of the OAR assessed 773 eligible patients and one hundred thirty-one fractures were identified. The sensitivity and specificity of the OAR for ankle injuries was 98% and 40.8%. For midfoot injuries, the sensitivity and specificity of the OAR was 100% and 43.8%. We concluded that the OAR are applicable in our population with potential advantages for reducing the number of unnecessary investigations and shortening the patients' length of stay in accident and emergency departments.

A comparison of surgical and conservative treatment in ankle ligament tears

Good results have been reported after both primary repair and conservative management of grade III ankle sprains. This prospective study found no advantage of operative treatment compared to taping; no significant differences were found between the groups with regard to objective or subjective stability, functional scores, or the overall result.

[Value of magnetic resonance tomography (MRI) in diagnosis of triplane fractures of the distal tibia]

The rare transitional fractures occur in adolescents at a time of incomplete dosis of the epiphysis. The anatomy of this fracture type is complex with the fracture line running in multiple planes. Conventional plain film radiographs often underestimate the extent and geometry of the fracture due to its transverse components. This study was performed to asses the benefit of MR-imaging compared to plain film radiographs in diagnosis and analysis regarding fracture-type, anatomy and dislocation of fracture. During a time period of 18 months we treated 15 patients with a fracture of the distal tibial epiphysis. In addition to plain film radiographs they got MRI of the distal tibia. Plain film radiographs and MRI were anonymized and diagnosed by 2 surgeons and 2 radiologists. 12 transitional fractures were diagnosed in plain radiographs as well as MRI, but regarding our criteria as above, we found two wrong classifications of fracture-type, an underestimation of fracture dislocation of an average of 0.5 mm in plain film radiographs and two rotational dislocations were missed. The MRI was found to provide anatomical detail and information superior to plain film radiographs.

Chondral and osteochondral injuries. Diagnosis and management

Osteochondral lesions are relatively common and usually occur as a result of trauma. They often are unrecognized acutely and lead to osteochondral defects and eventually osteoarthritis. Detection of these lesions has been aided by bone scan, CT, and MR imaging. Acute osteochondral fragments can be replaced and internally fixed. Chronic osteochondral defects can be treated with several methods designed to stimulate healing by either fibrocartilage or healing by transplantation of bone and cartilage or cartilage alone. The goal of all treatment methods is to provide a stable, congruent joint surface, restore function, and prevent the evolution of osteoarthritis in the injured joint.

Fractures of the ankle: pathogenesis and treatment

From the foregoing, one may reduce the following principles for the management of ankle injuries: The mechanism of injury and the diagnosis, including ligamentous injury, can be made from initial radiographs. A displaced fracture of only one malleolus must be accompanied by ligamentous injury of either the deltoid or syndesmotic ligaments, or both. When there is only one break in the ring of the ankle mortise, there is no potential for significant displacement; thus, ORIF is rarely necessary. With two breaks in the ring, the potential for displacement exists, even after successful manipulation, which usually makes operative treatment a more attractive option. Closed reduction is done by reversing the direction of the injuring forces, though it is not necessary to do so in precise inverse order to their occurrences. When ORIF is used, all significant malleolar fractures should be rigidly fixed to allow early motion, which, along with delayed weight bearing, is especially beneficial when comminution of the articular surface exists. Syndesmotic fixation is usually unnecessary if the malleolar fractures can be reduced anatomically and securely fixed. The reduction, whatever technique is used, should result in full congruency of the ankle mortise and a level joint line. Trimalleolar fractures, especially when they involve more than 25% of the tibial plafond, are much more likely than bimalleolar fractures to be associated with posttraumatic arthritis.

Trimalleolar fracture with a double fragment of the posterior malleolus: a case report and modified operative approach to internal fixation

Fractures of the medial and lateral malleoli are frequently associated with fractures of the posterior malleolus, comprising trimalleolar fractures. The posterior fragment may be posteromedial or posterolateral and its size determines the necessity for surgical or non-surgical treatment. The authors describe a case of trimalleolar fracture with double involvement of the posterior malleolus, both a posteromedial and posterolateral fragment. A modified transmalleolar operative approach for internal fixation is recommended when dealing with such complex trimalleolar fractures of the ankle.

Pure dislocation of the ankle: three case reports and literature review

Ankle dislocation without fracture is an extremely rare injury. The results of treatment are reported for three patients who had a posteromedial open dislocation, a lateral open dislocation, and a posterior closed dislocation of the ankle. Management consisted of immediate reduction, debridement and capsular suture in the open dislocations, and immobilization with a short leg cast in all patients. At followup no patient had tibiotalar joint instability; a 10 degrees to 15 degrees loss in the range of dorsiflexion was observed in two patients. One patient reported paresthesia in the area of the superficial peroneal nerve. The three patients achieved good long-term functional and radiographic results. Predisposing factors that contribute to the pathogenesis of this lesion are internal malleolus hypoplasia, ligamentous laxity, weakness of the peroneal muscles, and previous ankle sprains. Among the three patients, medial malleolus hypoplasia was present in one patient and previous sprains were seen in the clinical history of another patient.

Management of ankle sprains

Without adequate care, acute ankle trauma can result in chronic joint instability. Use of a standardized protocol enhances the management of ankle sprains. In patients with grades I or II sprains, emphasis should be placed on accurate diagnosis, early use of RICE (rest, ice, compression and elevation), maintenance of range of motion and use of an ankle support. Sprains with complete ligament [corrected] tears (grade III) may require surgical intervention. Although early motion and mobility are recommended, ligamentous strength does not return until months after an ankle sprain.

Open reduction and internal fixation of tibial pilon fractures

Although it is evident that the fracture of the tibial plafond is a complex, often debilitating injury, its management is not clear. These injuries generally fall into one of two categories. The low-energy, rotational type of fracture has been shown to have excellent clinical and functional results with open reduction and internal fixation. The high-energy, compression type of fracture has had uniformly moderate results and historically high complication rates. Some authors think that bridging external fixation with or without limited internal fixation should be employed in high-energy fractures. Others believe that open reduction and internal fixation to avoid articular incongruence and development of axial malalignment is needed for good long-term outcome. The authors believe the latter. Staging the treatment of the patient can minimize development of soft tissue complications. The authors follow the recommendations of Patterson and Sirkin and believe that high-energy pilon fractures should be temporized with an external fixator with or without fibular plating to restore length. Any open would should be addressed at this time. Definitive fixation should be planned for between 10 and 14 days, by which time the soft tissue envelop is likely to be ready to accept the further insult of surgery. The surgical technique should be well planned for and include the use of meticulous soft tissue techniques and indirect reduction methods. With the proper attention to detail, long-term results will be maximized.

Limited dorsiflexion predisposes to injuries of the ankle in children

Injuries to the ankle are common in children. We investigated whether decreased dorsiflexion predisposes to such fractures and sprains. Passive dorsiflexion in children with ankle injuries was compared with that in a control group of patients with a normal ankle. The uninjured side was examined to determine flexibility in those patients with ankle injuries. In 82, the mean dorsiflexion was 5.7 degrees with the knee extended and 11.2 degrees with the knee flexed. In 85 controls, the mean dorsiflexion was 12.8 degrees with the knee extended and 21.5 degrees with the knee flexed (p < 0.001, Student's t-test). There was a strong association between decreased ankle dorsiflexion and injury in children. A flexible triceps surae appeared to absorb energy and protect the bone and ligaments, while stiffness predisposed to injury. We suggest that children with tight calf muscles should undergo a regimen of stretching exercises to improve their flexibility.

Incidence of lateral talar dome lesions in SER IV ankle fractures

Osteochondral lesions of the talar dome are commonly the result of ankle trauma. While the technique of surgical repair of ankle fractures has been well reported, there are no studies that correlate the presence or absence of talar dome lesions. A possible explanation for this may be lack of intraoperative inspection of the talar articular surface. This retrospective study evaluates the incidence of lateral talar dome lesions in 50 supination-external rotation stage IV ankle fractures. Specifically, operative reports were reviewed for the presence of lateral talar dome lesions documented through intraoperative inspection. Overall, 19 of 50 fractures, or 38%, were found to have a lateral talar dome lesion. While the bimalleolar and deltoid ligament tear type fractures exhibited more talar dome lesions, there was no significant difference between these two fracture types (p = .1111). There was no statistically significant difference among the three types (unimalleolar, bimalleolar, and trimalleolar) of supination-external rotation ankle fractures (p = .0804). The authors conclude that intraoperative inspection of the lateral talar dome should be a routine part of ankle fracture repair.

The ANK device: a new approach in the treatment of the fractures of the lateral malleolus associated with the rupture of the syndesmosis

The ANK device was developed for the treatment of fractures of the lateral malleolus occurring with rupture of the syndesmosis. While it provides the anatomic reduction of the fracture and the syndesmosis, it allows the physiologic movements of the fibula. It is not used for comminuted fractures of the lateral malleolus and in cases where fibular medullary canal is narrow. We included forty-nine patients who had the ANK device applied and at least 2 years follow-up. The mean follow-up was 41 months (range 24-124). The fractures were evaluated according to the Lauge-Hansen classification; 25 cases were evaluated as supination-external rotation, 11 cases were pronation-abduction, and 13 cases were pronation-external rotation type fractures. There were also 46 fractures of the medial malleolus and three ruptures of the deltoid ligament. Twenty-nine (59,2%) patients were evaluated as excellent, 12 (24,5%) as good, 5 (10.2%) as fair and 3 (6.1%) as poor. Arthrosis was observed in 3 (6.1%) of the patients.

A sample of Chinese literature MRI diagnosis of interosseous membrane injury in Maisonneuve fractures of the fibula

OBJECTIVE

In Maisonneuve fractures of the fibula (MFF) it remains controversial whether there is an injury of the interosseous membrane (IOM) and how severely it ruptures. The author studied injuries to the IOM in MFF by MRI to elucidate this question.

METHOD

Twelve patients were examined with MRI before operation. MRI examination to the leg was performed with knee coil in 2 steps to obtain a complete image of the IOM. Using axial scan, we took T1 (TR500/TE40 msec), T1STIR and T2 sequence. The asymptote side was also examined in three patients as a comparison.

RESULT

IOM was ruptured in a range of 32-112 mm, on average 79 mm proximal to the talar dome in all 12 patients. No IOM rupture was found at the level of high fibular fractures. IOM usually orients at the site 30 mm proximal to the talar dome. Anatomy and rupture of IOM are clearly visualized with T1 (TR500/TE40 msec) STIR sequence; haemorrhage and oedema would be seen better on a T2 image.

CONCLUSION

The injury level of IOM in MFF is only at the distal 1/3 part of the leg; it is not consistent with high fibular fractures. MFF is a special type of pronation-external rotation type, there are four stages in the classification of MFF: 1) injury of medial structures, including medial malleolar fracture or rupture of the deltoid ligament; 2) rupture of the anterior tibiofibular ligament or avulsion fracture of one of its bone insertions, or one associated with interosseous ligament rupture and partial rupture of IOM in the distal 1/3 of the leg; 3) fracture of the proximal part of the fibula; 4) avulsion fracture of the posterior tibial tubercle.

Effect of a semi-rigid ankle stabilizer on performance in persons with functional ankle instability

STUDY DESIGN

Within-group repeated measures.

OBJECTIVES

To determine the effect of a semi-rigid prophylactic ankle stabilizer (PAS) on performance of subjects with post-acute, unilateral ankle sprains who have mechanically stable ankles, but are functionally impaired.

BACKGROUND

Most studies on PAS performance to date are limited to subjects with noninjured, nonimpaired ankles. No research has been reported to determine the effect PASs have on performance in subjects who have a mechanically stable, nonacute ankle sprain with functional impairment.

METHODS AND MEASURES

Twenty-five subjects (8 men and 17 women; average height = 168.91 +/- 33.02 cm, average weight = 61.10 +/- 29.5 kg, and average age = 16.2 +/- 6 years) met the qualification criteria of the study. Subjects had unilateral grade I or II lateral ankle sprains of 3 to 4 weeks duration and were cleared medically to return to activities of daily living. Each subject's injured ankle was mechanically stable as determined by physical exam but was functionally impaired as determined by instability during the modified Rhomberg test. Separate 2 x 2 ANOVAs with repeated measures on brace condition (Aircast SportStirrup and nonbraced control) and test session (test session 1 and test session 2) were completed to assess the effect of ankle stabilization on 2 dependent variables (36.58-m shuttle-run and vertical-jump).

RESULTS

Shuttle-run time was significantly faster for the braced condition (mean = 9.43 +/- .72 seconds) than for the nonbraced control (mean = 9.57 +/- .75 seconds), regardless of test session. Shuttle-run time was significantly faster for test session 2 (mean = 9.43 +/- .79 seconds) than for test session 1 (mean = 9.57 +/- .68 seconds), regardless of brace condition. No significant main or interaction effects occurred for vertical-jump.

CONCLUSIONS

Use of a semi-rigid PAS significantly increased shuttle-run but not vertical-jump performance. This effect was immediate and did not require PAS acclimation.

Measures of functional limitation as predictors of disablement in athletes with acute ankle sprains

STUDY DESIGN

Prospective multivariate design.

OBJECTIVES

To determine the usefulness of activity scores, self-reported athletic ability, and selected measures of physical impairment as predictors of disability duration in athletes with ankle inversion sprains.

BACKGROUND

Although several measures of physical impairment and functional limitation are used to assess the consequences of injury following ankle sprain, researchers have yet to establish which measures provide the most accurate predictions of disability duration.

METHODS AND MEASURES

Physical impairment, activity limitation, and disability duration were measured in 21 athletes (13 men and 8 women; mean age = 20.3 +/- 1.7 years) with acute ankle sprains. Sagittal plane ankle range of motion and volumetric displacement were used as impairment indicators. Weight-bearing activity scores (task completion count) and self-reported athletic ability (visual analog scale) were used to represent functional limitation. Elapsed time from injury to return to full athletic participation was used as the criterion measure of disability duration.

RESULTS

The impairment measures accounted for approximately one-third of the variance in disability duration (R2 = 0.342). Adding the activity limitation measures to the regression model improved predictions of disability duration (R2 = 0.670; stepwise R2 change = 0.328). The measures of activity limitation alone, however, accounted for approximately 67% (R2 = 0.665) of the total variance in the number of days lost due to injury.

CONCLUSION

Measures of activity limitation were the strongest predictors of elapsed time from injury to return to full athletic participation.

Injury toll following the 1997 Maccabiah Games bridge collapse: implications of major disasters for sports medicine teams

A major disaster was encountered at the 1997 Maccabiah Games in Israel. As the Australian team was about to enter the main stadium for the opening ceremony, a pedestrian bridge they were crossing collapsed, killing 4 athletes and injuring many others. The aim of this paper is to establish the rates, types and anatomical locations of musculoskeletal injuries incurred by members of the Australian Maccabiah Games team, with particular reference to the impact of the bridge collapse. In total, the 410 members of the team (360 athletes and coaches and 50 team officials) reported 166 injuries from their participation in sport and 30 musculoskeletal injuries associated with the collapse of the bridge. The most common sports-related injuries were sprains and strains to the hip/thigh, lumbar spine and ankle/foot regions, while the bridge collapse resulted in, most commonly, sprains and contusions to the hip/thigh, knee, lower leg and ankle/foot regions. In addition, team members incurred many medical and psychological conditions. This paper makes several recommendations for sports medicine staff based on the experience of this significant sport disaster.