Adult distal radius fractures classification systems: essential clinical knowledge or abstract memory testing?

Assessment of Reproducibility and Agreement of the IDEAL Classification for Distal Radius Fractures

Objective  To analyze the reproducibility and intra- and interobserver agreement of the IDEAL classification for distal radius fractures. Methods  This qualitative, analytical study evaluated 50 pairs of radiographs in two views of patients with distal radius fractures. There were ten observers with different levels of orthopedic training who assessed the radiographs in three different evaluations. The results underwent the Cohen and Fleiss Kappa tests to determine intra- and interobserver agreement levels. Statistical calculations used Excel and SPSS, version 26.0. Results  The Cohen Kappa index values for intraobserver evaluation indicated poor to little agreement (-0.177-0.259), with statistical significance in only one instance. The Fleiss Kappa index values revealed little agreement among the resident group (0.277-0.383) with statistical significance, poor to little agreement among the general orthopedists (0.114-0.225) with statistical significance in most instances, and moderate agreement among hand surgeons (0.449-0.533) with statistical significance. Conclusion  The IDEAL classification had interobserver agreement levels ranging from poor to moderate, influenced by the physicians' training level. Other intraobserver agreement levels ranged from poor to little agreement but without statistical significance.

Certain fracture patterns in children/adolescents would be better called 'Barton equivalent' fractures

We have encountered consecutive children/adolescents with a volar Barton fracture (VBF) pattern without involving the physis. These were managed by buttress plating; thus, we would like to report the radiological and clinical outcomes through retrospective case series and suggest the revisiting of the 'VBF category' in this population. We screened children/adolescents with a diagnosis of trauma to the bony structures in the wrist from 2008 to 2019. Of these patients, 16 who met our inclusion/exclusion criteria were investigated. At the final follow-up performed at least 2 years postoperatively, radiologic and clinical outcomes were evaluated. The mean age at the time of injury was 12.88 years old. At the final follow-up, the volar tiltings, radial inclinations and ulnar variances were 10.13°, 20.88° and -0.50 mm, respectively. None of these radiologic parameters were significantly different from the contralateral values, except the radial inclination. The mean visual analog scale score was 0.38. The mean range of motion arcs were 136.56° and 157.81° in the flexion-extension and pronation-supination arcs, respectively, and the grip strength was 22.00 kg. The mean modified Mayo Wrist Score was 92.8. The radiologic and clinical outcomes compared with the contralateral side were not significantly different from those in a previous report. A VBF pattern without involving the physis in the child/adolescent population was treated satisfactorily by buttress plating. Thus, including the previously reported 'SH-II in sagittal plane' injuries, the current injury pattern would be better called a 'Barton equivalent' fracture. Level of Evidence: Level IV, retrospective case series.

Topology-Optimized Splints vs Casts for Distal Radius Fractures: A Randomized Clinical Trial

Importance

To date, there is currently no evidence-based medical support for the efficacy of topology-optimized splints in treating distal radius fractures.

Objective

To assess the clinical efficacy and complication rates of topology-optimized splints in the treatment of distal radius fractures after closed manual reduction.

Design, Setting, and Participants

This 12-week, multicenter, open-label, analyst-blinded randomized clinical trial (comprising a 6-week intervention followed by a 6-week observational phase) was carried out from December 3, 2021, to March 10, 2023, among 110 participants with distal radius fractures. Statistical analysis was performed on an intention-to-treat basis between June 3 and 30, 2023.

Intervention

Participants were randomly assigned to 2 groups: the intervention group received topology-optimized splint immobilization and the control group received cast immobilization after closed manual reduction for 6weeks. After this period, immobilization was removed, and wrist rehabilitation activities commenced.

Main Outcomes and Measures

The primary outcome was the Gartland-Werley (G-W) wrist score at 6 weeks (where higher scores indicate more severe wrist dysfunction). Secondary outcomes encompassed radiographic parameters, visual analog scale scores, swelling degree grade, complication rates, and 3 dimensions of G-W wrist scores.

Results

A total of 110 patients (mean [SD] age, 64.1 [12.7] years; 89 women [81%]) enrolled in the clinical trial, and complete outcome measurements were obtained for 101 patients (92%). Median G-W scores at 6 weeks were 15 (IQR, 13-18) for the splint group and 17 (IQR, 13-18) for the cast group (mean difference, -2.0 [95% CI, -3.4 to -0.6]; P = .03), indicating a statistically significant advantage for the splint group. At 12 weeks, no clinically significant differences in G-W scores between the 2 groups were observed. Complication rates, including shoulder-elbow pain and dysfunction and skin irritation, were less common in the splint group (shoulder-elbow pain and dysfunction: risk ratio, 0.28 [95% CI, 0.08-0.93]; P = .03; skin irritation: risk ratio, 0.30 [95% CI, 0.10-0.89]; P = .02).

Conclusions and Relevance

Findings of this randomized clinical trial suggest that patients with distal radius fractures that were managed with topology-optimized splints had better wrist functional outcomes and fewer complications at 6 weeks compared with those who received casting, with no difference at week 12. Therefore, topology-optimized splints with improved performance have the potential to be an advisable approach in the management of distal radius fractures.

Trial Registration

Chinese Clinical Trial Registry: ChiCTR2000036480.

Managing the Extra-Articular Distal Radius Malunion

Distal radius fractures are common injuries. Satisfactory outcomes are typically achieved with appropriate nonoperative or operative treatment. A proportion of these injuries develop symptomatic malunions, which may be treated surgically with distal radius corrective osteotomy. A thorough understanding of the anatomy, biomechanics, radiographic parameters, and indications is needed to provide appropriate treatment. Factors, including surgical approach, osteotomy type, use of bone graft, fixation construct, management of associated tendon and/or nerve conditions, soft tissue contracture releases, and need for ulnar-sided procedures, should be considered. A comprehensive evaluation is necessary to guide understanding for when salvage procedures may be preferred.

Distal radius fractures: Classifications concordance among orthopedic residents on a teaching hospital

BACKGROUND

Several classification systems have been developed to support orthopedic surgeons regarding diagnostic, treatment, or prognostic outcomes of distal radius fracture (DRF). However, the best classification system for this fracture remains controversial. We aimed to identify the reliability of three different DRF classifications among orthopedists in training (medical residents).

METHODS

Orthopedic residents (n = 22) evaluated thirty cases of DRF in anteroposterior and lateral projections in three different periods (0, 6, 12 months). Each radiography was sorted with three different classifications: Frykman, AO/OTA, and Jupiter-Fernandez. All assessments were blinded to the investigators. The inter- and intra-observer reliability was evaluated using the Cohen's kappa coefficient. An additional analysis was performed for a simpler sub-classification of the AO/OTA (27, 9, or 3 groups).

RESULTS

Inter-observer agreement for AO/OTA, Frykman, and Jupiter-Fernandez classifications was slight (k = 0.15), fair (k = 0.31), and fair (k = 0.30), respectively. Intra-observer agreement showed similar results: AO/OTA, k = 0.14; Frykman, k = 0.28; and Jupiter-Fernandez, k = 0.28. When the AO/OTA classification was simplified (9 or 3 descriptions), the inter-observer agreement improved from slight (k = 0.16) to fair (k = 0.21 and k = 0.30, respectively). A similar improvement from slight (k = 0.14) to fair (k = 0.32 and k = 0.21) was detected for intra-observer agreement.

CONCLUSIONS

The more complex the DRF classification system, the more complex is to reach reliable inter- and intra-observer agreements between orthopedic trainees. Senior residents did not necessarily show greater kappa values in DRF classifications.

Frykman VIII Fracture Secondary to Falling Onto an Outstretched Hand (FOOSH)

This is the case of a 41-year-old woman who presented with pain in the wrist after a fall from her bicycle, after which she tried to block her fall by outstretching her hand. She sustained a Frykman VIII fracture, with a fracture of the distal radius and ulnar styloid. Her labs were unremarkable, and she had no previous medical history. Her case was an example of a classic fracture due to FOOSH (falling onto an outstretched hand) which can easily be avoided by learning how to break falls properly. The patient's symptoms, diagnosis, treatment, and ways to avoid this injury are presented.

Outcome Analysis of Adult Distal Radius Fractures Managed during COVID-19 Pandemic

Introduction

COVID-19 pandemic created extreme pressure situation on health care services across the globe with shortage of medical staff and beds. The management of fragility fracture also affected significantly. The distal radius fractures (DRFs) are one of the common frailty fractures. There was a significant shift in the treatment of such injuries with new guidelines leaning toward more of non-operative management.

Case Report

A retrospective cross-sectional study of DRFs (DRF) treated during COVID pandemic for a period of 1 year in the United Kingdom. This included all radiologically confirmed cases of DRFs with isolated adult injuries excluding polytrauma, same limb other injuries, associated neurovascular injuries, and age below 18 years. All patient's data were collected from hospital records retrospectively from April 2020 to March 2021. There were a total of 179 patients with distal radius fracture, of which 141 (78.8%) were females and 38 (21.2%) males. The mean age was 68.2 years (SD 68.20 ± 15.63) and there were greater number of patients with intra-articular fracture. There were 28.5% (Grades 1 and 2, Group I) extra-articular fractures; 69.8% (Grades 3-8, Group II) were intra-articular fractures and 3 Barton's fractures (Group III) accounted to 1.7%. 137 patients were (76.5%) treated to non-operatively and 42 (23.5%) were treated surgically. 135 (75.4%) patients had good and 43 (24%) satisfactory clinical outcomes. 3 (1.6%) patients required osteotomy for malunited fractures. Fracture grade I and II is significantly associated with non-operative procedure (100.0% vs 84.3%) with P < 0.001.

Conclusion

This study confirmed that non-operative treatment is still a good option even in intra-articular fractures. Surgical fixation should be considered in young patients and those with higher grade of fracture classification and greater angulation at presentation. A virtual physiotherapy is still a good option.

Performance of ChatGPT, human radiologists, and context-aware ChatGPT in identifying AO codes from radiology reports

While radiologists can describe a fracture's morphology and complexity with ease, the translation into classification systems such as the Arbeitsgemeinschaft Osteosynthesefragen (AO) Fracture and Dislocation Classification Compendium is more challenging. We tested the performance of generic chatbots and chatbots aware of specific knowledge of the AO classification provided by a vector-index and compared it to human readers. In the 100 radiological reports we created based on random AO codes, chatbots provided AO codes significantly faster than humans (mean 3.2 s per case vs. 50 s per case, p < .001) though not reaching human performance (max. chatbot performance of 86% correct full AO codes vs. 95% in human readers). In general, chatbots based on GPT 4 outperformed the ones based on GPT 3.5-Turbo. Further, we found that providing specific knowledge substantially enhances the chatbot's performance and consistency as the context-aware chatbot based on GPT 4 provided 71% consistent correct full AO codes for the compared to the 2% consistent correct full AO codes for the generic ChatGPT 4. This provides evidence, that refining and providing specific context to ChatGPT will be the next essential step in harnessing its power.

Coronal translation of the forearm, proximal capitate, and ulnar styloid predict radial inclination in distal radius fractures in older female patients

Aims

The aims of this study were to identify means to quantify coronal plane displacement associated with distal radius fractures (DRFs), and to understand their relationship to radial inclination (RI).

Methods

From posteroanterior digital radiographs of healed DRFs in 398 female patients aged 70 years or older, and 32 unfractured control wrists, the relationships of RI, quantifiably, to four linear measurements made perpendicular to reference distal radial shaft (DRS) and ulnar shaft (DUS) axes were analyzed: 1) DRS to radial aspect of ulnar head (DRS-U); 2) DUS to volar-ulnar corner of distal radius (DUS-R); 3) DRS to proximal capitate (DRS-PC); and 4) DRS to DUS (interaxis distance, IAD); and, qualitatively, to the distal ulnar fracture, and its intersection with the DUS axis.

Results

In the study (fracture) and control groups, respectively, the mean values were: RI, 17.2° (SD 7.2°; -7° to 35°) and 25.6° (SD 2.6°; 21° to 30°); DRS-U, 13.5 mm (SD 1.7; 4.9 to 20.8) and 15.3 mm (SD 0.72; 13.8 to 16.3); DUS-R, 13.4 mm (SD 2.1; 4.8 to 18.5) and 12.0 mm (SD 0.99; 9.7 to 13.9); DRS-PC (positive value radial to DRS, negative value ulnar), 0.14 mm (SD 5.4; -10.9 to 22.7) and -6.1 mm (SD 1.6; -10.6 to -2.3); and IAD, 25.3 mm (SD 2.5; 17.6 to 31.1) and 27.1 mm (SD 1.5; 24.5 to 31.0). All means were significantly different between the study and control groups. RI correlated strongly with DRS-PC. Ulnar styloid fracture intersection with the DUS axis, reflective of ulnar translation of both radial and ulnar shafts, was associated with significantly lower RI.

Conclusion

After DRF, the relationship of the proximal capitate to the DRS axis in the coronal plane correlates with the final radial inclination. Additionally, ulnar styloid intersection with the DUS axis is associated with even lower radial inclination. DRF reduction should seek to restore the normal coronal relationship of both radial and ulnar shafts to their distal counterparts.

Three Column Fixation Through a Single Incision in Distal Radius Fractures

Purpose  The purpose of this study was to evaluate the clinical and functional results of 67 patients with distal radius fracture (DRF), treated with a modified surgical technique that allows three-column fixation through the same palmar approach. Patients and Methods  Between 2014 and 2019, we treated 67 patients using a particular surgical technique. All patients suffered DRF, classified using the universal classification system. Two different intervals were developed palmary: the first ulnarly to the flexor carpi radialis tendon for direct visualization of the distal radius and the second one radially to the radial artery for direct visualization of the styloid process. An anatomic volar locking compression plate was applied to all patients. The radial styloid process was fixed and stabilized either with Kirschner-wires or an anatomic plate through the same incision. Functional results were evaluated based on the Disabilities of the Arm, Shoulder and Hand and Mayo wrist scores. Range of motion and grip strength of the injured wrist were statistically compared with the opposite side. Results  The mean follow-up was 47 months (13-84). All fractures were united, and all patients recovered to the preinjury level of activity. The mean flexion-extension range was 73.8° to 55.2° and the supination-pronation range 82.8° to 67°. No infection or nonunion occurred. No major complications were reported. Conclusion  Open reduction and internal fixation, under specific indications, is the best treatment option in DRF. The described technique provides excellent visualization to the distal radius surfaces and allows the internal fixation of the radial columns through the same skin incision. Therefore, it can constitute an efficient choice in the treatment armamentarium of DRF.

Comparison of the Effects of Regular Periods of Immobilization and Prolonged Immobilization on Hand Function Post Distal Radial Fracture

Introduction Distal radius fracture (DRF) is one of the most common orthopedic cases managed in the emergency room. DRF treatment is either non-operative or operative. Regardless of the treatment methodology, a period of immobilization of 4-6 weeks is required. Purpose The study aims to evaluate hand function for patients who sustained DRF with different immobilization periods in King Abdul-Aziz Medical City, National Guard Hospital - Jeddah (NGHA) from December 2016 until December 2019. Materials and methods This is a retrospective cohort study where we collected data of DRF patients managed in NGHA. Data was collected directly from NGHA medical records (December 2016-December 2019). A total of 44 patients met the inclusion criteria. Patients were divided into two groups; a group that was immobilized as per protocol (six weeks) and a group that deviated from protocol and immobilization exceeded six weeks. A data collection sheet included the patient's demographics, history, fracture description, management method, and hand function measurements. Results Of the 44 participants, 24 (54%) deviated from protocol; the remaining 20 (46%) were immobilized as per protocol. The prolonged immobilization group had limitations in hand function, restriction in extension (P-value = 0.641), and a decrease in grip strength (P-value = 0.291) compared to the per-protocol group. Flexion and radial deviation were affected similarly in both groups. Conclusion Although the results were not significant, immobilization for more than six weeks is associated with decreased hand function, range of motion (ROM), grip strength, and higher pain scores based on occupational therapy (OT) measurements.

Evaluation of Intra- and Interobserver Reproducibility of the New AO/OTA Classification for Distal Radius Fractures Compared with the Fernandez Classification

Objective  To evaluate the inter- and intraobserver reliability and reproducibility of the new AO/OTA 2018 classification for distal radius fractures and to compare it with the Fernandez classification system. Method  A questionnaire was applied in the Qualtrics software on 10 specialists in hand surgery who classified 50 radiographs of distal radius fractures according to the Fernandez and AO/OTA 2018 classifications and, subsequently, indicated their treatment. The questionnaire was applied in time T0 and repeated after 4 weeks (t1) . The mean agreement between the answers, and the reliability and inter- and intraobserver reproducibility were analyzed using kappa indexes. Results  The mean interobserver agreement in the Fernandez classification was 76.4, and it was 59.2% in the AO/OTA 2018 classification. The intraobserver agreements were 77.3 and 56.6%, respectively. The inter- and intraobserver kappa indexes for the Fernandez classification were 0.57 and 0.55, respectively, and, in the AO/OTA 2018 classification, they were 0.34 and 0.31, respectively. Conclusion  The AO/OTA 2018 classification showed a low intra- and interobserver reproducibility when compared with the Fernandez classification. However, both classifications have low intra- and interobserver indexes. Although the Fernandez classification did not obtain excellent results, it remains with better agreement for routine use.

Computed Tomography and Pathobiomechanical-Based Treatment of Volar Distal Radius Fractures

Today, there are various classifications for distal radius fractures (DRF). However, they are primarily based on plain radiographs and do not provide sufficient information on the best treatment option. There are newer classifications that simultaneously consider the pathobiomechanical basis of the fracture mechanism and analysis of computed tomography images. Main determinants of which type of DRFs occurs are the strength/direction of the applied forces on the carpus and radius, and the position of the wrist relative to the radius during the fall. Reconstruction of the mechanism of injury provides information about which anatomic structures are involved, such as torn ligaments, bone fragments, and the dislocated osteoligamentous units. This article attempts to combine and modify current pathobiomechanically oriented classifications with an improved understanding of the "key fragments" to subsequently offer a treatment approach to stabilize these critical fragments through specific types of internal fixation.

Variations in Strain Distribution at Distal Radius under Different Loading Conditions

Distal radial fractures exhibit various fracture patterns. By assuming that the strain distribution at the distal radius affects the diversification of the fracture pattern, a parameter study using the finite element model of a wrist developed from computed tomography (CT) images was performed under different loading conditions. The finite element model of the wrist consisted of the radius, ulna, scaphoid, lunate, triquetrum, and major carpal ligaments. The material properties of the bone models were assigned on the basis of the Hounsfield Unit (HU) values of the CT images. An impact load was applied to the scaphoid, lunate, and triquetrum to simulate boundary conditions during fall accidents. This study considered nine different loading conditions that combine three different loading directions and three different load distribution ratios. According to the analysis results, the strain distribution at the distal radius changed with respect to the change in the loading condition. High strain concentration occurred in regions where distal radius fractures are commonly developed. The direction and distribution of the load acting on the radius were considered to be factors that may cause variations in the fracture pattern of distal radius fractures.

Wrist fracture management and the role of surgical care practitioner through the patient's journey

The presentation of this case study involves an exploration of the patient's journey in detail after having a traumatic wrist fracture, which is recognised as one of the most common fractures encountered daily in emergency services by junior doctors and practitioners. However, this article not only analyses the medical guidance for this type of case, but also the importance of the surgical care practitioner role in trauma and orthopaedics. All practitioners attending patients in emergency services are required to develop a good knowledge of anatomy, physiology, patient's examination technique, classifications and consequently being aware of the possible surgical options for treatment of the fracture. They will also need to fully understand the legal implications of consent to ensure safe practice.

Kirschner Wire Fixation of Distal Radius Fractures, Indication, Technique and Outcomes

Distal radius fractures are the most common upper extremity fracture that present to US emergency departments. Given the variable presentation, including age and fracture pattern, there are many techniques that have been utilized to treat them. Closed reduction and percutaneous pin (CRPP) fixation remains a viable option in extra-articular and simple intra-articular fracture patterns. CRPP techniques flourished in the mid-twentieth century until the treatment patterns shifted to primarily volar-locked plating in the twenty-first century. Although several meta-analyses have been performed comparing outcomes and complications of CRPP versus alternative methods, controversy remains over which treatments are superior.

Artificial intelligence for the detection of vertebral fractures on plain spinal radiography

Vertebral fractures (VFs) cause serious problems, such as substantial functional loss and a high mortality rate, and a delayed diagnosis may further worsen the prognosis. Plain thoracolumbar radiography (PTLR) is an essential method for the evaluation of VFs. Therefore, minimizing the diagnostic errors of VFs on PTLR is crucial. Image identification based on a deep convolutional neural network (DCNN) has been recognized to be potentially effective as a diagnostic strategy; however, the accuracy for detecting VFs has not been fully investigated. A DCNN was trained with PTLR images of 300 patients (150 patients with and 150 without VFs). The accuracy, sensitivity, and specificity of diagnosis of the model were calculated and compared with those of orthopedic residents, orthopedic surgeons, and spine surgeons. The DCNN achieved accuracy, sensitivity, and specificity rates of 86.0% [95% confidence interval (CI) 82.0-90.0%], 84.7% (95% CI 78.8-90.5%), and 87.3% (95% CI 81.9-92.7%), respectively. Both the accuracy and sensitivity of the model were suggested to be noninferior to those of orthopedic surgeons. The DCNN can assist clinicians in the early identification of VFs and in managing patients, to prevent further invasive interventions and a decreased quality of life.

A new classification of impacted proximal humerus fractures based on the morpho-volumetric evaluation of humeral head bone loss with a 3D model

BACKGROUND

This study aimed to classify the pathomorphology of impacted proximal humeral fractures according to the control volume theory, with the intention to introduce a severity index to support surgeons in decision making.

METHODS

In total, 50 proximal humeral fractures were randomly selected from 200 medical records of adult patients treated from 2009 to 2016. Four nonindependent observers used 2 different imaging modalities (computed tomography scans plus volume rendering; 3D model) to test the classification reliability. A fracture classification system was created according to the control volume theory to provide simple and understandable patterns that would help surgeons make quick assessments. The impacted fractures table was generated based on an evaluation of the calcar condition, determined by the impairment of a defined volumetric area under the cephalic cup and the humeral head malposition. In addition to the main fracture pattern, the comminution degree (low, medium, high), providing important information on fracture severity, could also be evaluated.

RESULTS

From 3D imaging, the inter- and intraobserver reliability revealed a k value (95% confidence interval) of 0.55 (0.50-0.60) and 0.91 (0.79-1.00), respectively, for the pattern code, and 0.52 (0.43-0.76) and 0.91 (0.56-0.96), respectively, for the comminution degree.

CONCLUSIONS

The new classification provides a useful synoptic framework for identifying complex fracture patterns. It can provide the surgeon with useful information for fracture analysis and may represent a good starting point for an automated system.

Higher Mortality in Men Compared with Women following Distal Radius Fracture in Population Aged 50 Years or Above: Are Common Distal Radius Fracture Classifications Useful in Predicting Mortality?

Introduction

Distal radius fractures (DRF) are one of the most common fractures with growing incidence in developed countries and are a reliable predictor of another osteoporotic fracture. Data concerning DRF mortality are conflicting and vague. Usefulness of common DRF classification systems in predicting mortality is unexplored.

Methods

We identified all patients hospitalized between January 1^st 2008 and May 30^th 2015 with isolated distal radius fracture, aged 50 y/o or above, in a 1^st level trauma center in Poland. Fractures were evaluated according to AO, Frykman, and Fernandez classifications. Mortality ratios and long-term survival analysis with Kaplan-Meier estimator and log-rank tests with univariate and multivariate Cox proportional hazards model were used.

Results

We enrolled 1308 consecutive patients. The average age of the entire cohort was 72.5 ± 12 years. The study group consisted of 256 men (19.6%) with mean age 66 ± 12 y/o and 1052 women (80.4%) with mean age 74 ± 12 y/o. Men were statistically younger at the time of the fracture than women (p<0.0001). After 1-year follow-up the overall study group mortality ratio was 4.5%, being 2.2-fold higher in men compared to women. In long-term survival analysis, excess men mortality remained significant. Factors associated with higher mortality at any point of the study were age (HR: 1.08, 95%CI: 1.07-1.10, p<0.000001), male sex (HR: 1.92, 95%CI: 1.34-2.77; p<0.001), AO type A (HR: 1.64 95%CI 1.19-2.25, p<0.01), and Frykman type I (HR: 2.12 95%CI: 1.36-3.29, p<0.001).

Conclusion

Distal radius fractures are connected with premature mortality. Men have higher mortality compared with women following distal radius fracture in population aged 50 years or above. Simple extra articular fractures classified as AO type A or Frykman type I may be predictors of higher mortality in DRF cohort.

Distal radius fractures are difficult to classify

BACKGROUND

Traditionally, distal radius fractures (DRFs) have been described using eponyms, e.g. Colles, Smith, Barton, Chauffeur. During the last half of the 20^th century several classification systems for DRF have emerged. We evaluated the inter- and intra-observer agreement of the AO/OTA, Frykman and Older classification systems.

METHODS

Four observers, an intern, an orthopaedic registrar, an orthopaedic consultant and a radiology consultant, independently evaluated DRF radiograms and classified the fractures according to the AO/OTA, Frykman and Older classification systems. After an interval of 6 months, radiograms of 30 randomly chosen patients were re-evaluated by the same observers.

RESULTS

Radiograms of 573 DRF patients were evaluated in the study. The inter-observer reliability of the AO/OTA fracture types (A, B and C) was 'weak' (kappa = 0.45). The agreement dropped to 'minimal' (kappa = 0.24) regarding the AO/OTA groups (A2, A3, B1, B2, B3, C1, C2 and C3). The reliability of the Frykman classification system was 'weak' (kappa = 0.41), and we observed the lowest inter-observer reliability for the Older classification system (kappa = 0.10). The kappa values for the intra-observer reproducibility of the AO/OTA fracture types (A, B and C) ranged from 0.58 to 0.87. For the AO/OTA groups (A2, A3, B1, B2, B3, C1, C2 and C3) the reproducibility was lower ranging from 'minimal' to 'weak'. The intra-observer reproducibility of the Frykman system was 'weak' to 'moderate' and even worse for the Older classification system.

CONCLUSION

Based on these findings the AO/OTA classification system seems to be most reliable for routine use, however, with lower kappa values concerning the agreement for the groups. The Frykman and Older classification systems cannot be recommended because of less convincing results.

Artificial intelligence for analyzing orthopedic trauma radiographs

Background and purpose - Recent advances in artificial intelligence (deep learning) have shown remarkable performance in classifying non-medical images, and the technology is believed to be the next technological revolution. So far it has never been applied in an orthopedic setting, and in this study we sought to determine the feasibility of using deep learning for skeletal radiographs. Methods - We extracted 256,000 wrist, hand, and ankle radiographs from Danderyd's Hospital and identified 4 classes: fracture, laterality, body part, and exam view. We then selected 5 openly available deep learning networks that were adapted for these images. The most accurate network was benchmarked against a gold standard for fractures. We furthermore compared the network's performance with 2 senior orthopedic surgeons who reviewed images at the same resolution as the network. Results - All networks exhibited an accuracy of at least 90% when identifying laterality, body part, and exam view. The final accuracy for fractures was estimated at 83% for the best performing network. The network performed similarly to senior orthopedic surgeons when presented with images at the same resolution as the network. The 2 reviewer Cohen's kappa under these conditions was 0.76. Interpretation - This study supports the use for orthopedic radiographs of artificial intelligence, which can perform at a human level. While current implementation lacks important features that surgeons require, e.g. risk of dislocation, classifications, measurements, and combining multiple exam views, these problems have technical solutions that are waiting to be implemented for orthopedics.

The role of brachioradialis release during AO type C distal radius fracture fixation

INTRODUCTION

Open reduction and internal fixation of distal radius fractures often necessitates release of the brachioradialis from the radial styloid. However, whether this common procedure makes the reduction and fixation easier and affects the elbow function has not been fully understood.

HYPOTHESIS

Brachioradialis (BR) release during volar plate fixation for type C distal radius fractures makes internal reduction and fixation easier, and it does not adversely affect wrist or elbow function.

MATERIAL AND METHODS

A total of 74 patients treated with 2.4mm volar locking compression column plate (VCP) were analyzed for type C distal radius fractures prospectively. The patients were divided into two groups, group A with BR release and group B without BR release. The two groups were compared in terms of "internal reduction and fixation time" during the operation, wrist and elbow function including the scores of Gartland and Werley (G-W), Patient-related wrist evaluation score (PRWE), Mayo Elbow Performance Score (MEPS), the Disabilities of the arm, shoulder, and hand (DASH) and a Visual analog scale (VAS) for pain at 6 and 12 months postoperatively. The radial inclination angle, palmar tilt angle and ulnar variance were also measured from the radiographs.

RESULTS

According to the follow-up of the 74 patients, no significant differences were observed between the two groups on MEPS, DASH, G-W, PRWE, VAS and radiological outcomes at 6 and 12 months postoperatively. Mean time of reduction and internal fixation was significantly shorter in group A than that in group B.

CONCLUSION

Release of the BR for type C distal radius fractures facilitated the surgical procedure and did not adversely affect elbow and wrist function.

LEVEL OF EVIDENCE

II, prospective comparative study.