The influence of three-dimensional computed tomography reconstructions on the characterization and treatment of distal radial fractures

The Role of Computed Tomography and Radiographs in the Management of Intertrochanteric Fractures

Introduction

The Intertrochanteric fracture is a common hip trauma encountered in elderly patients. There is a lack of general agreement regarding its surgical management and choice of implant. Purpose of this study to conclude the final decision matrix regarding surgical management of intertrochanteric fractures based on parameters assessed on plain radiographs and CT scan.

Materials and methods

We have retrospectively evaluated 55 patients with intertrochanteric fractures presented to our institute after informed consent with radiographs and CT scans between July 2017 to July 2018. Assessment of various parameters regarding fracture geometry and classification as well as measurement was done.

Results

Mean lateral wall thickness in present study was 20.76mm. Incidence of coronal fragments was 90.9% and absence of coronal fragment in 5 patients. We noted the cases with anterior comminution had also a posterior comminution rendered the fracture unstable in almost 20 % cases.

Conclusion

Better understanding of fracture geometry by combined used of radiograph and CT scan enhanced preoperative planning, choice of suitable implant, helps in reduction manoeuvre and improving quality of osteosynthesis.

Cone-beam computed tomography in the treatment of distal radius fractures

Cone-beam computed tomography (CBCT) is a relatively new imaging technique in hand surgery. Being the most common fractures in adults, distal radius fractures are of special importance not only to hand surgeons. The quantity alone calls for fast, efficient and reliable diagnostic procedures. Surgical techniques and possibilities are progressing, especially regarding intra-articular fracture patterns. The demand for exact anatomic reduction is high. There is an overall consensus regarding the indication for preoperative three-dimensional imaging and it is frequently used. Typically, it is obtained by multi-detector computed tomography (MDCT). Postoperative diagnostic procedures are usually limited to plain x-rays. Commonly accepted recommendations regarding postoperative 3D imaging are not yet established. There is a lack of relevant literature. In case of an indication for a postoperative CT scan, it is generally also obtained by MDCT. CBCT for the wrist is not widely used as yet. This review focuses on the potential role of CBCT in the perioperative management of distal radius fractures. CBCT allows for high-resolution imaging with a potentially lower radiation dose compared with MDCT, both with and without implants. It is easily available and can be operated independently, thus being time-efficient and making daily practice easier. Due to its many advantages, CBCT is a recommendable alternative to MDCT in the perioperative management of distal radius fractures.

Poor reliability and reproducibility of 3 different radiographical classification systems for distal ulna fractures

BACKGROUND AND PURPOSE

Classification of fractures can be valuable for research purposes but also in clinical work. Especially with  are fractures, such as distal ulna fractures, a treatment algorithm based on a classification can be helpful. We compared 3 different  classification systems of distal ulna fractures and investigated their reliability and reproducibility.

PATIENTS AND METHODS

patients with 97 fractures of the distal ulna, excluding the ulnar styloid, were included. All fractures were  independently classified by 3 observers according to the classification by Biyani, AO/OTA 2007, and AO/OTA 2018. The classification process was repeated after a minimum of 3 weeks. We used Kappa value analysis to determine inter- and intra-rater agreement.

RESULTS

The inter-rater agreement of the AO/OTA 2007 classification was judged as fair, ĸ 0.40, whereas the agreement of AO/OTA 2018 and Biyani was moderate at ĸ 0.42 and 0.43 respectively. The intra-rater agreement was judged as moderate for all classifications.

INTERPRETATION

The differences between the classifications were small and the overall impression was that neither of them was good enough to be of substantial clinical value. The Biyani classification, being developed specifically for distal ulna fractures, was the easiest and most fitting for the fracture patterns seen in our material, but lacking options for fractures of the distal diaphysis. Standard radiographs were considered insufficient for an accurate classification. A better radiographic method combined with a revised classification might improve accuracy, reliability, and reproducibility.

Distal radius fractures

The management of distal radius fractures has evolved considerably in the last two decades. Techniques and hardware have improved so much that the surgeon can usually assure good results in these debilitating fractures. Yet no one method can be used for all injuries, as the personality of each fracture demands a customized approach. Furthermore, what works in one age group may not work in another. For this reason, every available treatment has its own space in our options. The need for surgeons to be well versed in all techniques is critical. We offer a concise update of important evolutionary and current treatment guidelines for this common fracture.

Assessment of Usefulness of CT Scan in AO Classification of Intertrochanteric Fractures: A Prospective Observational Study

OBJECTIVE

The sliding hip screw (SHS) is the gold standard for the management of stable intertrochanteric (IT) fractures. However, intramedullary implants are now being increasingly used for management of unstable IT fractures especially those with a compromised or vulnerable lateral wall. Therefore, accurate classification of fracture is important to ensure proper surgical planning and choice of implant. The AO classification for IT fractures is based on plain radiographs alone and many authors have reported it to have poor inter- and intra-observer agreement. Therefore, the objectives of the study were to assess the improvement in inter- and intra-observer agreement of the AO classification after addition of CT scan to plain radiographs, to assess the change in pattern of AO classification on addition of CT scan to plain radiographs and to assess percentage of times, stable lateral wall seen on plain radiographs is classified as unstable or broken on CT scans.

METHOD

Fifty-four patients of intertrochanteric fracture were included in study. Plain radiographs of patients were shown to three orthopedic surgeons. They were asked to document the AO classification of the fracture, and comment on the integrity of the lateral wall. Then, CT scans with 3D reconstructions of the same patients were provided along with the radiographs and they were asked to classify the fracture again. Inter- and intra-observer agreement of the AO classification based on plain radiographs alone and once CT scan with 3D reconstruction was added to the plain radiographs was determined using Kappa coefficients. Pattern of change in classification on addition of CT scan to plain radiographs was also assessed.

RESULT

The mean kappa value for inter- and intra-observer agreement for AO classification on plain radiographs alone were 0.58 (moderate) and 0.66 (substantial), respectively. Upon addition of CT scan to plain radiographs, both improved to 0.70 (substantial) and 0.77 (substantial), respectively. The AO classification of the fracture changed 28.70% times (93 of 324 observations) upon addition of CT scan to plain radiographs. 96.77% times (90 of 93 observations) the classification was upgraded to higher group, while it was downgraded in only 3.22% times (3 of 93). 55.91% times this change was observed in AO 31 A 2 group (52 of 93 observations). In 17.59% cases (57 of 324 observations), fractures which were classified as stable (A1.1-A2.1) on radiographs alone, were reclassified as unstable (A2.2-3.3) upon addition of CT scan to plain radiographs. In 11.4% cases (37 of 324 observations), the lateral wall was classified as vulnerable or broken on CT scans where it was classified intact on plain radiographs.

CONCLUSION

Addition of CT scans with 3D reconstructions to plain radiographs improves the intra- and inter-observer agreement of the AO classification. Addition of CT scan results in change in classification of the fracture in about one out of three cases. This most commonly happens in the AO 31 A 2 group. Most of the times, this results in the classification of fracture being upgraded. Many fractures which are initially classified as stable (A1.1-A2.1) on radiographs are reclassified as unstable (A2.2-3.3) on addition of CT scans. The lateral wall is also classified as vulnerable or broken more number of times on CT scans than plain radiographs alone. Therefore, we conclude that CT scan with 3 D reconstructions definitely helps in better pre-operative classification of intertrochanteric fractures especially in select group of fractures (AO 31 A 2) where stability and integrity of lateral wall is difficult to assess.

Closed Reduction Techniques for Distal Radius Fractures and Appropriate Casting Methods

Distal radius fractures are one of the most common orthopedic injuries. After history, physical examination, and diagnostic imaging, treatment begins with closed reduction and immobilization to restore an upper extremity that has both acceptable alignment and stability. Whether for definitive nonoperative management or in preparation for surgical fixation, it is important to understand the principles of closed reduction and immobilization. This article presents a brief review of indications and a technical guide to successful closed reduction and casting for the orthopedic surgeon.

Computer-Aided Assessment of Displacement and Reduction of Distal Radius Fractures

This study aims to investigate displacements and reductions of distal radius fractures using measurement indices based on the computer-aided three-dimensional (3D) radius shape model. Fifty-two distal radius fracture patients who underwent osteosynthesis were evaluated with pre- and post-operative distal radius 3D images. In the 3D images, three reference points, i.e., the radial styloid process (1), sigmoid notch volar, and dorsal edge (2) (3) were marked. The three-dimensional coordinates of each reference point and the barycentric coordinates of the plane connecting the three reference points were evaluated. The distance and direction moved, due to the reductions for each reference point, were (1) 12.1 ± 8.1 mm in the ulnar-palmar-distal direction, (2) 7.5 ± 4.1 mm in the ulnar-palmar-proximal direction, and (3) 8.2 ± 4.7 mm in the ulnar-palmar-distal direction relative to the preoperative position. The barycentric coordinate moved 8.4 ± 5.3 mm in the ulnar-palmar-distal direction compared to the preoperative position. This analyzing method will be helpful to understand the three-dimensional direction and the extent of displacements in distal radius fractures.

Minimally Invasive Surgery: Is There a Role in Distal Radius Fracture Management?

PURPOSE OF REVIEW

This review explores minimally invasive surgical techniques for distal radius fractures and guides their use in conjunction with, or as an alternative to, volar locked plating.

RECENT FINDINGS

Fractures of the lunate facet, die-punch fractures, and marginal articular shear injuries present challenges that cannot be easily addressed with volar plating. The use of external fixation, Kirschner wires, and dorsal bridge plating should all be considered. These techniques, in combination and in addition to volar locked plating, continue to play an important role in fracture management. Arthroscopically assisted surgery with minimally invasive fixation allows for detailed inspection of the radiocarpal joint. Closed treatment and casting continue to play an important role in distal radius fracture care. The role of minimally invasive surgery for distal radius fractures is still being defined. While fixation using a volar locking plate is by far the most common treatment method, other techniques should be considered to improve outcomes and decrease complications.

Indications, surgical approach, reduction, and stabilization techniques of distal radius fractures

Distal Radius fractures (DRF) are one of the most common injuries in the upper extremity and incidence is expected to rise due to a growing elderly population. The complex decision to treat patients operatively or conservatively depends on a large variety of parameters which have to be considered. No unanimous consensus has been reached yet, which operative approach and fixation technique would produce the best postoperative functional results with lowest complication rates. This article addresses the available evidence for indications, approaches, reduction, and fixation techniques in treating DRF.

Association of scapholunate dissociation and two-part articular fractures of the distal radius

Scapholunate dissociation may occur in association with distal radial fractures and is easily missed at initial presentation. The aim of this study was to examine variances in the scapholunate distance with respect to subtypes of two-part partial articular distal radial fractures. Axial computed tomography (CT) scans of acute two-part intra-articular radial fractures were assessed retrospectively from 80 patients and compared to 20 controls. From each scan, two images were analysed to identify the scaphoid, lunate and articular fracture line in the distal radius for fracture type categorization. The images were overlaid on a standardized distal radius template and the scapholunate distance measured. Significant increase in the scapholunate distance was noted in fracture subtypes: radial styloid oblique; dorsal ulnar column; sagittal ulnar column; and volar coronal. We conclude that these findings support the need for a higher index of suspicion for scapholunate dissociation in these distal radial fracture subtypes. Level of evidence: III.

SPRING PLATES IN DISTAL RADIO FRACTURES: "IN VITRO" MECHANICAL PROPERTIES

Background:

Distal radius fractures are one of the most common orthopedic injuries and appear in various patterns. Volar plate fixation is not always considered the gold standard treatment.

Objective:

To measure the resistance of a fragment-specific fixation assembly model obtained by plate fixation associated with different K-wire sizes.

Method:

In this original experimental study, novel II, axial compression of bone materials was tested.

Results:

In both groups, the maximum force supported by the fixation method in our study was ten times greater than the physiological load to which the wrist was subjected under physiological conditions.

Discussion:

In this study, we obtained encouraging results when compared to results reported in the literature. Our study showed that our bone fixating system was mechanically adequate for articular fractures of the intermediate column of the radius (Melone classification). The results were similar or superior to the results of pressure resistance and stiffness when data from the literature was used as reference.

Conclusion:

The proposed fixation method demonstrated adequate resistance for fixation of the intermediate column of the distal radius. Increasing K wire size caused augmented resistance of the fixation. Level of Evidence II, Prospective comparative study.

Single-shot CT after wrist trauma: impact on detection accuracy and treatment of fractures

OBJECTIVE

To evaluate accuracy of fracture detection and therapeutic impact of a single-shot CT protocol as a primary imaging tool in all patients with clinical suspicion of wrist injury, and evaluate the resulting impact on therapy.

MATERIALS AND METHODS

We performed a single-institution study on all patients with suspicion of fractures of the wrist and carpus. All patients underwent conventional radiography, thereafter single-shot wrist CT, and then 1-year follow-up. Physicians and radiologists prospectively scored likelihood of fracture presence on a five-point scale before and after CT. Three surgeons proposed a treatment regimen (functional, cast, reduction, or operative) based on clinical and radiological data, first with knowledge of conventional radiography, and then with knowledge of CT. The reference standard for fracture presence was based on all data. We performed receiver operating characteristic (ROC) analyses and calculated proportion of wrists with treatment changes due to CT imaging.

RESULTS

Ninety-eight patients participated (63% female, mean age 53, range, 18-87 years old) with 100 wrist CTs. Conventional radiography detected true-positive fractures in 45, and CT in 61 wrists. The areas under the curve for fracture detection were 0.85 (95% CI 0.77-0.93) for conventional radiography and 0.97 (95% CI 0.93-1.00) for CT. Treatment changed in 24 (24%, 95% CI 16-33%) - 31 (31%, 95% CI 23-41%) wrists, mostly involving a decrease in the rate of cast immobilization.

CONCLUSIONS

Single-shot CT in patients with clinical suspicion of wrist injury increases accuracy of fracture detection. This has a significant impact therapy in this population, mainly on cast immobilization.

TRIAL REGISTRATION

We registered the study at www.clinicaltrials.gov , NL43482.091.13.

Computed Tomography vs Standard Radiograph in Preoperative Planning of Distal Radius Fractures with Articular Involvement

Introduction

Distal radius fractures with articular involvement are more likely to require surgical management. Treatment decisions are based on parameters which are obtained from plain radiographs. This study aims to determine the differences between computed tomography and standard radiographs in the preoperative planning of distal radius fractures with articular involvement. This was performed by measuring the intraobserver and interobserver reliability between three systems used to interpret the main fracture characteristics and two treatment decisions.

Materials and methods

Forty-three cases of distal radius fractures with articular involvement were included. Fracture displacement was measured using plain radiographic and computed tomography. Five orthopedic surgeons evaluate the images to determine the AO/OTA classification, the articular fragments, the biomechanical columns involved, and recommend a surgical approach and implant for fracture fixation.

Results

An articular step-off was identified in 13 cases (30%) with the standard radiographs and in 22 (51%) cases with the computed tomography (p = 0.00). Interobserver variation for preoperative planning was slight when evaluated using the standard radiographs. Computed tomography improves reliability for AO/OTA classification and articular fragments but not for the biomechanical columns. Intraobserver variation for preoperative planning was slight to moderate for AO/OTA classification and slight to fair for identification of articular fragments and biomechanical columns. With regard to selection of the surgical approach, there was slight to moderate variation and, finally, for fracture fixation it was slight to fair.

Conclusion

Information provided by conventional radiography and computed tomography are sufficiently different as to induce the surgeon to select different treatments for the same fracture.

How to cite this article

Azi ML, Teixeira MB, de Carvalho SF, et al. Computed Tomography vs Standard Radiograph in Preoperative Planning of Distal Radius Fractures with Articular Involvement. Strategies Trauma Limb Reconstr 2019;14(1):15–19.

Evidence-Based Review of Distal Radius Fractures

Distal radius fractures are one of the most commonly treated fractures in the United States. The highest rates are seen among the elderly, second only to hip fractures. With the increasing aging population these numbers are projected to continue to increase. Distal radius fractures include a spectrum of injury patterns encountered by general practitioners and orthopedists alike. This evidence-based review of distal radius fractures incorporates current and available literature on the diagnosis, management, and treatment of fractures of the distal radius.

Distal Radius Fractures: AAOS Appropriate Use Criteria Versus Actual Management at a Level I Trauma Center

BACKGROUND

The aim of this study is to determine whether the American Academy of Orthopaedic Surgeons' (AAOS) Appropriate Use Criteria (AUC) for distal radius fractures correlates with actual treatment by orthopedic hand surgeons at a level I trauma center.

METHODS

ICD-9 codes were used to retrospectively identify patients who presented with wrist fractures over 1 year. Patients with isolated distal radius fractures were evaluated using the AAOS AUC application for distal radius fractures. Actual treatment was then compared with treatment recommended by the AUC.

RESULTS

Of the 112 patients, 64 (57%) received treatment that matched the AAOS AUC recommendation as an "appropriate treatment." Actual management matched the AUC recommendation 100%, 7%, and 50% of the time, for Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type A, B, and C fractures, respectively. Surgery was performed for type A, B, and C fractures 30%, 7%, and 50% of the time, respectively. For type B fractures, only the 2 cases that were managed operatively were in agreement with the AUC. For type C fractures, increased patient age (57 years and older) was significantly associated with nonoperative treatment decisions. Surgeon decisions for nonoperative treatment were in agreement with the AUC recommendations 40% of the time, whereas surgeon decisions for surgery matched the AUC recommendations 97% of the time.

CONCLUSIONS

We found low agreement between actual treatment decisions and the AUC-recommended "appropriate" treatments, especially for the type B and C fractures that were managed nonoperatively. The AUC favors surgery for all intra-articular fractures, while we emphasized age and fracture displacement in our decision-making process.

Use of Computed Tomography in Determining the Occurrence of Dorsal and Intra-articular Screw Penetration in Volar Locking Plate Osteosynthesis of Distal Radius Fracture

Background: The use of volar locking plate in distal radius fracture can lead to extensor tendon rupture due to dorsal screw penetration. The aim of our study was to investigate the occurrence of dorsal and intra-articular screw penetration using CT scan after volar distal radius osteosynthesis for distal radius fractures.

Methods: Thirty patients who underwent distal volar locking plate for distal radius fracture were included in a retrospective study. In all 30 patients no dorsal and intra-articular screw penetration were detected on standard AP and lateral views of a plain radiograph. CT scan of the operated wrist was performed to determine the number of intra-articular and dorsal screw penetrations. Clinical examination was performed to determine the wrist functions in comparison to the normal wrist.

Results: Nineteen wrists were noted to have screw penetration either dorsally or intraarticularly. The highest incidence is in the 2nd extensor compartment where 13 screws had penetrated with a mean of 2.46 mm. Six screws penetrated into the distal radial ulnar joint and five screws into the wrist joint with a mean of 2.83 mm and 2.6 mm, respectively. However, there was no incidence of tendon irritation or rupture.

Conclusions: This study demonstrated a high incidence of dorsal and intra-articular screw penetration detected by CT scan which was not apparent in plain radiograph. We recommend that surgeons adhere to the principle of only near cortex fixation and downsizing the locking screw length by 2 mm.

PROPOSAL TOMOGRAPHIC CLASSIFICATION FOR INTRA-ARTICULAR DISTAL RADIUS FRACTURES

Objective:

The objective of this study was to present a proposal tomographic classification for intra-articular distal radius fractures.

Methods:

This descriptive study was based on observing tomographic images from 74 patients with distal radius fractures. The cases were grouped by similarity according to the presence of several parameters which determine fracture complexity; the results of the descriptive analysis were transcribed as tomographic classification.

Results:

The proposal tomographic classification for intra-articular distal radius fractures comprised three major groups and nine sub-groups, which are organized by increasing severity according to the presence of spacing between articular fragments, angulation, loss of radial height, cortical depression, and associated dislocation.

Conclusion:

This proposal tomographic classification for intra-articular distal radius fractures can help professionals indicate therapeutic options. Level of Evidence IV; Case series.

Treatment of Intra-articular Distal Radius Fractures

This review of current literature discusses the morphology of the volar aspect of the distal radius; the surgical procedure, arthroscopic findings, and clinical results of a plate presetting and arthroscopic reduction technique for acute intra-articular fractures; and a novel simulation guidance system for malunited intra-articular fractures. Classification of intra-articular distal radius fractures is also discussed, focusing on central depression fracture fragments, associated soft tissue injuries, and results for measuring scapholunate distances at different sites. Problems of the distal radioulnar joint are reviewed, in particular, functional outcomes of the authors' prospective cohort study on unstable intra-articular fractures involving the distal radioulnar joint.

Can experienced surgeons predict the additional value of a CT scan in patients with displaced intra-articular distal radius fractures?

There are no clear guidelines when an additional CT scan should be obtained for the treatment of displaced intra-articular distal radius fractures (DRF). This study aimed to investigate whether surgeons can predict the usefulness of CT scans to facilitate choice of treatment plan and/or pre-operative planning for DRF. Four surgeons evaluated 51 patients with displaced DRF. The choice of treatment (operative or nonoperative) was based on conventional radiographs. Subsequently, the surgeons were asked whether they would have requested an additional CT scan to determine this treatment choice, and also whether they required a CT scan for pre-operative planning. After 4 weeks, the additional CT scan was provided and the cases were assessed again. Based on these data, we calculated the number needed to scan (NNS) and number needed to harm (NNH) for two decision models. Model 1: Only provide a CT scan if the surgeon requested one based on their judgment of the X-rays. Model 2: CT scans for all displaced intra-articular DRF. For choice of treatment, the NNS was lower for model 1 than for model 2 (2.6 vs. 4.3) and the NNH is higher for model 1 (3.1 vs. 1.3). For pre-operative planning, the NNS (1.3 vs. 1.4) and NNH (3.7 vs. 3.4) were comparable for both models. Surgeons are able to predict the usefulness of an additional CT scan for intra-articular displaced DRF for OR indication. However, for pre-operative planning the usefulness of a CT scan is much harder to predict.

The use of ultra-low-dose CT scans for the evaluation of limb fractures

Aims

To evaluate whether an ultra-low-dose CT protocol can diagnose selected limb fractures as well as conventional CT (C-CT).

Patients and Methods

We prospectively studied 40 consecutive patients with a limb fracture in whom a CT scan was indicated. These were scanned using an ultra-low-dose CT Reduced Effective Dose Using Computed Tomography In Orthopaedic Injury (REDUCTION) protocol. Studies from 16 selected cases were compared with 16 C-CT scans matched for age, gender and type of fracture. Studies were assessed for diagnosis and image quality. Descriptive and reliability statistics were calculated. The total effective radiation dose for each scanned site was compared.

Results

The mean estimated effective dose (ED) for the REDUCTION protocol was 0.03 milliSieverts (mSv) and 0.43 mSv (p < 0.005) for C-CT. The sensitivity (Sn), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) of the REDUCTION protocol to detect fractures were 0.98, 0.89, 0.98 and 0.89 respectively when two occult fractures were excluded. Inter- and intra-observer reliability for diagnosis using the REDUCTION protocol (κ = 0.75, κ = 0.71) were similar to those of C-CT (κ = 0.85, κ = 0.82). Using the REDUCTION protocol, 3D CT reconstructions were equivalent in quality and diagnostic information to those generated by C-CT (κ = 0.87, κ = 0.94).

Conclusion

With a near 14-fold reduction in estimated ED compared with C-CT, the REDUCTION protocol reduces the amount of CT radiation substantially without significant diagnostic decay. It produces images that appear to be comparable with those of C-CT for evaluating fractures of the limbs. Cite this article: Bone Joint J 2016;98-B:1668-73.

The value of CT compared to radiographs in the classification and treatment plan of trochanteric fractures

INTRODUCTION

The clinical relevance of classification for trochanteric fractures is limited and little agreement exists on what type of implant should be used. It is unknown whether more advanced radio-diagnostics, such as CT, result in better agreement on the treatment. We assessed the effect of CT on agreement of classification and subsequent treatment for trochanteric fractures.

MATERIALS AND METHODS

Eleven observers (five radiologists, four trauma surgeons and two orthopedic residents) assessed 30 radiographs and CTs of trochanteric fractures. Each rating included an assessment according to the AO classification and of the preferred type of implant. The inter-observer agreement of the AO classification and on the choice of implant was calculated.

RESULTS

The inter-observer agreement was κ0.70 (SE 0.03) for radiographic assessment of the main groups of the AO classification and κ0.68 (SE 0.03) for CT assessment. The agreement on choice of implant was κ0.63 (SE 0.05) if the choice was made with radiographs and κ0.69 (SE 0.05) with CTs. Six out of the 13 fractures were classified differently after assessment of the CT. Most corrections in choice of implant occurred for the assessment of A3 fractures.

CONCLUSIONS

This study confirmed that trochanteric fractures can be reliably classified on both radiographs and CT, according to the main groups of the AO classification. The implementation of CT for trochanteric fractures does not lead to higher agreement on fracture classification or choice of treatment. Therefore, the clinical relevance of CT for classification of trochanteric fractures seems low. For specific subgroups such as A3 fractures, CT may be of value for adequate fracture classification and subsequent treatment strategies.

Distal Radius Fractures: Approaches, Indications, and Techniques

Distal radius fractures remain among the most common fractures of the upper extremity. The indications for operative management continue to evolve based on outcomes from the most recent clinical studies. Advancements over the past decade have expanded the variety of fixation options available; however, the clinical superiority of a particular treatment modality remains without consensus. Each approach requires the use of unique surgical techniques, and the choice of a particular implant system should be based on the surgeon's familiarity with the implant design and its limitations. As our understanding of the management of distal radius fractures improves, so will our indications for each specific treatment modality.

Four-Corner Concept: CT-Based Assessment of Fracture Patterns in Distal Radius

Operative treatment using plate fixation is an important adjunct in the treatment of distal radius fractures, although the evidence for its superiority over other modalities remains limited. We propose a new concept for fractures of the distal radius, based on the three-column model of the distal radius, and on the expanding knowledge about the different fracture patterns obtained by evaluation of the distal radius by computed tomographic (CT) scan. All fracture types can be characterized by subdividing the wrist joint into four corners, each with its own characteristics in terms of mobility, stability, and transfer of forces in the intact distal radius. Recognition of the specific fracture types based on this four-corner concept enables a tailored approach to treatment.

Greater Tuberosity Fractures: Does Fracture Assessment and Treatment Recommendation Vary Based on Imaging Modality?

BACKGROUND

For greater tuberosity fractures, 5-mm displacement is a commonly used threshold for recommending surgery; however, it is unclear if displacement can be assessed with this degree of precision and reliability using plain radiographs. It also is unclear if CT images provide additional information that might change decision making.

QUESTION/PURPOSES

We asked: (1) Does interobserver agreement for assessment of the amount and direction of fracture-fragment displacement vary based on imaging modality (radiographs only; 2-dimensional [2-D] CT images and radiographs; and 3-dimensional [3-D] and 2-D CT images and radiographs)? (2) Does the likelihood of recommending surgery vary based on imaging modality? (3) Does the level of confidence regarding the decision for treatment vary based on imaging modality?

METHODS

We invited 791 orthopaedic surgeons to complete a survey on greater tuberosity fractures. One hundred eighty (23%) responded and were randomized on a 1:1:1 basis in one of the three imaging modality groups and evaluated the same set of 22 fractures. We described age, sex, mechanism of injury, days between injury and imaging, and that patients had no comorbidities or signs of neurovascular damage for every case. One hundred sixty-four of the 180 respondents completed the study and there was an imbalance in noncompletion between the three groups (two of 67 [3.0%] in the radiograph only group; nine of 57 [16%] in the 2-D CT and radiograph group; and five of 56 [8.9%] in the 3-D CT, 2-D CT, and radiograph group; p = 0.043 by Fisher's exact test). Participants assessed amount (in millimeters) and direction (posterosuperior/posteroinferior/anterosuperior/anteroinferior/no displacement) of displacement; recommended treatment (surgical or nonoperative); and indicated their level of confidence regarding the recommended treatment on a scale from 0 to 10 for every case. Overall recommendation for treatment was expressed as a surgery score per surgeon by dividing the amount of cases they would operate on by the total number of cases (n = 22) and presented as a percentage. Confidence regarding the decision for treatment was calculated by averaging the confidence score per surgeon, ranging from 0 to 10. We compared interobserver agreement using kappa for categorical variables and intraclass correlation (ICC) for continuous variables. We used multivariable linear regression to assess difference in surgery score and confidence level between imaging groups, controlling for surgeon characteristics.

RESULTS

Interobserver agreement for assessment of amount (radiographs: ICC, 0.55, 2-D CT + radiographs ICC, 0.53, 3-D CT + 2-D CT + radiographs ICC, 0.57; p values on all comparisons >0.7) and direction (radiographs: kappa, 0.30, 2-D CT + radiographs kappa, 0.43, 3-D CT + 2-D CT + radiographs kappa, 0.40; p values for all comparisons >0.096) of displacement did not vary by imaging modality. 2-D CT and radiographs (β regression coefficient [β], 3.1; p = 0.253) and 3-D CT, 2-D CT and radiographs (β, 1.6; p = 0.561) did not result in a difference in recommendation for surgery compared with radiographs alone. 2-D CT and radiographs (β, 0.40; p = 0.021) and 3-D CT, 2-D CT and radiographs (β, 0.44; p = 0.011) were associated with slightly higher levels of confidence compared with radiographs alone.

CONCLUSIONS

Imaging modality, with the numbers evaluated, does not influence interobserver agreement of greater tuberosity fracture assessment, nor did it influence the recommendation for surgical treatment. However, surgeons did feel slightly more confident about their treatment recommendation when assessing CT images with radiographs compared with radiographs alone. Our results therefore suggest no additional value of CT scans for assessment of greater tuberosity fractures when displacement seems to be minimal on plain radiographs. CT scans could be helpful in borderline cases, or in case other fractures can be expected (eg, an occult surgical neck fracture).

LEVEL OF EVIDENCE

Level III, diagnostic study.

Three-Dimensional Computed Tomographic Analysis for Comminution of Pertrochanteric Femoral Fracture: Comminuted Anterior Cortex as a Predictor of Cutting Out

Background:

Fixed angle sliding hip screw devices allow controlled impaction between the head neck fragment and the femoral shaft fragment in the surgical treatment of pertrochanteric fractures. This study was performed to evaluate the frequency and pattern of comminution at the fracture site, which may prevent the intended impaction.

Materials and Methods:

Three-dimensional computed tomography was used to investigate 101 pertrochanteric fractures treated with fixed angle sliding hip screw devices, with emphasis on the comminuted cortex. A comminuted fracture was defined as a fracture that had a third fracture fragment at the main fracture line.

Results:

There were 40 fractures without comminution and 61 with comminution. All 61 comminuted fractures had a comminuted posterior cortex, and 3 of 61 fractures also had comminution at the anterior cortex. The prevalence of cutting out of the implant from the femoral head was significantly higher in cases involving comminution at both the posterior and anterior cortices than in cases involving comminution only at the posterior cortex (66.7 % and 3.4 %, p < 0.0001).

Conclusion:

The posterior cortex was comminuted in 60.4% of pertrochanteric fractures and the anterior cortex in 3.0%. Intended impaction at the fracture site could not be obtained at any cortex in cases with comminution at both the anterior and posterior cortices; comminution at the anterior cortex may be a predictor of cutting out.

Fixation Options for the Volar Lunate Facet Fracture: Thinking Outside the Box

Background Fractures of the distal radius with small volar ulnar marginal fracture fragments are difficult to stabilize with standard volar locking plates. The purpose of this study is to describe alternative techniques available to stabilize these injuries. Materials and Methods Five patients were identified retrospectively with unstable volar lunate facet fracture fragments treated with supplemental fixation techniques. The demographic data, pre- and postoperative radiographic parameters, and early outcomes data were analyzed. The AO classification, preoperative and final postoperative ulnar variance, articular step-off, volar tilt, radial inclination, and teardrop angle were measured. The lunate subsidence and length of the volar cortex available for fixation were measured from the initial injury films. Description of Technique Lunate facet fixation was based on the morphology of the fragment, and stabilization was achieved with headless compression screws in three patients, a tension band wire construct in one, and two cortical screws in another. Results Five patients with a mean age of 58 years (range: 41-82) were included. There were two AO C3.2 and three B3.3 fractures. Preoperative radiographic measurements including radial inclination, tilt, and ulnar variance all improved after surgery and were maintained within normal limits at 3-month follow-up. There was no change in the teardrop angle at final follow-up (70-64 degrees; p = 0.14). None of the patients had loss of fixation or volar carpal subluxation. The mean visual analog scale pain score at 3 months was 1 (range: 0-2). Conclusions The morphology of volar lunate facet fracture fragments is variable, and fixation must be customized to the particular pattern. Small fragments may preclude the use of plates and screws for fixation. These fractures can be managed successfully with tension band wire constructs and headless screws. These low-profile implants may decrease the risk of tendon irritation that might accompany distally placed plates.

Computed tomography's influence on the classifications and treatment of the distal radius fractures

INTRODUCTION

Distal radius fractures are common in emergency centers. The radiographic routine includes at least two radiographic projections used for diagnosing most of these fractures. Computed tomography (CT) is indicated for evaluating complex fractures that affect the articular surface, as well as the fragments' size and position. There are not enough comparative studies on choosing classification and treatment by means of the four radiographic projections and computed tomography (CT) and the association of these with the levels of expertise.

METHODS

We conducted a randomized cross-sectional study by observing images from 61 patients with distal radius fractures organized in two phases: the first phase comprising radiographic images alone and the second one with those same images associated with tomograms. Seventeen evaluators with different levels of training and expertise classified the fractures according to the AO and Universal classification systems and proposed treatment guidelines.

RESULTS

The agreement between the AO and Universal classification ratings was poor (worse for the former), with smaller Fleiss' kappa resulting from data obtained by orthopedics residents and non-specialist orthopedists. CT influenced the classification choice, with a higher change frequency for more complex patterns in the AO classification system and intra-articular and irreducible fractures in the Universal classification system, especially in the group comprised of orthopedic residents and orthopedic physicians. CT did not influence the treatment choice made by the group comprised of hand surgery residents and hand surgeons.

CONCLUSION

The less experienced in hand surgery the observer was, the more important computed tomography was for determining the fracture pattern.

The effect of three-dimensional computed tomography reconstructions on preoperative planning of tibial plateau fractures: a case-control series

BACKGROUND

Tibial plateau fractures are a common intra-articular injury for which computed tomography (CT) scans are routinely used for preoperative planning. Three-dimensional reconstructions of CT scans have been increasingly investigated in recent years, however their role has yet to be defined. We wish to investigate the role of three-dimensional computed tomography reconstructions (3D-CT) in the preoperative planning of tibial plateau fractures.

METHODS

Twelve cases of tibial plateau fractures including plain film radiographs and conventional CT scans were distributed to 21 observers (orthopaedic residents and consultants). The observers filled out a preoperative plan checklist created for this study. Three months later the same cases were distributed, in random order, this time including 3D-CT reconstructions. The same preoperative checklists were completed, and compared to the previous checklists.

RESULTS

The preoperative plan checklist was able to detect differences between cases and between observers. No significant differences were detected between the total plan scores when comparing conventional CT to 3D-CT. Sub-analysis of plan specifics (incisions, hardware, adjuncts) was also not significantly different. The level of training of the observer or the fracture complexity did not affect these results.

CONCLUSIONS

No significant changes were made to observer's preoperative plans with the addition of 3D-CT. 3D-CT reconstructions come at a cost to the system, and therefore their usefulness should be investigated prior to widespread use. Our study demonstrates that the addition of 3D-CT reconstructions to the preoperative workup of tibial plateau fractures did not change management plans when compared to plans made using traditional CT-scans.

Comparative use of the computer-aided angiography and rapid prototyping technology versus conventional imaging in the management of the Tile C pelvic fractures

INTRODUCTION

Computed tomography (CT) scan with three-dimensional (3D) reconstruction has been used to evaluate complex fractures in pre-operative planning. In this study, rapid prototyping of a life-size model based on 3D reconstructions including bone and vessel was applied to evaluate the feasibility and prospect of these new technologies in surgical therapy of Tile C pelvic fractures by observing intra- and perioperative outcomes.

MATERIALS AND METHODS

The authors conducted a retrospective study on a group of 157 consecutive patients with Tile C pelvic fractures. Seventy-six patients were treated with conventional pre-operative preparation (A group) and 81 patients were treated with the help of computer-aided angiography and rapid prototyping technology (B group). Assessment of the two groups considered the following perioperative parameters: length of surgical procedure, intra-operative complications, intra- and postoperative blood loss, postoperative pain, postoperative nausea and vomiting (PONV), length of stay, and type of discharge.

RESULTS

The two groups were homogeneous when compared in relation to mean age, sex, body weight, injury severity score, associated injuries and pelvic fracture severity score. Group B was performed in less time (105 ± 19 minutes vs. 122 ± 23 minutes) and blood loss (31.0 ± 8.2 g/L vs. 36.2 ± 7.4 g/L) compared with group A. Patients in group B experienced less pain (2.5 ± 2.3 NRS score vs. 2.8 ± 2.0 NRS score), and PONV affected only 8 % versus 10 % of cases. Times to discharge were shorter (7.8 ± 2.0 days vs. 10.2 ± 3.1 days) in group B, and most of patients were discharged to home.

CONCLUSIONS

In our study, patients of Tile C pelvic fractures treated with computer-aided angiography and rapid prototyping technology had a better perioperative outcome than patients treated with conventional pre-operative preparation. Further studies are necessary to investigate the advantages in terms of clinical results in the short and long run.

Distal radius fractures: emergency department evaluation and management

Musculoskeletal injuries are the second most common cause of presentation to emergency departments. Distal radius fractures are an especially common injury pattern that often require evaluation and fracture management in an emergency department. This article reviews the evaluation of distal radius fractures including physical examination and radiographic review. Also discussed is management of distal radius fractures including splinting in the setting of an emergency department consultation.

The effectiveness of skeletal imaging for quality assessment in posterior cruciate ligament reconstruction: reliability and validity of radiographs and computed tomography

PURPOSE

For intra- and postoperative evaluation of precise and anatomic graft tunnel position, radiographs (XR) and computed tomography (CT) scans have been suggested. The purpose of this study was to evaluate the reliability and validity of XR and CT for quality assessment following PCL reconstruction.

METHODS

Postoperative radiographs and CT scans were obtained in 45 consecutive patients following a standard single-bundle PCL reconstruction. Femoral and tibial tunnel apertures were correlated to femoral and tibial measurement grid systems. To assess the reliability and validity of XR and CT scans three independent observers evaluated radiographic and CT images for the position of femoral and tibial tunnel apertures.

RESULTS

Almost perfect inter- and intra observer agreement (0.79-0.99) was found for all CT measurements except for the distance of the tunnel position to the previous physis line. Almost perfect and strong inter- and intraobserver agreement (0.70-0.98) was found for all tibial measurements on XR which tended to increase with repeated interpretation and to decrease with low levels of observer qualification. Femoral measurements yielded only poor-to-moderate reliability (0.02-0.5) between raters on XR but strong intraagreement within experienced observers (0.45-0.86). Specificity for XR was calculated with 75.7 % for P2 and P3 and with 71 % for femoral tunnel depth and height.

CONCLUSION

XR and CT represent complementary imaging modalities and both offer considerable accuracy and precision for the determination of femoral and tibial tunnel apertures following PCL reconstruction and can be recommended for intra- and postoperative quality assessment.

Radiographic interpretation of distal radius fractures: visual estimations versus digital measuring techniques

PURPOSE

Distal radius fractures are a common injury. In the emergency room, trainees regularly assess these fractures using visual estimation. Our hypothesis is that assessment of radiographic parameters has sufficient accuracy for rendering treatment consistent with formal measurements.

METHODS

This study compared visual measurements made by 25 orthopaedic residents and attending physicians to formal measurements made by a single fellowship trained musculoskeletal radiologist in a series of patients with distal radius fractures. A search was performed utilizing the ICD-9 code for distal radius fracture in all patients presenting to a single institution emergency department. Participants used visual estimation to rate 25 radiographs. Parameters estimated included radial inclination, radial height, volar tilt, and the presence of intra-articular displacement. Analysis using Lin concordance coefficients, Bland Altman plots, and the Kappa statistic evaluated the agreement between visual estimation and formal measurements. The proportion of raters whose estimates would have resulted in a course of treatment that conflicted with the formal reading quantified the potential impact of visual estimation on treatment.

RESULTS

Concordance coefficients were poor for radial inclination (ρc = 0.13), radial height (ρc = 0.24), and volar tilt (ρc = 0.46). The Kappa statistic for intra-articular displacement was 0.4. Analysis performed according to level of training did not result in substantial improvements in these statistics. Treatment based on visual estimates conflicted with formal readings 34 % of the time for radial inclination, 38 % of the time for radial height, 27 % of the time for volar tilt, and 31 % of the time for intra-articular displacement.

DISCUSSION

Visual estimation is not an adequate form of measurement for evaluation of patients with distal radius fractures. Physicians should be mindful of these results when developing treatment plans based solely upon visual estimation.

Does the CT improve inter- and intra-observer agreement for the AO, Fernandez and Universal classification systems for distal radius fractures?

INTRODUCTION

Distal radius fractures are very common upper limb injuries irrespective of the patient's age. The aim of our study is to evaluate the reliability of the three systems that are often used for their classification (AO - Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation, Fernandez and Universal) and to assess the need for computed tomography (CT) scan to improve inter- and intra-observer agreement.

MATERIALS AND METHODS

Five orthopaedic surgeons and two hand surgeons classified radiographs and CT scans of 26 patients using the Fernandez, AO and Universal systems. All data were recorded using MS Excel and Kappa statistics were performed to determine inter- and intra-observer agreement and to evaluate the role of CT scan.

RESULTS

Fair-to-moderate inter-observer agreement was noted with the use of X-rays for all classification systems. Intra-observer reproducibility did not improve with the addition of CT scans, especially for the senior hand surgeons.

CONCLUSIONS

The agreement rates observed in the present study show that currently there is no classification system that is fully reproducible. Adequate experience is required for the assessment and treatment of these injuries. CT scan should be requested only by experienced hand surgeons in order to help guide treatment, as it does not significantly improve inter- and intra-observer agreement for all classification systems.

Controversies in the management of distal radius fractures

Controversies span the entire spectrum of management of distal radius fractures-fracture assessment, diagnosis, treatment, and evaluation of outcomes. The utility of multiple radiographic views described in the literature has not been validated. Likewise, the several classification systems that exist have yet to demonstrate substantial interobserver and intraobserver reliability. Nonsurgical controversies involve fracture reduction, use of anesthesia, type of fracture immobilization, and forearm position during healing. Surgical controversies include surgical indications, need for release of carpal tunnel, fracture fixation method, and the need for augmentation (ie, bone graft). Postoperatively, rehabilitation, medication, and physical therapy also remain highly controversial. The best outcome measure has yet to be established. A strong need remains for high-level, prospective studies to determine the most effective way to assess, diagnose, treat, and measure outcomes in patients with distal radius fractures.

Usefulness and reliability of two- and three-dimensional computed tomography in patients older than 65 years with distal humerus fractures

BACKGROUND

Distal humerus fractures are difficult to characterise and to classify according to the AO system. In this multicentre study, our objectives were to assess the usefulness of computed tomography (CT) and to measure intra-observer and inter-observer reliability according to observer experience.

MATERIALS AND METHODS

An online survey of professional practice was performed using a questionnaire based on a clinical case. Participants were asked to determine the AO classification using radiographs then to reappraise their answers after the addition of CT images. For the reliability study, 16 observers in five centres evaluated radiographs and CT scans of 26 distal humerus fractures. They used the radiographs to determine the AO classification and assess the main fracture characteristics then reappraised their findings after adding the CT images. The radiographs and 2D CT images were read twice at an interval of 2 weeks, and during the second reading, 3D CT images were available also. At least 1 month later, the same observers performed similar readings 2 weeks apart (radiographs and 2D CT images at the first reading and addition of 3D CT images at the second reading).

RESULTS

Correct fracture classification was achieved in 95% of cases with the CT images compared to only 73% with the radiographs. CT led to diagnostic and therapeutic changes in 90% and 25% of cases, respectively. Inter-observer reliability was poor for both AO classification and fracture characteristics, not only with the radiographs and 2D CT images, but also with the added 3D CT images. In contrast, intra-observer reliability improved after the addition of 3D CT images. Assessment accuracy was influenced by image quality and geographic origin of the observer but not by observer experience.

CONCLUSION

CT improves diagnostic accuracy and, in some cases, changes the surgical strategy. In our study of a large number of observers, CT did not improve inter-observer agreement about the study variables. Intra-observer agreement was improved by 3D CT but not by 2D CT. Accuracy was not influenced by years of observer experience but was dependent on image quality, proficiency with computer-based tools and, above all, image observation and interpretation.

LEVEL OF EVIDENCE

Level III.

Pathogenesis and prevention of posttraumatic osteoarthritis after intra-articular fracture

Posttraumatic osteoarthritis (PTOA) occurs after traumatic injury to the joint. It is most common following injuries that disrupt the articular surface or lead to joint instability. The reported risk of PTOA following significant joint trauma is as high as 75%; articular fractures can increase the risk more than 20-fold. Despite recent advances in surgical management, the incidence of PTOA following intra-articular fractures has remained relatively unchanged over the last few decades. Pathogenesis of PTOA after intra-articular fracture is likely multifactorial and may be associated with acute cartilage injury as well as chronic joint overload secondary to instability, incongruity, and malalignment. Additional studies are needed to better elucidate how these factors contribute to the development of PTOA and to develop advanced treatment algorithms that consist of both acute biologic interventions targeted to decrease inflammation and cellular death in response to injury and improved surgical methods to restore stability, congruity, and alignment.

Diagnostic accuracy of two-dimensional and three-dimensional imaging and modeling of radial head fractures

To tests the hypothesis that classification and characterization of fractures of the radial head is more accurate with 3D than 2D computed tomography images and radiographs, using a prospective study design with intraoperative inspection as the reference standard. Treating surgeons and first assistants completed a questionnaire assigning a fracture type according to the Broberg and Morrey modification of Mason's classification, evaluating selected fracture characteristics, and electing preferred management based upon radiographs and 2D images alone; then adding 3D-CT; then 3D printed physical models; and finally intra-operative visualization. The addition of the 3D CT and physical models improved the sensitivity for fracture line separating the entire head from the neck, comminution of the radial neck, fracture involving the articular surface, articular fracture gap greater than 2 mm, impacted fracture fragments, greater than 3 articular fragments, and articular fragments judged too small to repair. There were no significant differences in diagnostic performance with the addition of 3D models. The addition of 3D CT and models improved the reliability of Broberg and Morrey classification. We conclude that 3DCT and 3D physical modeling provide more accurate fracture classification and characterization of fracture of the radial head with less proposed variability in treatment. We did not demonstrate a clear advantage for modeling over 3DCT reconstructions.

LEVEL OF EVIDENCE

Diagnostic, Level I.

Intra-articular distal radius fractures involving the distal radioulnar joint (DRUJ): three dimensional computed tomography-based classification

PURPOSE

The purpose of this study was to analyze fracture patterns and the magnitude of displacement in the distal radioulnar joint (DRUJ), by three-dimensional (3D) computed tomography (CT), for distal radius fractures with intra-articular displacement of the radiocarpal joint.

METHODS

We reconstructed 3D images for 72 consecutive patients with displaced intra-articular distal radius fracture on the basis of fine-cut axial CT data. The fracture patterns involving the DRUJ were classified on the basis of the location and direction of fracture lines, and the extent of fracture comminution. We measured the maximum spatial distance of the gap and the step between the fragments in each 3D image, and the magnitudes of displacement between the groups were compared by analysis of variance followed by post-hoc analysis by use of Tukey's test.

RESULTS

Sixty wrists had a fracture involving the DRUJ. We classified the 60 wrists into 3 types of fracture pattern. Type 1 was a transverse fracture with minimum displacement. Type 2, in which fracture lines extended into the distal margin of the sigmoid notch, was the most common longitudinal fracture. Type 3 was a fracture with multiple fragments. The step and gap in Type 3 was significantly larger than that in the other types.

CONCLUSIONS

Eighty-three percent of intra-articular distal radius fractures had DRUJ involvement, and 28% of the wrists had multiple fragments. For Type 3 fractures with dorsal or proximal comminution displacement was significantly larger than for simple Type 1 and 2 fractures. Surgical intervention for the DRUJ fragment may be beneficial when there is remarkable intra-articular displacement.

Dorsal locked plate fixation of distal radius fractures

Distal radius fractures are common, and internal fixation for operative management of these injuries is widely accepted. Although use of the volar approach for plate fixation has become more popular, benefits of the dorsal surgical approach include the potential for direct reduction and assessment of articular alignment, evaluation and management of concomitant intrinsic intercarpal ligament injury, and initiation of early range of motion. For certain fracture patterns, dorsal plate fixation is the preferred surgical technique. Improvements in implant design, in particular the use of low-profile dorsal plates, has decreased the rate of complications seen previously with this technique. Here, we provide an overview of the evaluation of patients with distal radius fractures, as well as the surgical indications and contraindications, techniques, and complications after dorsal locked plate fixation of intra-articular distal radius fractures.

Diagnostic accuracy of 2- and 3-dimensional computed tomography and solid modeling of coronoid fractures

PURPOSE

This study measured the diagnostic performance characteristics and reliability of 2-dimensional (2DCT) and 3-dimensional (3DCT) computed tomography images and modeling of coronoid fractures.

METHOD

The treating surgeon and first assistant evaluated 28 fractures for fracture type, specific characteristics, and proposed treatment. The observers evaluated the fractures 4 times: first based upon 2DCT computed images and radiographs; second with the addition of 3DCT images; third with the addition of 3D models; and finally based upon intra-operative exposure, which was considered the reference standard.

RESULTS

The diagnostic performance characteristics did not improve with more sophisticate imaging and models. The addition of 3DCT reconstructions improved the inter-observer reliability for fracture classification, characteristics, and proposed treatment.

CONCLUSION

More sophisticated images and modeling improved reliability but not accuracy when characterizing coronoid fractures.

AO type-C distal radius fractures: the influence of computed tomography on surgeon's decision-making

BACKGROUND

Computed tomography (CT) has become a widely accepted adjunct imaging tool in the preoperative evaluation of complex intra-articular distal radius fractures. The aim of this study was to evaluate the impact of CT scanning compared with plain X-rays on the choice of intervention in complex distal radius fractures.

METHODS

Five orthopaedic surgeons were given the de-identified plain films (AP, lateral and oblique) of 20 closed complex intra-articular distal radius fractures (AO23-C), randomly selected from our institution's prospectively maintained fracture database. Each surgeon individually selected a management option for each patient from a series of five interventions, ranked in increasing level of invasiveness. The same patients' CT scans (in randomized order) were blindly reviewed after a 1-week interval by the same clinicians with the same management options again offered. Kappa statistic was used to measure the intra-observer agreement between X-ray and CT decisions, and inter-observer agreement within each modality.

RESULTS

The intra-observer agreement on management between X-rays alone versus CT scan was poor, with an average kappa score of 0.038. Inter-observer agreement based on X-ray alone was higher than that based on CT alone. Regression analysis indicated a trend towards a slightly higher level of invasiveness when the management decision was based on the CT compared with plain X-rays.

CONCLUSION

There is a very poor intra- and inter-rater agreement between decision-making based on X-ray and on CT. Decision-making based on CT could increase the level of invasiveness in the surgical management of complex distal radius fractures.

Fragment-specific fixation for complex intra-articular fractures of the distal radius: results of a prospective single-centre trial

The goal was to evaluate the efficacy of 2.4 mm column-specific plating for intra-articular distal radius fractures. In total, 105 patients with AO type C distal radius fractures were operated on using the locking distal radius system, Synthes. Follow-up assessments including clinical (wrist and forearm range of motion, grip strength), radiological (articular step, radial length and inclination, volar tilt, and ulnar variance), and functional scores (Disabilities of the Arm, Shoulder, and Hand; Patient Rated Wrist Evaluation) were made at regular intervals until 1 year. Union was obtained in all patients. Articular surface was anatomically reconstructed in 74 patients (70.5%). Clinical and functional evaluation showed significant continuous improvements over the first year. C1 fractures had a better chance of anatomical reduction compared with C2 and C3 fractures. Fracture type, quality of reduction, and presence of degenerative changes did not show a significant effect on functional outcome scores. Column-specific fixation of the distal radius can achieve satisfactory results in complex intra-articular fractures.

Diagnostic accuracy of 2- and 3-dimensional imaging and modeling of distal humerus fractures

PURPOSE

This investigation used prospectively recorded intraoperative evaluation as the reference standard for distal humerus fracture type and characteristics, in order to measure the diagnostic performance characteristics of computed tomography (CT) and physical models. In secondary analyses, we assessed the reliability of classification.

METHODS

Thirty-five fractures were evaluated by the treating surgeon and first assistant on radiographs and 2-dimensional CT (2DCT) images first; a second time based on radiographs and 2- and 3-dimensional CT (3DCT) images; a third time based on 2- and 3DCT as well as 3D physical models; and a fourth time based on intraoperative visualization of the fracture characteristics. The intraoperative evaluation of the attending surgeon was used as the reference standard.

RESULTS

The addition of 3DCT and the 3D models to 2DCT and radiographs led to significant improvements in sensitivity, but not specificity, in the diagnosis and proposed treatment, and improved the interobserver agreement with respect to specific fracture characteristics but not classification.

CONCLUSION

Increasingly sophisticated imaging and modeling leads to slight but significant improvements in diagnostic performance characteristics and interobserver agreement on fracture characteristics.

The effects of a displaced dorsal rim fracture on outcomes after volar plate fixation of a distal radius fracture

INTRODUCTION

The purpose of this study was to determine whether a displaced dorsal rim fracture has an adverse effect on wrist function after volar plate fixation of a dorsally displaced distal radius fracture (DRF).

MATERIALS AND METHODS

Two matched cohorts of 23 matched patients, one with a displaced dorsal rim fracture >2mm (group 1), and the other without a dorsal rim fracture (group 2) were analysed in this study of volar locking plate fixation for dorsally unstable DRFs. The two cohorts were analysed for differences in wrist function and wrist pain, radiographic parameters and arthritic grades of radiocarpal joints. Displacement of dorsal rim fragments and diameters of the retained articular portions of dorsal rims in group 1 were measured.

RESULTS

No significant difference was found between the two groups in overall wrist function or wrist pain. Mean displacement of dorsal rims in group 1 was 3.0mm and the mean diameter of the retained articular portion of dorsal articular wall was 2.0mm. No significant difference was found between the two groups in terms of any radiographic parameters or the arthritic grading of radiocarpal joints.

CONCLUSION

A displaced dorsal rim fracture does not appear to affect outcomes adversely after volar locking plate fixation of dorsally displaced DRFs.