Do traction radiographs of distal radial fractures influence fracture characterization and treatment?

Distal Humerus Traction Radiographs: Is the Interobserver and Intraobserver Reliability Comparable With Computed Tomography?

OBJECTIVES

To compare the interobserver and intraobserver reliability of traction radiographs with 2-dimensional computed tomography (2D CT) in distal humerus fracture classification and characterization.

DESIGN

Randomized controlled radiographic review of retrospectively collected data.

SETTING

Academic Level 1 trauma center.

PATIENTS/PARTICIPANTS

Skeletally mature patients with intra-articular distal humerus fractures with both traction radiographs and CT scans were reviewed by 11 orthopaedists from different subspecialties and training levels.

INTERVENTION

The intervention involved traction radiographs and 2D CT.

MAIN OUTCOME MEASUREMENTS

The main outcome measurements included interobserver and intraobserver reliability of fracture classification by the OTA/AO and Jupiter-Mehne and determination of key fracture characteristics.

RESULTS

For the OTA/AO and Jupiter-Mehne classifications, we found a moderate intraobserver agreement with both 2D CT and traction radiographs (κ = 0.70-0.75). When compared with traction radiographs, 2D CT improved the interobserver reliability of the OTA/AO classification from fair to moderate (κ = 0.3 to κ = 0.42) and the identification of a coronal fracture from slight to fair (κ = 0.2 to κ = 0.34), which was more pronounced in a subgroup analysis of less-experienced surgeons. When compared with 2D CT, traction radiographs improved the intraobserver reliability of detecting stable affected articular fragments from fair to substantial (κ = 0.4 to κ = 0.67).

CONCLUSIONS

Traction radiographs provide similar diagnostic characteristics as 2D CT in distal humerus fractures. For less-experienced surgeons, 2D CT may improve the identification of coronal fracture lines and articular comminution.

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.

Timing of Treatment of Open Fractures of the Distal Radius in Patients Younger Than 65 Years

The authors aimed to characterize surgical and functional outcomes of open fractures of the distal radius in patients younger than 65 years. At their level I trauma center, the authors conducted a retrospective review of 92 patients (age range, 16-64 years) who had 94 open fractures of the distal radius (average follow-up, 30 months; range, 3-95 months). Sixty-four fractures received definitive treatment at the time of initial débridement; 30 received definitive fixation and soft tissue coverage after staged débridement. Primary surgical outcome was development of deep surgical site infection requiring repeat surgical débridement; secondary surgical outcome was surgical complications requiring reoperation. Functional outcome was assessed by wrist range of motion. Overall infection rate was 15% (14 of 94 fractures). Seven (11%) of 64 fractures in the immediate definitive fixation group developed infection compared with 7 (23%) of 30 fractures in the staged treatment group (P=.13). Twenty-one (33%) of 64 fractures in the immediate definitive fixation group required reoperation compared with 15 (50%) of 30 in the staged treatment group (P=.11). Deep surgical site infections and surgical complications associated with open fractures of the distal radius are driven by soft tissue injury. [Orthopedics. 2019; 42(4):219-225.].

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.

Classification systems for distal radius fractures

Background and purpose - The reliability of conventional radiography when classifying distal radius fractures (DRF) is fair to moderate. We investigated whether reliability increases when additional computed tomography scans (CT) are used. Patients and methods - In this prospective study, we performed pre- and postreduction posterior-anterior and lateral radiographs of 51 patients presenting with a displaced DRF. The case was included when there was a (questionable) indication for surgical treatment and an additional CT was conducted within 5 days. 4 observers assessed the cases using the Frykman, Fernández, Universal, and AO classification systems. The first 2 assessments were performed using conventional radiography alone; the following 2 assessments were performed with an additional CT. We used the intraclass correlation coefficient (ICC) to evaluate reliability. The CT was used as a reference standard to determine the accuracy. Results - The intraobserver ICC for conventional radiography alone versus radiography and an additional CT was: Frykman 0.57 vs. 0.51; Fernández 0.53 vs. 0.66; Universal 0.57 vs. 0.64; AO 0.59 vs. 0.71. The interobserver ICC was: Frykman: 0.45 vs. 0.28; Fernández: 0.38 vs. 0.44; Universal: 0.32 vs. 0.43; AO: 0.46 vs. 0.40. Interpretation - The intraobserver reliability of the classification systems was fair but improved when an additional CT was used, except for the Frykman classification. The interobserver reliability ranged from poor to fair and did not improve when using an additional CT. Additional CT scanning has implications for the accuracy of scoring the fracture types, especially for simple fracture types.

Management of Complex Distal Radius Fractures: Review of Treatment Principles and Select Surgical Techniques

Most distal radius fractures are the result of low-energy mechanisms that can be successfully treated either non-operatively or with a variety of operative techniques if indicated. Complex distal radius fractures occur most commonly in high-energy injuries with extensive comminution or bone loss and associated soft tissue or vascular injuries. These high-energy fractures can present many challenges in reconstructing the distal radius. Effective restoration of the bony architecture requires a thorough knowledge of distal radius anatomy, understanding of the goals of treatment, versatility in surgical approaches, and familiarity with multiple fixation options.

Statistical analysis on the concordance of the radiological evaluation of fractures of the distal radius subjected to traction

OBJECTIVE

The objective of this study was to evaluate the current classifications for fractures of the distal extremity of the radius, since the classifications made using traditional radiographs in anteroposterior and lateral views have been questioned regarding their reproducibility. In the literature, it has been suggested that other options are needed, such as use of preoperative radiographs on fractures of the distal radius subjected to traction, with stratification by the evaluators. The aim was to demonstrate which classification systems present better statistical reliability.

RESULTS

In the Universal classification, the results from the third-year resident group (R3) and from the group of more experienced evaluators (Staff) presented excellent correlation, with a statistically significant p-value (p < 0.05). Neither of the groups presented a statistically significant result through the Frykman classification. In the AO classification, there were high correlations in the R3 and Staff groups (respectively 0.950 and 0.800), with p-values lower than 0.05 (respectively <0.001 and 0.003).

CONCLUSION

It can be concluded that radiographs performed under traction showed good concordance in the Staff group and in the R3 group, and that this is a good tactic for radiographic evaluations of fractures of the distal extremity of the radius.

Distal radial traction radiographs: interobserver and intraobserver reliability compared with computed tomography

BACKGROUND

Distal radial fracture characterization with standard radiographs has been consistently poor, leading to a widespread use of computed tomography (CT) with this injury. Traction radiographs have recently been shown to improve interobserver reliability for fracture characterization and treatment. Our goal was to compare five traction radiographs and CT images to evaluate the interobserver and intraobserver reliability of individual fracture fragment identification, the correct identification of fracture fragments on CT imaging compared with traction images, and the consistency of treatment recommendations.

METHODS

Eleven observers were asked to evaluate two blinded presentations of either traction images or CT images displaying seventeen different intra-articular distal radial fractures. Each observer was then asked to identify the presence or absence of six specific fracture fragments (radial column, dorsal wall, dorsal ulnar corner, volar ulnar corner, volar rim, and central impaction) and recommend treatment (nonoperative, open reduction and internal fixation, and external fixation or distraction plating). Analyses were conducted to evaluate the interobserver reliability of traction images and CT images for fracture fragment identification, the intraobserver variability of fracture fragment identification, the correct fracture fragment identification with traction radiographs compared with a gold standard CT scan, and the consistency in treatment selection.

RESULTS

Interobserver reliability for traction images and CT images were both fair to poor. Intraobserver variability for fragment identification was similar for each fragment, without significance. Treatment recommendations based on traction radiographs agreed in 80.9% of the cases for open reduction and internal fixation and in 67.9% for external fixation compared with CT images.

CONCLUSIONS

Traction radiographic images are a suitable alternative to CT imaging for identifying and assessing distal radial fractures.

Safety of immediate open reduction and internal fixation of geriatric open fractures of the distal radius

INTRODUCTION AND AIM

There is a paucity of literature regarding outcomes of open fractures of the distal radius. No study has detailed this injury or treatment strategy in the geriatric population. The purpose of this study was to determine the safety of immediate open reduction and internal fixation of geriatric open fractures of the distal radius.

METHODS

A total of 21 geriatric patients with open fractures of the distal radius treated with a single definitive procedure were identified from a prospectively collected database. We reviewed patient demographics, injury characteristics and treatment specifics. Our primary outcome was surgical-site infection defined by need for antibiotics or repeat surgery. Our secondary outcome was need for other re-operation. Patients were contacted and functional scores obtained.

RESULTS

Patients were followed up for an average of 26 months. One deep infection and one nonunion occurred, and they required repeat surgery. Four minor operative complications occurred, including stiffness requiring manipulation and prominent fixation devices requiring removal. Patients maintained an average wrist flexion-extension arc of 89° and pronation-supination arc of 137°. The average QuickDASH (shortened disabilities of the arm, shoulder and hand questionnaire) score was 17.4, indicating minimal disability of the upper extremity.

CONCLUSIONS

Immediate open reduction and internal fixation of geriatric open fractures of the distal radius yields adequate functional results with low risk of major complications.