w w w . r b o . o r g . b r
Original
article
Statistical
analysis
on
the
concordance
of
the
radiological
evaluation
of
fractures
of
the
distal
radius
subjected
to
traction
夽
Daniel
Gonc¸alves
Machado,
Sergio
Auto
da
Cruz
Cerqueira,
Alexandre
Fernandes
de
Lima,
Marcelo
Bezerra
de
Mathias,
José
Paulo
Gabbi
Aramburu,
Rodrigo
Ribeiro
Pinho
Rodarte
∗HospitalCentraldaPolíciaMilitardoRiodeJaneiro,RiodeJaneiro,RJ,Brazil
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t
i
c
l
e
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n
f
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Articlehistory:
Received3November2014 Accepted29December2014 Availableonline21January2016
Keywords:
Fracturesoftheradius Radiography
Traction
a
b
s
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c
t
Objective:Theobjectiveofthisstudywastoevaluatethecurrentclassificationsfor frac-turesofthedistalextremityoftheradius,sincetheclassificationsmadeusingtraditional radiographsinanteroposteriorandlateralviewshavebeenquestionedregardingtheir repro-ducibility.Intheliterature,ithasbeensuggestedthatotheroptionsareneeded,suchasuse ofpreoperativeradiographsonfracturesofthedistalradiussubjectedtotraction,with strati-ficationbytheevaluators.Theaimwastodemonstratewhichclassificationsystemspresent betterstatisticalreliability.
Results:IntheUniversalclassification,theresultsfromthethird-yearresidentgroup(R3)and fromthegroupofmoreexperiencedevaluators(Staff)presentedexcellentcorrelation,with astatisticallysignificantp-value(p<0.05).Neitherofthegroupspresentedastatistically significantresultthroughtheFrykmanclassification.IntheAOclassification,therewere highcorrelationsintheR3andStaffgroups(respectively0.950and0.800),withp-values lowerthan0.05(respectively<0.001and0.003).
Conclusion: Itcanbeconcludedthatradiographsperformedundertractionshowedgood con-cordanceintheStaffgroupandintheR3group,andthatthisisagoodtacticforradiographic evaluationsoffracturesofthedistalextremityoftheradius.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.
夽
WorkperformedintheOrthopedicsandTraumatologyService,HospitalCentraldaPolíciaMilitardoRiodeJaneiro,RiodeJaneiro,RJ, Brazil.
∗ Correspondingauthor.
E-mail:rrodarte@globo.com(R.R.P.Rodarte).
http://dx.doi.org/10.1016/j.rboe.2014.12.010
Análise
estatística
da
concordância
na
avaliac¸ão
radiológica
das
fraturas
de
rádio
distal
submetidas
a
trac¸ão
Palavras-chave: Fraturasdorádio Radiografia Trac¸ão
r
e
s
u
m
o
Objetivo: Avaliarasclassificac¸õesatuaisdafraturadaextremidadedistaldorádio,poisas classificac¸õesfeitasemradiografiastradicionaisnasincidênciasanteroposterioreperfiltêm sidoquestionadasquantoasuareprodutibilidadeeésugeridapelaliteraturaanecessidade deoutrasopc¸ões,comousodasradiografiaspré-operatóriassubmetidasatrac¸ãodefraturas derádiodistal,estratificadospelosavaliadores,comvistasademonstrarquaisclassificac¸ões apresentammelhorconfiabilidadeestatística.
Resultados: Naclassificac¸ãoUniversalosresultadosdosgruposdeR3eStaffapresentaram umaótima correlac¸ão,comum p-valorestatisticamentesignificativo (p<0,05). Quando avaliadaa classificac¸ãode Frykman,nenhumgrupoapresentouum resultado estatisti-camente significativo.Na classificac¸ão AO,nosgrupos R3 eStaff, a correlac¸ãofoi alta (respectivamente0,950e0,800)comump-valorabaixode0,05(respectivamente<0,001 e0,003).
Conclusão: Atrac¸ãoparafeituradasradiografiassemostroucomumaboaconcordância principalmentenosgruposavaliadoresdemaiorexperiência(Staff)enoresidentede3o anoeéumaboatáticanaavaliac¸ãoradiográficadafraturadaextremidadedistaldorádio. ©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.
Introduction
Fracturesofthedistalextremityofthe radiusarevery fre-quentinjuriesnowadaysandthis,alongwithtechnological advances,hasledtomuchdebateamongorthopedistswith regardtoimprovementoftheirtreatment.1
Thedifferentapproachesandoutcomeshavestimulated authorstoseekclassificationsystemsthatwouldguide diag-nosisandtreatment.2Classificationsforthedistalextremity oftheradiushavetheaimsofrankingtheinjuries,enabling betterknowledgeandservingasfacilitatorsinthe decision-making process, either for conservative treatment or for surgicaltreatment,andwithregardtothelatter,determining whichtechniquewouldbebest.Awidevarietyofmethodsfor treatingthedistalextremityoftheradiusexists,3goingfrom conservativetosurgicaltreatment,usingdifferenttechniques (fixationusingKirschnerwires;ligamentotaxisusingan exter-nalfixatorwithorwithoutassociatedKirschnerwires;open reductionusingrigidinternalfixation;andabsolute stabiliza-tionbymeansofosteosynthesisusingaplateandscrewswith orwithoutgrafting).Useofimagingtechnologyfor classifica-tionswithinorthopedicshasbeenanalyzedbyresearchers,4 inrelationtoradiography,5,6computedtomographyor mag-netic resonance imaging.7 The reproducibility of fracture evaluationsthroughusingclassificationsystemsisextremely importantforreliability.Useofsuchsystemsisanimportant stageinquantifyingtheseverityoftheinjuryandthis demon-stratesthesafetyofusingcertainclassifications.8–11Interand intraobserverconsistencyisaprerequisiteforefficientuseof anyclassificationsystem.
Classificationsthataremadeusingtraditionalradiographs inposteroanterior and lateral views have been questioned regardingtheirreproducibility.INtheliterature,ithasbeen
suggested that there is a need for other options, such as computed tomography.9 However,amongthelimitationsof computedtomographyisitsgreatercostandhigherradiation doseinrelationtoradiography.Radiographyperformedunder tractionisamongtheotheroptionsoflowercostandgreater practicality,andthismayincreasethereliabilityofanalyses onjointfractures.12
Theobjectiveofthisstudywastoevaluatethecurrent clas-sificationsystemsforfracturesofthedistalradiusbymeans of preoperative radiographs produced under traction, with stratificationbytheevaluators, withaviewto demonstrat-ing whichclassificationsystemspresentthe beststatistical reliability.
Methodology
A retrospective observational study was conducted in our institutionbasedon30radiographsonpatientswhohadbeen admitted tothe orthopedicsand traumatology service and whounderwentsurgicalprocedurestotreatfracturesofthe distalextremityoftheradius.
Theauthorsdeclarethatthisstudywasinaccordancewith theDeclarationofHelsinki.
Universalclassification(Cooney)
I. extra-articularwithoutdisplacement II. extra-articularwithdisplacement
A. stableandreducible B. unstableandreducible C. irreducible
III. intra-articularwithoutdisplacement IV. intra-articularwithdisplacement
A. stableandreducible B. unstableandreducible C. irreducible
D. complex
Frykmanclassification
I. extra-articular
II. extra-articular+fracturingofthedistalulna III. intra-articular(radiocarpaljoint)
IV. intra-articular(radiocarpaljoint)+fracturingofthedistal ulna
V. intra-articular(distalradioulnarjoint)
VI. intra-articular(distalradioulnarjoint+fracturingofthe distalulna
VII. intra-articular(radiocarpalanddistalradioulnarjoints) VIII. intra-articular (radiocarpal and distal radioulnar
joints)+fracturingofthedistalulna
AOclassification
A–extra-articular
A1–ulnaandradiusintact
A2–simpleandimpactedfracturesoftheradius A3–multifragmentedfractureoftheradius
B–partialintra-articular
B1–sagittalfactureoftheradius
B2–frontalanddorsaledgefractureoftheradius B3–frontalandvolaredgefractureoftheradius
C–completeintra-articularfractureoftheradius
C1–simpleatjointandsimpleinmetaphysis
C2–simpleatjointandmultifragmentedinmetaphysis C3–multifragmentedatjoint
Eachgroupaccordingtoyearofresidencycomprisedthree residents. Thus, three evaluators were first-year residents, threewere second-yearresidentsandthreewere third-year residents.Threestaffphysiciansalsoformedpartofthegroup, asareferencegroup.
Statisticalanalysis
Theresultsfromanalyzingtheradiographswithregardtothe differentclassificationsystems(Frykman,AOandUniversal) weretabulatedandtheSPSSstatisticalpackage(IBM),version 13.0,wasusedfortheconcordanceanalysis.
Firststage:exploratoryanalysisofthecentraltrendand dispersionmeasurementsonthevariablesobtained.
Secondstage:evaluationoftheintraandinter-group inter-examinerconcordance(R1/R2/R3andStaff)bymeansofthe intraclasscorrelation(ICC).
Thirdstage:identificationofconcordancebetweenthe con-trolgroup(Staff)andR3intheuniversalclassificationwithand withoutthesubtypes.
Results
Thethreeclassificationspresentedverydifferentresultsin correlationsthatweremadewiththeaimofexaminingthe consistencyoftheevaluationsbetweenthegroupsof evalua-tors.
In evaluating the universal classification proposed by Cooney,13 thegroups ofevaluators presentedbehaviorthat differedgreatly.
Thegroupoffirst-yearresidentspresentedlow concord-ance(0.236),withlowstatisticalsignificance(p-value=0.278). Thegroupofsecond-yearresidentspresentedgreater con-cordance,althoughstillatanintermediatelevel(0.566),with ap-valueof0.064,whichwasatthelimitofsignificance.
The results from the R3 and Staff groups presented excellent correlations, withstatisticallysignificant p-values (p<0.05).When theCooneyclassificationwasusedwithout evaluatingthecriterionofstabilityofposition(fullStaff ver-susStaff),theconcordancewasseentoincrease(from0.725 to0.786),withasignificantp-value(p<0.05).WhentheR3and Staffgroupswerecompared,thisshowedhighconcordance betweenthegroups(Table1).
WhentheFrykmanclassificationwasevaluated,noneof the groupspresentedastatisticallysignificantresult(allof thempresentedp-values>0.05),althoughtheStaffgroup pre-sentedanadequatecorrelation(0.885)(Table2).
AnalysisontheAOclassificationshowedthatthegroups presentedbehavioraldifferences(Table3).
TheR1grouppresentedlowconcordanceandalsoap-value withlowstatisticalsignificance.
TheR2grouppresentedgoodcorrelation,withap-valueof 0.032(statisticallysignificant).
For the R3 and Staff groups, the correlationswere high (respectively 0.950 and 0.800), withp-valuesless than 0.05 (respectively<0.001and0.003).
Table1–Analysisontheintraclasscorrelationbetween thegroupsofevaluatorsusingCooney’suniversal classificationsystem.
Group Correlation pvalue
R1 0.236 0.278
R2 0.566 0.064
R3 0.828 0.009
Staff(Complete) 0.725 0.012
Staff 0.786 0.003
Staff/R3 0.738 0.008
Table2–Analysisontheintraclasscorrelationbetween thegroupsofevaluatorsusingFrykman’sclassification system.
Group Correlation pvalue
R1 0.222 0.302
R2 0.557 0.077
R3 0.515 0.159
Staff 0.885 0.835
Source:Hospital.
Table3–Analysisontheintraclasscorrelationbetween thegroupsofevaluatorsusingtheAOclassification system.
Group Correlation pvalue
R1 0.057 0.432
R2 0.656 0.032
R3 0.95 <0.001
Staff 0.8 0.003
Source:Hospital.
Discussion
Fracturesofthedistalextremityoftheradiusareamongthe mostfrequenttypesoffracturesoftheskeleton,accordingto Reisetal.,14andaccountforupto10%ofskeletalfractures. Paksimaetal.15statedthattheyareresponsibleforoneinsix emergencyorthopediccasesattended.
Theconcernforobservingradiographicresultsinrelation tofunctionaloutcomeshasbeenevaluatedrecently.16
Theinitialstatusofthefracture,3alongwiththe comminu-tion,isconsideredtobeafactorthatcontributestowardthe outcomefromthefracture.
Theexistenceofvariousclassificationsdemonstratesthat thereisaneedtoobtainasingleidealclassificationthatwould beverywide-rangingand wouldprovidesupportfor thera-peuticandprognosticconduct.17Morethan20classification systemsforfracturesofthedistalextremityoftheradiushave beendescribed.Ifaclassificationsystemhasfulfilledallthe premisesforsupplyingsupport,itwillstillneedtopresent intraandinterobserverreproducibility.Severalauthorshave statedthat choosingtheidealtreatmentforstabilizing the fracture is of fundamental importance.3,10,15 According to DowningandKarantana,18no otherfracture treatmenthas been influenced bytechnology inthe way thattreatments forfracturesofthe distalextremityoftheradiushave.18,19 Therefore,theprospectofmakinganappropriatediagnosis, classifyingthefracturewithgreaterreproducibilityand reli-ability and choosing the most appropriate technique have becomethepillarsforachievingthebestresultpossible.20–22 Recognizingthe characteristicsofthe fractureisextremely important,23–25sincecertainfactorsthatpredictinstability,as describedbyLafontaineetal.,26needtobewellrecognizedin makingtheradiographicassessment.
Inastudy onradiographicassessmentwithouttraction, Flinkkiläetal.27suggestedthattheAOandFrykman classifi-cationspresentedlowvalueandthatthiswasaccompanied
bylowconcordanceregardingtheclinicaloutcome.The per-centage concordancebetween different evaluators through usingthecomplete AOclassificationhasrangedfrom17to 40%fromradiographsandfrom17to50%fromtomography. InthestudybyKrederetal.,28theinterobserverconcordance valuesfromtheAOclassificationwas0.67betweenresidents and 0.86 between surgeons, through evaluating the major types (A, Band C). When all the subtypes were used, the concordancedecreasedto0.25and0.42,respectively.Useof additionaltoolssuchascomputedtomographyhastheaim ofimprovingtheclassification.Betterresultswithregardto identifyingthepresenceorabsenceofsixspecificfragments of thefracture (radial column, dorsal wall, dorsoulnar cor-ner,volar-ulnarcorner,volaredgeandcentralimpaction),so astomaketreatmentrecommendations arefoundthrough radiography undertraction and computed tomography.9 In ourstudy,weobservedagoodcorrelationthroughthe uni-versalclassification.TheFrykmanclassificationshowedalow levelofconcordanceinthepresentstudy,andthiswasinline withtheliterature.Ontheotherhand,theAOclassification presentedexcellentconcordance.AccordingtoKüc¸üketal.,22 theclassificationsystemsforevaluatingfracturesofthe dis-talextremityoftheradiuspresentedinconsistentresultsand theysuggestedthattherewasaneedtocreatenew classi-fications. Inthestudy byEvans etal.,29,30 the sensitivityof radiographsformakingclassificationsusingtheFrykmanand AOsystemswasonly12.5%.Theseauthorsstatedthat evalua-tionsusingradiographsalonewereinsufficientandsuggested thattherewasaneedforothertypesofexaminationsinorder toincreasethereliabilityandreproducibility,aswefoundin thepresentedstudy,inwhichweachievedgoodconcordance usingtheuniversalandAOclassificationsystems.
Conclusion
In the present study, it was observed that evaluations on radiographs produced under traction presented high concordance through the AO and universal classification systems.
RegardingtheFrykmanclassification,wedidnotfindgood reliabilityfromthisevaluation,evenonradiographsproduced undertraction.
We conclude that radiographs produced under traction showed good concordance, especially in the groups with greaterexperiencethatwereevaluated(staffandthird-year residents),andthatthisisagoodtacticinmakingradiographic assessmentsoffracturesofthedistalextremityoftheradius throughCooney’suniversalclassificationandtheAO classifi-cation.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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