The diagnosis of displacement in scaphoid fractures is notorious for poor inter-observer reliability. We tested whether training can improve inter-observer reliability and sensitivity, specificity, and accuracy for the diagnosis of scaphoid fracture displacement on radiographs and CT scans. Our results suggest training can improve inter-observer reliability and sensitivity, specificity and accuracy for the diagnosis of scaphoid fracture displacement, but the improvements are slight (1). These findings are encouraging for future research regarding inter-observer variation and how to reduce it further.

The Broberg and Morrey modification of the Mason classification of radial head fractures has substantial inter-observer variation. This study used a large web-based collaborative of experienced orthopaedic surgeons to test the hypothesis that three-dimensional reconstructions of computed tomography (CT) scans improve the inter-observer reliability of the classification of radial head fractures according to the Broberg and Morrey modification of the Mason classification. It was found that although three-dimensional CT scans led to some small but significant decreases in inter-observer variation, there is still considerable disagreement regarding classification and characterization of radial head fractures. Three-dimensional CT scans may be insufficient to optimize inter-observer agreement (2). Another study measured observer variation in radiographic rating of elbow arthrosis and found that the four grades of the Broberg and Morrey classification system have only fair inter-observer reliability that is influenced by subspecialty and experience (3). Binary rating systems might be more reliable.

Loss of contact between radial head fracture fragments is strongly associated with other elbow or forearm injuries. It was found that radiographic signs of radial head fracture instability, such as loss of contact, have moderate inter-observer reliability. This characteristic seems clinically useful, because loss of contact between at least one radial head fracture fragment and the remaining radial head and neck is strongly associated with associated ligament injury or other fractures (4).

Several studies support the use of CT for diagnosing coronal plane fracture lines of the distal radius, but the inter-observer reliability of these observations is less well-studied. It was found that two-dimensional computed tomography does not improve observer agreement on the diagnosis of coronal plane articular fracture lines in the lunate facet of the distal radius (5).

Studies of traumatic elbow instability suggest that recognition of a pattern in the combination and character of the fractures and joint displacements helps predict soft tissue injury and guide the treatment of traumatic elbow instability, but there is no evidence that patterns can be identified reliably. We therefore determined the inter-observer reliability of identifying specific patterns of traumatic elbow instability on radiographs for subgroups of orthopaedic surgeons and the diagnostic accuracy of radiographic diagnosis. It was found that specific patterns of traumatic elbow instability can be diagnosed with moderate inter-observer reliability and reasonable accuracy on radiographs (6).

References

1. Buijze GA, Guitton TG, van Dijk CN, Ring D; Science of Variation Group. Training improves interobserver reliability for the diagnosis of scaphoid fracture displacement. Clin Orthop Relat Res. 2012 Jul;470(7):2029-34. Doi: 10.1007/s11999-012-2260-4. PubMed PMID: 22290132; PubMed Central PMCID: PMC3369105.
2. Guitton TG, Ring D; Science of Variation Group. Interobserver reliability of radial head fracture classification: two-dimensional compared with three-dimensional CT. J Bone Joint Surg Am. 2011 Nov 2;93(21):2015-21. Doi: 10.2106/JBJS.J.00711. PubMed PMID: 22048097.
3. Lindenhovius A, Karanicolas PJ, Bhandari M, Ring D; COAST Collaborative. Radiographic arthrosis after elbow trauma: interobserver reliability. J Hand Surg Am. 2012 Apr;37(4):755-9. doi: 10.1016/j.jhsa.2011.12.043. Epub 2012 Mar 6. PubMed PMID: 22397846.
4. Bruinsma WE, Guitton T, Ring D; Science of Variation Group. Radiographic loss of contact between radial head fracture fragments is moderately reliable. Clin Orthop Relat Res. 2014 Jul;472(7):2113-9. doi: 10.1007/s11999-014-3592-z. PubMed PMID: 24711128; PubMed Central PMCID: PMC4048410.
5. Wijffels MM, Guitton TG, Ring D; Science of Variation Group. Inter-observer variation in the diagnosis of coronal articular fracture lines in the lunate facet of the distal radius. Hand (N Y). 2012 Sep;7(3):271-5. Doi: 10.1007/s11552-012-9421-5. PubMed PMID: 23997731; PubMed Central PMCID: PMC3418374.
6. Doornberg JN, Guitton TG, Ring D; Science of Variation Group. Diagnosis of elbow fracture patterns on radiographs: interobserver reliability and diagnostic accuracy. Clin Orthop Relat Res. 2013 Apr;471(4):1373-8. Doi: 10.1007/s11999-012-2742-4. Epub 2012 Dec 18. PubMed PMID: 23247817; PubMed Central PMCID: PMC3586040.