The substantial variation in treatment recommendations and final treatment choices from clinician-to-clinician suggests that clinician bias and incentives may be having more influence on care than what matters most to a given patient (their values). 

Radiographic measures of alignment  of a fracture of the distal radius influences surgeon treatment recommendations. Threshold values are sometimes offered as a guide to treatment. In one study, surgeons that received measurements rather than radiographs recommended operative treatment significantly more often but were less likely to agree on treatment modality than surgeons evaluating actual radiographs (1). Radiographic criteria explained 49% of the variation in recommendations. These findings suggest that there may be radiographic factors other than measures of deformity that some surgeons use to determine recommendations for surgery (1).

In another study, surgeon recommendation for operative treatment of a distal radius fracture was determined by radiographic factors and was not influenced by clinical information (2). Surgery was recommended on average 52% of the time whether or not surgeons received clinical information. Women surgeons, surgeons with less than 21 years of experience, and hand surgeons were more likely to recommend operative treatment, but these factors explained only 1% of the variation. Radiographic criteria explained 49% of the variation.  

One of our recent studies found no difference in inter-observer reliability, decision-making, and confidence in decision-making in the treatment of distal radius fractures changes if radiographs are viewed on a messenger application on a mobile phone compared to a standard DICOM viewer (3). Mobile phone-based communication (e.g. What’s App or text) could facilitate remote decision-making for patients with distal radius fractures.

There is substantial variation in the classification and management of scapula fractures. The first purpose of another one of our studies was to analyze the inter-observer reliability of the OTA/AO classification and the New International Classification for Scapula Fractures. The second purpose was to assess the proportion of agreement among orthopaedic surgeons on operative or nonoperative treatment. The New International Classification was found to be more reliable (4). Body and process fractures generated more disagreement than intra-articular fractures and need more clear definitions for treatment decision-making.

Inter-observer reliability for the classification of proximal humeral fractures is limited. A study found that proximal humeral fracture classifications may be helpful conceptually, but they have poor inter-observer reliability even when 3-D rather than 2-D CT imaging is utilized (5). This may contribute to the similarly poor inter-observer reliability that was observed for selection of the treatment for proximal humeral fractures. The lack of a reliable classification confounds efforts to compare the outcomes of treatment methods among different clinical trials and reports.

Stable fixation of distal humerus fracture fragments is necessary for adequate healing and maintenance of reduction. The purpose of one of our studies was to measure the reliability and accuracy of interpretation of postoperative radiographs to predict which implants will loosen or break after operative treatment of bicolumnar distal humerus fractures. When experienced and skilled surgeons perform fixation of type C distal humerus fracture, the immediate postoperative radiograph is not predictive of fixation failure. Reoperation based on the probability of failure might not be advisable (6). 

Another study addressed the inter-observer variability in the treatment of little finger metacarpal neck fractures. Surgeons shown radiographs with measured angulation were more likely to recommend surgery than surgeons shown unmarked radiographs, and there was less variability among these surgeons, particularly for fractures with less angular deformity (7). These results show that measured fracture angulation has a small but significant influence on treatment recommendations for little finger metacarpal neck fractures. This might reflect anchoring bias and an undue attention to numerical thresholds. 

Decisions about return to activity and additional surgery are often made on the basis of radiographs obtained three months after injury. If radiographs three months after injury cannot reliably and accurately diagnose union, then patients may be needlessly disabled and might receive unnecessary treatments including surgery. We evaluated the accuracy and the reliability of the diagnosis of union or eventual union on radiographs obtained 3 months after open reduction and internal fixation of a fracture of the distal tibia by having 69 trauma surgeons evaluate radiographs of 33 consecutively treated patients in an online survey. Observers were also asked to judge specific criteria that are commonly used to diagnose fracture union. There was moderate inter-observer reliability for the diagnosis of union or diagnosis of “eventual union” (8). The inter-observer agreement for the various specific radiographic signs of union varied between fair to moderate. Therefore, decisions about activity level and additional treatment three months after injury should not be based on radiographs alone.

References

1. Neuhaus V, Bot AG, Guitton TG, Ring DC. Radiographs Versus Radiographic Measurements in Distal Radius Fractures. J Hand Microsurg. 2015 Jun;7(1):42-8. Doi: 10.1007/s12593-014-0164-0. Epub 2014 Oct 21. PubMed PMID: 26078502; PubMed Central PMCID: PMC4461633.
2. Neuhaus V, Bot AG, Guitton TG, Ring DC. Influence of surgeon, patient and radiographic factors on distal radius fracture treatment. J Hand Surg Eur Vol. 2015 Oct;40(8):796-804. doi: 10.1177/1753193414555284. Epub 2014 Oct 22. PubMed PMID: 25342650.
3. Özkan S, Mellema JJ, Ring D, Chen NC. Interobserver Variability of Radiographic Assessment Using a Mobile Messaging Application as a Teleconsultation Tool. Arch Bone Jt Surg. 2017 Sep;5(5):308-314. PubMed PMID: 29226202; PubMed Central PMCID: PMC5712397.
4. Neuhaus V, Bot AG, Guitton TG, Ring DC; Science of Variation Group, Abdel-Ghany MI, Abrams J, Abzug JM, Adolfsson LE, Balfour GW, Bamberger HB, Barquet A, Baskies M, Batson WA, Baxamusa T, Bayne GJ, Begue T, Behrman M, Beingessner D, Biert J, Bishop J, Alves MB, Boyer M, Brilej D, Brink PR, Brunton LM, Buckley R, Cagnone JC, Calfee RP, Campinhos LA, Cassidy C, Catalano L 3rd, Chivers K, Choudhari P, Cimerman M, Conflitti JM, Costanzo RM, Crist BD, Cross BJ, Dantuluri P, Darowish M, de Bedout R, DeCoster T, Dennison DG, DeNoble PH, DeSilva G, Dienstknecht T, Duncan SF, Duralde XA, Durchholz H, Egol K, Ekholm C, Elias N, Erickson JM, Esparza JD, Fernandes CH, Fischer TJ, Fischmeister M, Forigua Jaime E, Getz CL, Gilbert RS, Giordano V, Glaser DL, Gosens T, Grafe MW, Filho JE, Gray RR, Gulotta LV, Gummerson NW, Hammerberg EM, Harvey E, Haverlag R, Henry PD, Hobby JL, Hofmeister EP, Hughes T, Itamura J, Jebson P, Jenkinson R, Jeray K, Jones CM, Jones J, Jubel A, Kaar SG, Kabir K, Kaplan FT, Kennedy SA, Kessler MW, Kimball HL, Kloen P, Klostermann C, Kohut G, Kraan GA, Kristan A, Loebenberg MI, Malone KJ, Marsh L, Martineau PA, McAuliffe J, McGraw I, Mehta S, Merchant M, Metzger C, Meylaerts SA, Miller AN, Wolf JM, Murachovsky J, Murthi A, Nancollas M, Nolan BM, Omara T, Omid R, Ortiz JA, Overbeck JP, Castillo AP, Pesantez R, Polatsch D, Porcellini G, Prayson M, Quell M, Ragsdell MM, Reid JG, Reuver JM, Richard MJ, Richardson M, Rizzo M, Rowinski S, Rubio J, Guerrero CG, Satora W, Schandelmaier P, Scheer JH, Schmidt A, Schubkegel TA, Schulte LM, Schumer ED, Sears BW, Shafritz AB, Shortt NL, Siff T, Silva DM, Smith RM, Spruijt S, Stein JA, Pemovska ES, Streubel PN, Swigart C, Swiontkowski M, Thomas G, Tolo ET, Turina M, Tyllianakis M, van den Bekerom MP, van der Heide H, van de Sande MA, van Eerten PV, Verbeek DO, Hoffmann DV, Vochteloo AJ, Wagenmakers R, Wall CJ, Wallensten R, Wascher DC, Weiss L, Wiater JM, Wills BP, Wint J, Wright T, Young JP, Zalavras C, Zura RD, Zyto K. Scapula fractures: interobserver reliability of classification and treatment. J Orthop Trauma. 2014 Mar;28(3):124-9. Doi: 10.1097/BOT.0b013e31829673e2. PubMed PMID: 23629469.
5. Bruinsma WE, Guitton TG, Warner JJ, Ring D; Science of Variation Group. Interobserver reliability of classification and characterization of proximal humeral fractures: a comparison of two and three-dimensional CT. J Bone Joint Surg Am. 2013 Sep 4;95(17):1600-4. doi: 10.2106/JBJS.L.00586. PubMed PMID: 24005201.
6. Claessen FM, Stoop N, Doornberg JN, Guitton TG, van den Bekerom MP, Ring D; Science of Variation Group. Interpretation of Post-operative Distal Humerus Radiographs After Internal Fixation: Prediction of Later Loss of Fixation. J Hand Surg Am. 2016 Aug 10. pii: S0363-5023(16)30376-8. doi: 10.1016/j.jhsa.2016.07.094. [Epub ahead of print] PubMed PMID: 27522299.
7. Tosti R, Ilyas AM, Mellema JJ, Guitton TG, Ring D; Science of Variation Group. Interobserver variability in the treatment of little finger metacarpal neck fractures. J Hand Surg Am. 2014 Sep;39(9):1722-7. Doi: 10.1016/j.jhsa.2014.05.023. Epub 2014 Jul 14. PubMed PMID: 25034789.
8. van Kollenburg JA, Vrahas MS, Smith RM, Guitton TG, Ring D; Science of Variation Group. Diagnosis of union of distal tibia fractures: accuracy and interobserver reliability. Injury. 2013 Aug;44(8):1073-5. Doi: 10.1016/j.injury.2012.10.034. Epub 2012 Nov 28. PubMed PMID: 23200031.