Partial articular fractures of the radial head: How to understand them using computed tomography

A proposal for computed tomography-based algorithm for the management of radial head and neck fractures: the Proximal and Articular Radial fractures Management (PARMa) classification

Background

Owing to the great variety of fracture patterns and limitations of the standard radiographic investigation, all the already available classification systems for radial head and neck fractures (RHNFs) are limited by a poor-to-moderate degree of intraobserver and interobserver reliability. Although computed tomography (CT) is being increasingly used to better understand the fracture characteristics, a CT-based classification system of RHNFs is still lacking. Therefore, in this agreement study, we aimed to propose a classification system based on two-dimensional and three-dimensional (2D/3D) CT to test the hypothesis that this classification has good intraobserver and interobserver reliability. We have also provided a treatment algorithm.

Methods

Our proposed classification-Proximal and Articular Radial fractures Management (PARMa)-is based on 2D/3D CT imaging. It is divided into four types based on different fractures patterns. The 2D/3D scans of 90 RHNFs were evaluated in a blinded fashion by eight orthopedic and one radiology consultant, according to the proposed classification. The first phase of observation aimed to estimate the interobserver agreement. The second phase involved a new observation, 4 weeks after the first analysis, and estimated the intraobserver reliability. The standard radiographs of these 90 fractures were also evaluated by the same observers, with the same timing and methods, based on the same classification. Cohen's Kappa was applied for intraobserver agreement. Fleiss's Kappa was used both within and among the evaluators. Kendall's coefficient of concordance was employed to determine the strength of association among the appraisers' rankings. Furthermore, Krippendorff's alpha was chosen as an adjunctive analysis to assess between evaluators' agreement.

Results

For the intraobserver agreement, Fleiss' Kappa statistics confirmed the consistency (overall kappa values: 0.70-0.82). Cohen's Kappa statistics aligned with Fleiss' Kappa, with similar kappa values and significant P values (P < .001). For interobserver agreement, Fleiss' Kappa statistics for between appraisers showed moderate-to-substantial agreement, with kappa values ranging from 0.54 to 0.82 for different responses. The results relating to the appraisers' observation of standard radiographs showed that the overall Fleiss' Kappa values for intraobserver agreement ranged from 0.34 to 0.82, whereas Fleiss' Kappa statistics for interobserver agreement ranged from 0.40 to 0.69.

Conclusions

The proposed classification system is expected to be reliable, reproducible, and useful for preoperative planning and surgical management. Both 2D and 3D CT allow the identification of the magnitude and position of displacement and articular surface involvement.

Comparative study of open elbow arthrolysis with and without hinge external fixation for the treatment of post-traumatic elbow stiffness

BACKGROUND

The present study aimed to compare the functional outcomes of hinged external fixators and non-external fixation in open elbow arthrolysis (OEA) for post-traumatic elbow stiffness (PTES) and to evaluate their applicability and limitations in patients with posttraumatic elbow stiffness.

METHODS

The clinical data of patients with PTES treated with OEA at our hospital between March 2015 and June 2022 were retrospectively analyzed. The assessed variables were the operation time, intraoperative blood loss volume, duration of hospitalization, and treatment costs. The elbow range of motion (ROM), Mayo Elbow Performance Score (MEPS), shortened disabilities of the arm, shoulder and hand questionnaire (Q-DASH) score, Oxford Elbow score (OES), Broberg and Morrey score (BMS), visual analog scale (VAS) for pain, and complications such as pin tract infection and heterotopic ossification were compared between patients with and without hinge external fixation. We also compared the baseline characteristics and functional outcomes of patients with and without hinge external fixation.

RESULTS

A total of 156 patients (48 patients with hinged external fixators and 108 patients without external fixators) diagnosed with PTES were included in this study. The mean follow-up was 15.8 ± 3.6 months. Compared with patients without external fixators, those with external fixators showed significantly greater improvements in elbow flexion and extension ROM (59.6° ± 26.1° vs. 46.2° ± 26.2°, p = 0.004) but had a significantly longer duration of hospitalization (p < 0.001), significantly longer operation time (p < 0.001), significantly higher treatment costs (p < 0.001), and significantly greater intraoperative blood loss volume (p < 0.001). There were no significant differences between the two groups in terms of improvement in elbow rotation ROM, MEPS score, VAS score for pain, OES score, Q-DASH score, BMS score, or incidence of complications.

CONCLUSION

The use of a hinged external fixator in open arthrolysis for posttraumatic elbow stiffness may result in short-term improvements in flexion-extension range of motion but is accompanied by increased blood loss, longer operative time, extended hospitalization, and higher costs. Further studies are needed to confirm these findings.

CLINICAL TRIAL NUMBER

Not applicable.