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Do Traction Radiographs of Distal Radial Fractures Influence Fracture Characterization and Treatment?
Elan Goldwyn, MD1; Raymond Pensy, MD1; Robert V. O’Toole, MD1; Jason W. Nascone, MD1; Marcus F. Sciadini, MD1; Christopher LeBrun, MD1; Theodore Manson, MD1; Jordan Hoolachan, BS2; Renan C. Castillo, PhD2; W. Andrew Eglseder, MD1
1 R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, T3R62, Baltimore, MD 21201. E-mail address for R.V. O’Toole: rvo3@yahoo.com
2 Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205
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Investigation performed at R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Nov 21;94(22):2055-2062. doi: 10.2106/JBJS.J.01207
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Our center evaluates all distal radial fractures with traction radiographs before splinting. Although investigations of various imaging modalities to evaluate distal radial fractures have been presented in the literature, to our knowledge the use of traction radiographs has not been well described. We hypothesized that the addition of traction radiographs to standard radiographs increases interobserver and intraobserver reliability for injury descriptions, affects the choice of treatment plan, and decreases the perceived need for computed tomography.


Radiographs for fifty consecutive eligible patients with distal radial fractures that were treated at a level-1 trauma center were used to create two image sets for each patient. Set 1 included injury and splint radiographs, and Set 2 included the images from Set 1 plus traction radiographs. The image sets were stripped of all demographic data and were presented in random order to seven fellowship-trained orthopaedic surgeons. The surgeons independently reviewed each of the 100 image sets and answered ten questions regarding the description and treatment of the injury. Analyses were conducted with kappa statistics to evaluate interobserver reliability. Intraobserver variability was assessed with the McNemar test after adjusting for clustering.


Traction radiographs improved interobserver reliability for four of ten questions. With regard to intraobserver variability, responses to two questions were significantly changed. With the addition of traction radiographs, the observation of intra-articular fragments requiring reduction increased from 38.3% to 53.1% (p < 0.05) and the perceived need to order computed tomography for further evaluation decreased from 21.7% to 5.1% (p < 0.001). No other changes reached significance.


The addition of traction radiographs appeared to affect surgeons’ interobserver reliability in the evaluation of distal radial fractures. In addition, traction radiographs changed the rate of detection of intra-articular fragments requiring reduction and the perceived need for computed tomography. These data indicate that traction radiographs may provide some of the same information as computed tomographic scans at a lower cost and argue for additional research comparing computed tomographic scans and traction radiographs of the distal part of the radius.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    P.V. van Eerten MD
    Posted on November 22, 2012
    Do traction radiographs really improve distal radial fracture diagnostics?
    MMC Veldhoven Netherlands

    Elan Goldwyn and co-workers did an interesting, well performed study of traction radiographs in distal radial fractures. Their main conclusion is that traction radiographs appeared to affect the interobserver reliability. They showed an increase in kappa from 0.43 to 0.51 for intra versus extra-articular as main improvement. But what is the value of this improvement? It is still a kappa range from 0.40 -0.60, which means a moderate agreement. So unfortunately not a meaningful improvement. In the end of their article they state that it is their belief that traction radiographs reveal how well the displaced fragments can be brought into position. This final conclusion is not supported by the data presented in this study and seems to call for future investigation.

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