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Interobserver Reliability of Radial Head Fracture Classification: Two-Dimensional Compared with Three-Dimensional CT
Thierry G. Guitton, PhD; David Ring, MD, PhD; on behalf of the Science of Variation Group
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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.

Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA 02114. E-mail address for D. Ring: dring@partners.org
Investigation performed at Massachusetts General Hospital, Boston, Massachusetts, as part of the Science of Variation Group Collaborative
The Science of Variation Group: Brandon E. Earp, Amy L. Ladd, Peter J. Evans, Christina E. Kuo, Jan Biert, C.N. van Dijk, Phani K. Dantuluri, David E. Ruchelsman, K.J. Ponsen, Maximillian Soong, Tim R. Davis, Ashok K. Shyam, Laura S. Phieffer, C. Michael LeCroy, Martin Richardson, Andrew H. Schmidt, Peter L. Jebson, Paul E. Levin, Gregory J. Della Rocca, Charles A. Goldfarb, Kyle J. Jeray, David M. Kalainov, George S.M. Dyer, Neal T. Chen, A. Lee Osterman, George S. Athwal, Luke P. Leenen, Thomas W. Wright, Marc F. Swiontkowski, David J. Slutsky, Frede Frihagen, Scott F. Duncan, Rick F. Papandrea, Kevin C. Chung, Philip Blazar, Robert J. Feibel, Robert D. Zura, Huub J. van der Heide, Robert Z. Tashjian, Leon Elmans, John A. Jiuliano, Marco Rizzo, Samir Sodha, John A. McAuliffe, Randall W. Culp, Jorge Orbay, Charles Cassidy, Robert G.H. Albers, Leonid I. Katolik, Reid A. Abrams, Mark E. Baratz, Kenneth A. Egol, Joseph M. Conflitti, Doug P. Hanel, Jose M. Nolla, Michael Hausman, Andrew E. Caputo, Rudolf W. Poolman, Terry S. Axelrod, Michael D. McKee, J.C. Goslings, Parag K. Sancheti, Peter R.G. Brink, Carrie R. Swigart, Thomas B. Hughes, Keith A. Segalman, P.V. van Eerten, Brett D. Crist, Edward Diao, Richard S. Page, Lisa L. Lattanza, George Thomas, Jason C. Fanuele, Peter Kloen, Taco Gosens, Charalampos Zalavras, John S. Taras, Jeffrey A. Greenberg, Eric M. Hammerberg, Louis W. Catalano 3rd, Rodrigo F. Pesantez, Arie B. van Vugt, Steve C. Kronlage, Michael A. Baskies, Martin I. Boyer, Peter V. Giannoudis, Michael J. Prayson, and Elena Grosso.

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Nov 02;93(21):2015-2021. doi: 10.2106/JBJS.J.00711
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The Broberg and Morrey modification of the Mason classification of radial head fractures has substantial interobserver 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 interobserver reliability of the classification of radial head fractures according to the Broberg and Morrey modification of the Mason classification.


Eighty-five orthopaedic surgeons evaluated twelve radial head fractures. They were randomly assigned to review either radiographs and two-dimensional CT scans or radiographs and three-dimensional CT images to determine the fracture classification, fracture characteristics, and treatment recommendations. The kappa multirater measure (κ) was calculated to estimate agreement between observers.


Three-dimensional CT had moderate agreement and two-dimensional CT had fair agreement among observers for the Broberg and Morrey modification of the Mason classification, a difference that was significant. Observers assessed seven fracture characteristics, including fracture line, comminution, articular surface involvement, articular step or gap of ≥2 mm, central impaction, recognition of more than three fracture fragments, and fracture fragments too small to repair. There was a significant difference in kappa values between three-dimensional CT and two-dimensional CT for fracture fragments too small to repair, recognition of three fracture fragments, and central impaction. The difference between the other four fracture characteristics was not significant. Among treatment recommendations, there was fair agreement for both three-dimensional CT and two-dimensional CT.


Although three-dimensional CT led to some small but significant decreases in interobserver variation, there is still considerable disagreement regarding classification and characterization of radial head fractures. Three-dimensional CT may be insufficient to optimize interobserver agreement.

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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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