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Two and Three-Dimensional Computed Tomography for the Classification and Management of Distal Humeral FracturesEvaluation of Reliability and Diagnostic Accuracy
Job Doornberg, MS1; Anneluuk Lindenhovius, MS1; Peter Kloen, MD, PhD2; C. Niek van Dijk, MD, PhD2; David Zurakowski, PhD, MPH3; David Ring, MD1
1 Massachusetts General Hospital, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA 02116. E-mail address for D. Ring: dring@partners.org
2 Academic Medical Center, Meibergdreef 9, 1100 DD Amsterdam, The Netherlands. E-mail address for P. Kloen: p.kloen@amc.uva.nl
3 Departments of Orthopaedic Surgery and Biostatistics, Children's Hospital, Boston, 300 Longwood Avenue, Boston, MA 02115
View Disclosures and Other Information
Note: The authors acknowledge the substantial contributions of Drs. Chris Forthman, Chaitanya Mudgal, and Jesse B. Jupiter to this study.
In support of their research for or preparation of this manuscript, one or more of the authors received grants or outside funding from the AO Foundation. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at Massachusetts General Hospital and the Departments of Orthopaedic Surgery and Biostatistics, Children's Hospital, Boston, Massachusetts, and the Academic Medical Center, Amsterdam, The Netherlands

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Aug 01;88(8):1795-1801. doi: 10.2106/JBJS.E.00944
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Background: Complex fractures of the distal part of the humerus can be difficult to characterize on plain radiographs and two-dimensional computed tomography scans. We tested the hypothesis that three-dimensional reconstructions of computed tomography scans improve the reliability and accuracy of fracture characterization, classification, and treatment decisions.

Methods: Five independent observers evaluated thirty consecutive intra-articular fractures of the distal part of the humerus for the presence of five fracture characteristics: a fracture line in the coronal plane; articular comminution; metaphyseal comminution; the presence of separate, entirely articular fragments; and impaction of the articular surface. Fractures were also classified according to the AO/ASIF Comprehensive Classification of Fractures and the classification system of Mehne and Matta. Two rounds of evaluation were performed and then compared. Initially, a combination of plain radiographs and two-dimensional computed tomography scans (2D) were evaluated, and then, two weeks later, a combination of radiographs, two-dimensional computed tomography scans, and three-dimensional reconstructions of computed tomography scans (3D) were assessed.

Results: Three-dimensional computed tomography improved both the intraobserver and the interobserver reliability of the AO classification system and the Mehne and Matta classification system. Three-dimensional computed tomography reconstructions also improved the intraobserver agreement for all fracture characteristics, from moderate (average kappa [?2D] = 0.554) to substantial agreement (?3D = 0.793). The addition of three-dimensional images had limited influence on the interobserver reliability and diagnostic characteristics (sensitivity, specificity, and accuracy) for the recognition of specific fracture characteristics. Three-dimensional computed tomography images improved intraobserver agreement (?2D = 0.62 compared with ?3D = 0.75) but not interobserver agreement (?2D = 0.24 compared with ?3D = 0.28) for treatment decisions.

Conclusions: Three-dimensional reconstructions improve the reliability, but not the accuracy, of fracture classification and characterization. The influence of three-dimensional computed tomography was much more notable for intraobserver comparisons than for interobserver comparisons, suggesting that different observers see different things in the scans—most likely a reflection of the training, knowledge, and experience of the observer with regard to these relatively uncommon and complex injuries.

Clinical Relevance: In our opinion, three-dimensional computed tomography is helpful for preoperative planning of the operative treatment of fractures of the distal part of the humerus.

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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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