Intraobserver and Interobserver Reliability and the Role of Fracture Morphology in Classifying Femoral Shaft Fractures in Young Children.
ABSTRACT Spiral fractures of long bones have long been cited as indications of non-accidental trauma (NAT) in children; however, fracture types are only loosely defined in the literature, and intraobserver and interobserver variability in defining femoral fracture patterns is rarely mentioned. We sought to determine reliability in classifying femoral fractures in young children using a standard series of radiographs shown to physicians with varied backgrounds and training and to determine if a quantitative approach based on objective measurements made on plain radiographs could improve definition of these fractures.
On 50 radiographs, the fracture ratio-fracture length divided by bone diameter-was determined and radiographs were reviewed by 14 observers, including pediatric orthopaedic surgeons, emergency room physicians, and musculoskeletal radiologists, who classified the fractures as transverse, oblique, or spiral. A second review of the images in a different order was carried out at least 10 days after the first.
Overall, intraobserver agreement was strong, whereas interobserver reliability was moderate. Experience level did not correlate with either result. Complete agreement among all observers occurred for only 5 fractures: 3 transverse and 2 spiral. An average fracture ratio near 1.0 appeared to be predictiveof a transverse fracture and a ratio of >3.0, a spiral fracture; ratios between these 2 values resulted in essentially random classification.
The ability to reproducibly classify femoral fractures in young children is highly variable among physicians of different specialties. These results support the belief that fracture morphology has little predictive value in NAT because of the wide variability in what observers classify as a spiral fracture of the femur. Caution should be used in the use of descriptive terms such as spiral, oblique, or transverse when classifying femoral fractures, as well as when evaluating children for possible NAT, because of the variability in classification.
Level III-diagnostic study.
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ABSTRACT: Before being introduced to wide use, health status instruments should be evaluated for reliability and validity. Increasingly, they are also tested for responsiveness to important clinical changes. Although standards exist for assessing these properties, confusion and inconsistency arise because multiple statistics are used for the same property; controversy exists over how to measure responsiveness; many statistics are unavailable on common software programs; strategies for measuring these properties vary; and it is often unclear how to define a clinically important change in patient status. Using data from a clinical trial of therapy for back pain, we demonstrate the calculation of several statistics for measuring reproducibility and responsiveness, and demonstrate relationships among them. Simple computational guides for several statistics are provided. We conclude that reproducibility should generally be quantified with the intraclass correlation coefficient rather than the more common Pearson r. Assessing reproducibility by retest at one-to-two week intervals (rather than a shorter interval) may result in more realistic estimates of the variability to be observed among control subjects in a longitudinal study. Instrument responsiveness should be quantified using indicators of effect size, a modified effect size statistic proposed by Guyatt, or the use of receiver operating characteristic (ROC) curves to describe how well various score changes can distinguish improved from unimproved patients.Controlled Clinical Trials 09/1991; 12(4 Suppl):142S-158S.
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ABSTRACT: We reviewed cases of 75 battered children with fractures over a 2-year period. The average age was 16 months; 57% were boys. There were 154 fractures (2.0 per child); 77% were acute and 23% were old. The most common fracture occurred in the skull (32%) and the most common long bone fracture occurred in the tibia (16%). The most common long bone fracture pattern was transverse (41%); corner fractures accounted for 28% of long bone fractures. An isolated acute fracture was the orthopaedic injury in 65% of the children, whereas multiple fractures in various stages of healing were present in only 13% of children.Journal of Orthopaedic Trauma 02/1991; 5(4):428-33. · 1.54 Impact Factor
Article: Fractures caused by child abuse.Journal of Bone and Joint Surgery - British Volume 12/1993; 75(6):849-57. · 2.80 Impact Factor