Prospective comparison of magnetic resonance imaging and computed tomography in diagnosing occult scaphoid fractures.

BACKGROUND: Suspected scaphoid fracture (SF) after a fall on an outstretched hand is a common presentation in the emergency department. Magnetic resonance imaging (MRI) or computed tomography (CT) has been suggested to assist in the diagnosis or exclusion of SF. PURPOSE: To compare MRI and CT at diagnosing occult SFs. MATERIAL AND METHODS: We routinely perform CT scans in patients with clinically suspected occult SF, after 7-10 days of injury following two negative radiographs. All eligible patients with a clinically suspected SF, but negative radiographs and a negative CT, underwent an MRI scan to assess further for evidence of occult fracture. RESULTS: A total of 100 patients were included in our study. MRI showed fractures in 16% of the time (in 15 patients) when plain radiographs and CT did not. Of these fractures, 8% were SFs. In addition to fractures, 10% had bone bruising. A total of 25% of patients with fractures and bone bruising were referred to the hand surgery team for further follow-up. CONCLUSION: The study demonstrated that MRI would identify a radiographically occult SF more often than CT. This supports NICE guidelines which recommend MRI as the best early diagnostic tool for occult SFs.

Occult Fractures in Children with a Radiographic Fat Pad Sign of the Elbow: A Meta-Analysis of 10 Published Studies.

BACKGROUND: A radiographic fat pad sign after an elbow injury in children may indicate an occult fracture. Different incidences and locations of occult fractures have been reported. The primary objective of this meta-analysis was to assess the overall rate of occult fractures in children with a positive fat pad sign from the data of original studies. Secondary objectives were to assess the fracture types and to identify risk factors for sustaining an occult fracture. METHODS: A systematic literature search of the Embase, MEDLINE, and Cochrane databases was performed according to PRISMA guidelines. Studies on pediatric populations with a positive fat pad sign identified using a lateral elbow radiograph and with follow-up imaging were included in this meta-analysis. Included studies were assessed for risk of bias with use of the MINORS (Methodological Index for NOn-Randomized Studies) instrument. RESULTS: Ten studies with a total of 250 patients, of whom 104 had an occult fracture, were included. Accounting for heterogeneity between the studies, the overall occult fracture rate was 44.6% (95% confidence interval: 30.4% to 59.7%). The most common fracture locations were the supracondylar humerus (43%), proximal ulna (19%), proximal radius (17%), and lateral humeral condyle (14%). Definitions of a positive pad fad sign were not uniform among studies, and the follow-up imaging modality also varied (radiography, magnetic resonance imaging, or computed tomography). The average MINORS score was 10.1 for the 7 noncomparative studies and 18.7 for the 3 comparative studies, with both averages classified as moderate quality. We were not able to identify risk factors for an occult fracture in the presence of a positive fat pad sign. CONCLUSIONS: The occult fracture rate was 44.6% in pediatric elbow injuries with a positive fat pad sign. Supracondylar humeral fractures were the most frequently encountered type. The findings of this meta-analysis underline the potential clinical relevance of a positive fat pad sign in children and denote the opportunity for future studies to create evidence-based guidelines. LEVEL OF EVIDENCE: Level II. See Instructions for Authors for a complete description of levels of evidence.

Cordycepin promotes osteogenesis of bone marrow-derived mesenchymal stem cells and accelerates fracture healing via hypoxia in a rat model of closed femur fracture.

Fracture is the most frequently encountered traumatic large-organ injury observed in human patients. Cordycepin possesses beneficial effects in osteogenesis of mesenchymal stem cells (MSCs), but its effect on fracture healing is largely unknown. A rat model of closed femur fracture was established, and treated with therapy using bone marrow-derived MSCs (BMMSCs). The effect of cordycepin on the osteogenic process of BMMSCs in vitro was evaluated by Alizarin Red S (ARS) staining and expressions of osteogenic marker genes. Radiographic evaluations and four-point bending mechanical testing were performed on model rats after BMMSC treatment, to assess the effect of cordycepin on fracture healing. Cordycepin promoted osteogenesis of BMMSCs in vitro, and enhanced radiographic parameters and mechanical properties in rat closed femur fracture model using BMMSC therapy in vivo. A hypoxia inhibitor echinomycin could negate the above-mentioned therapeutic effects of cordycepin, indicating that the beneficial effects of cordycepin were mediated via hypoxic response pathway. This study demonstrates that cordycepin promotes osteogenesis of BMMSCs and accelerates fracture healing via hypoxia in a rat model of closed femur fracture, and proposes the clinical potential of cordycepin in bone fracture treatments.

Pretreatment with Pamidronate Decreases Bone Formation but Increases Callus Bone Volume in a Rat Closed Fracture Model.

Clinical concerns have been raised over prior exposure to bisphosphonates impairing fracture healing. To model this, groups of male Wistar rats were assigned to saline control or treatment groups receiving 0.15 mg/kg (low dose), 0.5 mg/kg (medium dose), and 5 mg/kg (high dose) Pamidronate (PAM) twice weekly for 4 weeks. At this point, closed fractures were made using an Einhorn apparatus, and bisphosphonate dosing was continued until the experimental endpoint. Specimens were analyzed at 2 and 6 weeks (N = 8 per group per time point). Twice weekly PAM dosing was found to have no effect on early soft callus remodeling at 2 weeks post fracture. At this time point, the highest dose PAM group gave significant increases in bone volume (+ 10%, p < 0.05), bone mineral content (+ 30%, p < 0.01), and bone mineral density (+ 10%, p < 0.01). This PAM dosing regimen showed more substantive effects on hard callus at 6 weeks post fracture, with PAM treatment groups showing + 46-79% increased bone volume. Dynamic bone labeling showed reduced calcein signal in the PAM-treated calluses (38-63%, p < 0.01) and reduced MAR (32-49%, p < 0.01), suggesting a compensatory reduction in bone anabolism. These data support the concept that bisphosphonates lead to profound decreases in bone turnover in fracture repair, however, this does not affect soft callus remodeling.

Distal radial torus fracture in an adult. A new type of occult wrist fracture?

Torus or buckle fractures typically affect children who have suffered indirect minor wrist injuries. They are axial compression-type metaphyseal fractures of cortical and cancellous bone, which are stable and their treatment therefore consists in immobilisation of the joint for three to four weeks. We present an atypical case of distal radius torus fracture in a 19-year-old adult male, which has not been previously reported in adults and can be considered a new type of occult fracture. Knowledge of this possibility is mandatory to be able to make a differential diagnosis of wrist sprain in adults, and avoid performing superfluous complementary tests due to the persistence of pain and functional incapacity.

In Vivo MR Imaging of Dual MRI Reporter Genes and Deltex-1 Gene-modified Human Mesenchymal Stem Cells in the Treatment of Closed Penile Fracture.

PURPOSE: The purpose of this study was to investigate the feasibility of dual magnetic resonance imaging (MRI) reporter genes, including ferritin heavy subunit (Fth) and transferrin receptor (TfR), which provide sufficient MRI contrast for in vivo MRI tracking, and the Deltex-1 (DTX1) gene, which promotes human mesenchymal stem cell (hMSC) differentiation to smooth muscle cells (SMCs), to treat closed penile fracture (CPF). METHODS: Multi-gene co-expressing hMSCs were generated. The expression of mRNA and proteins was assessed, and the original biological properties of hMSCs were determined and compared. The intracellular uptake of iron was evaluated, and the ability to differentiate into SMCs was detected. Fifty rabbits with CPF were randomly transplanted with PBS, hMSCs, Fth-TfR-hMSCs, DTX1-hMSCs, and Fth-TfR-DTX1-hMSCs. In vivo MRI was performed to detect the distribution and migration of the grafted cells and healing progress of CPF, and the results were correlated with histology. RESULTS: The mRNA and proteins of the multi-gene were highly expressed. The transgenes could not influence the original biological properties of hMSCs. The dual MRI reporter genes increased the iron accumulation capacity, and the DTX1 gene promoted hMSC differentiation into SMCs. The distribution and migration of the dual MRI reporter gene-modified hMSCs, and the healing state of CPF could be obviously detected by MRI and confirmed by histology. CONCLUSION: The dual MRI reporter genes could provide sufficient MRI contrast, and the distribution and migration of MSCs could be detected in vivo. The DTX1 gene can promote MSC differentiation into SMCs for the treatment of CPF and effectively inhibit granulation tissue formation.

An animal model of co-existing sarcopenia and osteoporotic fracture in senescence accelerated mouse prone 8 (SAMP8).

Sarcopenia and osteoporotic fracture are common aging-related musculoskeletal problems. Recent evidences report that osteoporotic fracture patients showed high prevalence of sarcopenia; however, current clinical practice basically does not consider sarcopenia in the treatment or rehabilitation of osteoporotic fracture. There is almost no report studying the relationship of the co-existing of sarcopenia and osteoporotic fracture healing. In this study, we validated aged senescence accelerated mouse prone 8 (SAMP8) and senescence accelerated mouse resistant 1 (SAMR1) as animal models of senile osteoporosis with/without sarcopenia. Bone mineral density (BMD) at the 5th lumbar and muscle testing of the two animal strains were measured to confirm the status of osteoporosis and sarcopenia, respectively. Closed fracture was created on the right femur of 8-month-old animals. Radiographs were taken weekly post-fracture. MicroCT and histology of the fractured femur were performed at week 2, 4 and 6 post-fracture, while mechanical test of both femora at week 4 and 6 post-fracture. Results showed that the callus of SAMR1 was significantly larger at week 2 but smaller at week 6 post-fracture than SAMP8. Mechanical properties were significantly better at week 4 post-fracture in SAMR1 than SAMP8, indicating osteoporotic fracture healing was delayed in sarcopenic SAMP8. This study validated an animal model of co-existing sarcopenia and osteoporotic fracture, where a delayed fracture healing might be resulted in the presence of sarcopenia.

Effect of cefazolin and cefuroxime on fracture healing in rats.

OBJECTIVE: To determine the effect of cefazolin and cefuroxime (the two most commonly used beta lactam antibiotics) at therapeutic doses in fracture healing in an animal model. MATERIAL AND METHODS: 75 adult male wistar rats (3months old) were selected. They were divided into three groups of 25 animals each (placebo, cefazolin and cefuroxime). A closed fracture was made in the middle third of the right femur of each rat and fixed with a Kirschner wire. Each group was treated with either saline (placebo), cefazolin or cefuroxime at therapeutic doses during fracture healing. Four weeks after fracture rats were killed and femora analysed through mechanical and histological testing. RESULTS: The group treated with cefuroxime showed a lower mechanical resistance of the healing callus and a lower histological grade than placebo. The group treated with cefazoline showed a similar mechanical resistance and histological grade of callus to placebo. CONCLUSION: Cefuroxime appear to disturb fracture healing more than cefazolin or placebo in Wistar rats. If those results are similar to human, the use of cefuroxime during fracture healing should be avoided in the clinical setting, if possible.

The sensitivity of ct scans in diagnosing occult femoral neck fractures.

Non-displaced hip fractures can be difficult to diagnose on plain film radiographs. When there is ongoing clinical suspicion of an occult fracture, further imaging is obtained. We investigated the sensitivity of computed tomography (CT) scans in detecting these fractures and the delays to surgery that three-dimensional imaging causes. We identified 78 CT scans performed for possible hip fractures over the past 3 years with the presence and absence of a fracture recorded. Based on subsequent imaging, the accuracy of CT scans was determined. CT scanning yielded sensitivity was 86% and specificity 98% for occult hip fracture (OHF). The median delay to definitive diagnosis was 37h. Our results demonstrate that CT scan does not bear sufficient sensitivity to detect all OHFs. We therefore recommend that MRI should be offered when a fracture is suspected. CT scans should be reserved for when MRI is not available, but a negative scan should be confirmed with subsequent MRI.

Does Anticoagulant Medication Alter Fracture-Healing? A Morphological and Biomechanical Evaluation of the Possible Effects of Rivaroxaban and Enoxaparin Using a Rat Closed Fracture Model.

Low molecular weight heparin (LMWH) is routinely used to prevent thromboembolism in orthopaedic surgery, especially in the treatment of fractures or after joint-replacement. Impairment of fracture-healing due to increased bone-desorption, delayed remodelling and lower calcification caused by direct osteoclast stimulation is a well-known side effect of unfractioned heparin. However, the effect of LMWH is unclear and controversial. Recent studies strongly suggest impairment of bone-healing in-vitro and in animal models, characterized by a significant decrease in volume and quality of new-formed callus. Since October 2008, Rivaroxaban (Xarelto) is available for prophylactic use in elective knee- and hip-arthroplasty. Recently, some evidence has been found indicating an in vitro dose independent reduction of osteoblast function after Rivaroxaban treatment. In this study, the possible influence of Rivaroxaban and Enoxaparin on bone-healing in vivo was studied using a standardized, closed rodent fracture-model. 70 male Wistar-rats were randomized to Rivaroxaban, Enoxaparin or control groups. After pinning the right femur, a closed, transverse fracture was produced. 21 days later, the animals were sacrificed and both femora harvested. Analysis was done by biomechanical testing (three-point bending) and micro CT. Both investigated substances showed histomorphometric alterations of the newly formed callus assessed by micro CT analysis. In detail the bone (callus) volume was enhanced (sign. for Rivaroxaban) and the density reduced. The bone mineral content was enhanced accordingly (sign. for Rivaroxaban). Trabecular thickness was reduced (sign. for Rivaroxaban). Furthermore, both drugs showed significant enlarged bone (callus) surface and degree of anisotropy. In contrast, the biomechanical properties of the treated bones were equal to controls. To summarize, the morphological alterations of the fracture-callus did not result in functionally relevant deficits.

Imaging of occult hip fractures: CT or MRI?

OBJECTIVES: Patients presenting with hip pain but normal plain radiographs may ultimately be shown on further investigation to have suffered an occult hip fracture (OHF). This diagnosis can be made with CT or MRI. Traditionally MRI has been considered a superior modality. We performed a retrospective review of all patients presenting to our service with a suspected OHF over a four-year period, investigated with either CT or MRI. DESIGN: Retrospective review. SETTING: Urban trauma centre. PATIENTS: Patients with suspected hip fractures and negative radiographs. INTERVENTION: CT or MRI. MAIN OUTCOME MEASURES: Detection rate; delay in request for further imaging; delay to theatre; re-presentations with missed fractures. RESULTS: A total of 179 patients were investigated, with a mean age of 82±13 years. The ultimate diagnosis was of an OHF in 71 cases and pelvic or acetabular fracture in 34. The average time from presentation plain radiograph to further imaging was 2.0±2.7 days, but was significantly shorter for CT. No patient re-presented with unidentified fractures or other localised hip pathology within a 12-month period. CONCLUSIONS: Modern imaging technology does not appear to miss clinically significant fractures. As CT is usually more accessible than MRI, the results of our study should encourage surgeons to consider CT as a first line investigation for occult hip fractures. We advocate a high index of suspicion and early imaging referral for elderly patients presenting with non-specific hip pain following a fall. Level 3 Evidence.

The validity of investigating occult hip fractures using multidetector CT.

OBJECTIVE: 10% of all hip fractures are occult on plain radiography, requiring further investigation to ascertain the diagnosis. MRI is presently the gold standard investigation, but frequently has disadvantages of time delay, resulting in increased hospital stay and mortality. Our aim was to establish whether multidetector CT (MDCT) is an appropriate first-line investigation of occult femoral neck (NOF) fractures. METHODS: From 2013, we elected to use MDCT as the first-line investigation in patients believed to have an NOF fracture with negative plain films. These were reported by consultant musculoskeletal radiologists. We retrospectively analysed the data of consecutive patients presenting to the University Hospital of Wales, over 30 months with a clinical suspicion of a hip fracture. RESULTS: 1443 patients were admitted during the study period. 209 (14.5%) patients had negative plain films requiring further investigation to exclude an NOF fracture, of which 199 patients had a CT. 93 patients had no fracture and 20 patients had isolated greater trochanter fractures. None of these patients progressed to develop an intracapsular femoral neck fracture at 4-month follow-up, although one patient sustained an extracapsular fracture following a high-energy fall whilst admitted. 26 femoral neck fractures were diagnosed on CT, whilst the remaining 60 patients were diagnosed with other pelvic ring fractures. CONCLUSION: When interpreted by experienced radiologists, MDCT has both sensitivity and specificity of 100%. ADVANCES IN KNOWLEDGE: We recommend the use of MDCT as a safe and appropriate first-line investigation for NOF fractures.

The effect of teicoplanin on fracture healing: an experimental study.

OBJECTIVES: This study aims to investigate the effect of teicoplanin on fracture healing stereologically and histopatologically. MATERIALS AND METHODS: Twenty male Wistar albino rats were separated into two as the study (teicoplanin) and control groups. After intramedullary fixation of the right tibia of all the rats with 0.5 mm Kirschner wire under general anesthesia, standard closed shaft fractures were created using fracture formation apparatus. Teicoplanin (10 mg/kg) and saline were administered intraperitoneally to the study and control groups, respectively. Control radiographs were taken at the end of the procedure and the rats were sacrificed after 28 days. New bone and connective tissue volumes were calculated on obtained tissue samples using unbiased stereological and histopathological techniques. RESULTS: It was observed that teicoplanin increased the formation of bone, vascularization, and connective tissue. There was a statistically significant difference between the two groups in respect of bone and vascular total volume (p<0.05). Although an increase was observed in connective tissue total volume, no statistically significant difference was detected between the two groups (p>0.05). CONCLUSION: In addition to its antibacterial effect, teicoplanin may increase new bone formation; thus, it may be used safely in the treatment of bone defects accompanied with infection.

Sensitivity and specificity of CT- and MRI-scanning in evaluation of occult fracture of the proximal femur.

OBJECTIVE: To estimate sensitivity and specificity of CT and MRI examinations in patients with fractures of the proximal femur. To determine the interobserver agreement of the modalities among a senior consulting radiologist, a resident in radiology and a resident in orthopaedics surgery. MATERIALS AND METHODS: 67 patients (27 males, 40 females, mean age 80.5) seen in the emergency room with hip pain after fall, inability to stand and a primary X-ray without fracture were evaluated with both CT and MRI. The images were analysed by a senior consulting musculoskeletal radiologist, a resident in radiology and a resident in orthopaedic surgery. Sensitivity and specificity were estimated with MRI as the golden standard. Kappa value was used to assess level of agreement in both MRI and CT finding. RESULTS: 15 fractures of the proximal femur were found (7 intertrochanteric-, 3 femoral neck and 5 fractures of the greater trochanter). Two fractures were not identified by CT and four changed fracture location. Among those, three patients underwent surgery. Sensitivity of CT was 0.87; 95% CI [0.60; 0.98]. Kappa for interobserver agreement for CT were 0.46; 95% CI [0.23; 0.76] and 0.67; 95% CI [0.42; 0.90]. For MRI 0.67; 95% CI [0.43; 0.91] and 0.69; 95% CI [0.45; 0.92]. CONCLUSION: MRI was observed to have a higher diagnostic accuracy than CT in detecting occult fractures of the hip. Interobserver analysis showed high kappa values corresponding substantial agreement in both CT and MRI.

Endochondral fracture healing with external fixation in the Sost knockout mouse results in earlier fibrocartilage callus removal and increased bone volume fraction and strength.

Sclerostin deficiency, via genetic knockout or anti-Sclerostin antibody treatment, has been shown to cause increased bone volume, density and strength of calluses following endochondral bone healing. However, there is limited data on the effect of Sclerostin deficiency on the formative early stage of fibrocartilage (non-bony tissue) formation and removal. In this study we extensively investigate the early fibrocartilage callus. Closed tibial fractures were performed on Sost(-/-) mice and age-matched wild type (C57Bl/6J) controls and assessed at multiple early time points (7, 10 and 14days), as well as at 28days post-fracture after bony union. External fixation was utilized, avoiding internal pinning and minimizing differences in stability stiffness, a variable that has confounded previous research in this area. Normal endochondral ossification progressed in wild type and Sost(-/-) mice with equivalent volumes of fibrocartilage formed at early day 7 and day 10 time points, and bony union in both genotypes by day 28. There were no significant differences in rate of bony union; however there were significant increases in fibrocartilage removal from the Sost(-/-) fracture calluses at day 14 suggesting earlier progression of endochondral healing. Earlier bone formation was seen in Sost(-/-) calluses over wild type with greater bone volume at day 10 (221%, p<0.01). The resultant Sost(-/-) united bony calluses at day 28 had increased bone volume fraction compared to wild type calluses (24%, p<0.05), and the strength of the fractured Sost(-/-) tibiae was greater than that that of wild type fractured tibiae. In summary, bony union was not altered by Sclerostin deficiency in externally-fixed closed tibial fractures, but fibrocartilage removal was enhanced and the resultant united bony calluses had increased bone fraction and increased strength.

Intra- and interobserver agreement on the Oestern and Tscherne classification of soft tissue injury in periarticular lower-limb closed fractures / Concordancia intra e interobservador de la clasificación de Oestern y Tscherne para lesiones de tejidos blandos en fracturas cerradas periarticulares del miembro inferior

Background: The soft tissues injury in periarticular fractures of the lower extremities determines the proper time to perform bone fixation. Objective: The aim of this study was to determine the intra and interobserver agreement in the Tscherne classification. Methods: This is a descriptive, prospective study for patients admitted to the Pablo Tobón Uribe Hospital (PTUH) with tibial plateau or tibial pilon fractures. We performed a standardize evaluation using video photography at the time of admission and 24, 48, and 72 h after admission. Fifteen five reviewers who had various levels of training produced a total of 1,200 observations. The intra- and interobserver agreement was assessed using a weighted kappa for multiple raters and more than two categories. Results: Twenty patients were admitted with tibial plateau and tibial pilon fractures. The intraobserver agreement for all 15 raters was kappa 0.81 (95% CI 0.79-0.83), and the interobserver agreement for all 15 raters was kappa 0.65 (95% CI 0.55-0.73). The interobserver agreement at 24 h was kappa 0.67 (95% CI 0.46-0.86). Conclusions: Classifying the severity of soft tissue injury is critical in planning the surgical management of fractures of the lower extremities. Based on our results, we can reasonably argue that the Tscherne classification produced an adequate level of agreement and could be used to standardize and to guide the treatment, and to conduct research studies.

Antecedentes: La lesión de los tejidos blandos en fracturas periarticulares del miembro inferior determina el momento adecuado para realizar la fijación ósea. Objetivo: El propósito de este estudio fue determinar la concordancia intra e interobservador para la clasificación de Tscherne. Métodos: Estudio descriptivo, prospectivo en pacientes ingresados al Hospital Pablo Tobón Uribe con fracturas de platillos tibiales o pilón tibial. Se realizó una evaluación estandarizada utilizando videos y fotografías al momento del ingreso y 24, 48 y 72 h después. Quince evaluadores que tenían diferentes niveles de entrenamiento produjeron 1200 observaciones. La concordancia intre e interobservador fue evaluada utilizando kappa ponderado para múltiples evaluadores y más de dos categorías. Resultados: Veinte pacientes fueron admitidos con fracturas de los platillos o del pilón tibial. La concordancia intraobservador para los 15 evaluadores fue kappa 0.81 (95% IC 0.79-0.83), y la concordancia interobservador para los 15 evaluadores fue kappa 0.65 (95% IC 0.55-0.73). La concordancia interobservador a las 24 h del ingreso fue kappa 0.67 (95% IC 0.46-0.86). Conclusión: Clasificar la gravedad de la lesión de los tejidos blandos es un paso fundamental en la planeación del manejo quirúrgico de las fracturas periarticulares del miembro inferior, con base en nuestros resultados podemos afirmar razonablemente que la clasificación de Oestern y Tscherne tiene un nivel de concordancia adecuado y podría utilizarse de forma sistemática para estandarizar la evaluación entre los ortopedistas para orientar el tratamiento y también con fines investigativos.

Clinical identifiers for detecting underlying closed cervical fractures.

BACKGROUND: Although uncommon, closed cervical fractures (CCFs) may present in orthopedic clinical settings despite previous workup. The objective of this study was to describe the characteristics associated with missed CCF. METHODS: The study was a retrospective database exploration of a cohort of subjects within a department of surgery with cervical pain. The sample consisted of 162 patients seen for a surgical consult for a number of cervical conditions. The examination time frame represented a clinical examination and imaging confirmation of diagnosis after an original initial visit by another provider. Descriptive and diagnostic accuracy values including sensitivity/specificity and positive/negative likelihood ratios (LR+/LR-) were calculated for each targeted variable. Clustered analyses were calculated using the patient history and situational characteristics. RESULTS: Eleven patients in the sample were diagnosed with CCF (6.7%). Six variables were significantly associated with a missed CCF. Using these six variables, it was found that failure to exhibit a condition of 2 of the 6 variables (1 or fewer) was the strongest in ruling out the condition (LR- = 0.0; post-test probability with a negative finding = 0%), whereas a finding of 4 of 6 was the most diagnostic for ruling in the condition (LR+ = 32; post-test probability with a positive finding = 70%). CONCLUSIONS: The findings in this sample suggest that select patient history or situational factors are still useful even after initial examination and clinicians must stay vigilant because CCFs may be missed during emergent care screens.

Intra- and interobserver agreement on the Oestern and Tscherne classification of soft tissue injury in periarticular lower-limb closed fractures.

BACKGROUND: The soft tissues injury in periarticular fractures of the lower extremities determines the proper time to perform bone fixation. OBJECTIVE: The aim of this study was to determine the intra and interobserver agreement in the Tscherne classification. METHODS: This is a descriptive, prospective study for patients admitted to the Pablo Tobón Uribe Hospital (PTUH) with tibial plateau or tibial pilon fractures. We performed a standardize evaluation using video photography at the time of admission and 24, 48, and 72 h after admission. Fifteen five reviewers who had various levels of training produced a total of 1,200 observations. The intra- and interobserver agreement was assessed using a weighted kappa for multiple raters and more than two categories. RESULTS: Twenty patients were admitted with tibial plateau and tibial pilon fractures. The intraobserver agreement for all 15 raters was kappa 0.81 (95% CI 0.79-0.83), and the interobserver agreement for all 15 raters was kappa 0.65 (95% CI 0.55-0.73). The interobserver agreement at 24 h was kappa 0.67 (95% CI 0.46-0.86). CONCLUSIONS: Classifying the severity of soft tissue injury is critical in planning the surgical management of fractures of the lower extremities. Based on our results, we can reasonably argue that the Tscherne classification produced an adequate level of agreement and could be used to standardize and to guide the treatment, and to conduct research studies.

ANTECEDENTES: La lesión de los tejidos blandos en fracturas periarticulares del miembro inferior determina el momento adecuado para realizar la fijación ósea. OBJETIVO: El propósito de este estudio fue determinar la concordancia intra e interobservador para la clasificación de Tscherne. MÉTODOS: Estudio descriptivo, prospectivo en pacientes ingresados al Hospital Pablo Tobón Uribe con fracturas de platillos tibiales o pilón tibial. Se realizó una evaluación estandarizada utilizando videos y fotografías al momento del ingreso y 24, 48 y 72 h después. Quince evaluadores que tenían diferentes niveles de entrenamiento produjeron 1200 observaciones. La concordancia intre e interobservador fue evaluada utilizando kappa ponderado para múltiples evaluadores y más de dos categorías. RESULTADOS: Veinte pacientes fueron admitidos con fracturas de los platillos o del pilón tibial. La concordancia intraobservador para los 15 evaluadores fue kappa 0.81 (95% IC 0.79-0.83), y la concordancia interobservador para los 15 evaluadores fue kappa 0.65 (95% IC 0.55-0.73). La concordancia interobservador a las 24 h del ingreso fue kappa 0.67 (95% IC 0.46-0.86). CONCLUSIÓN: Clasificar la gravedad de la lesión de los tejidos blandos es un paso fundamental en la planeación del manejo quirúrgico de las fracturas periarticulares del miembro inferior, con base en nuestros resultados podemos afirmar razonablemente que la clasificación de Oestern y Tscherne tiene un nivel de concordancia adecuado y podría utilizarse de forma sistemática para estandarizar la evaluación entre los ortopedistas para orientar el tratamiento y también con fines investigativos.