Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
J Bone Joint Surg Am. 2010 Feb;92(2):322-7. doi: 10.2106/JBJS.I.00493.
Fractures of the humeral medial epicondyle occur frequently in children. The decision to pursue operative or nonoperative treatment often hinges on the amount of perceived fracture displacement. This study was performed to assess both intraobserver and interobserver agreement in the measurements of displacement of these fractures on radiographs by orthopaedic surgeons with various levels of training.
We performed a retrospective review of the radiographs of thirty-eight patients with a fracture of the medial epicondyle of the humerus. Digital anteroposterior, lateral, and oblique radiographs of each involved elbow made at presentation were presented to five separate reviewers with different levels of orthopaedic training, including two junior residents (junior residents 1 and 2), one fellow, one junior attending surgeon, and one senior attending surgeon. Each reviewer recorded the amount of perceived displacement in millimeters. A difference of >2 mm between measurements represented clinical disagreement between reviewers. Intraobserver and interobserver agreement was assessed by calculating both the intraclass correlation coefficient and the percentage of clinical disagreement between ratings.
The intraclass correlation coefficients for intraobserver agreement regarding the measurements on the anteroposterior radiographs were 0.24 (95% confidence interval, 0.00 to 0.68) for junior resident 1, 0.82 (95% confidence interval, 0.41 to 0.95) for junior resident 2, 0.83 (95% confidence interval, 0.46 to 0.96) for the senior attending surgeon, 0.92 (95% confidence interval, 0.69 to 0.98) for the junior attending surgeon, and 0.98 (95% confidence interval, 0.92 to 1.00) for the fellow. The combined intraclass correlation coefficient for intraobserver agreement was 0.76. The reviewers as a group disagreed with their own measurements an average of 26% of the time. The intraclass correlation coefficient for interobserver reliability with regard to the measurements on the anteroposterior radiographs for the group was 0.80 (95% confidence interval, 0.64 to 0.89), and the reviewers disagreed with each other an average of 54% of the time. The intraclass correlation coefficient for interobserver agreement was 0.28 (95% confidence interval, 0.03 to 0.76) for the measurements on the lateral radiographs and 0.62 (95% confidence interval, 0.34 to 0.89) for the measurements on the oblique radiographs, with reviewers disagreeing an average of 87% of the time with regard to the measurements on the lateral radiographs and 64% of the time with regard to the measurements on the oblique radiographs.
Intraobserver agreement with regard to measurement of displacement of medial epicondyle fractures of the humerus varied among the reviewers but was low overall. Interobserver agreement was best for the measurements on the anteroposterior radiographs, but this was also low overall. These findings cast doubt on whether the amount of perceived displacement should be used as a criterion for choosing operative or nonoperative management of fractures of the humeral medial epicondyle. Agreement may be improved to acceptable levels by adopting a standard set of measurement guidelines, which include use of the anteroposterior radiograph when possible and consistently measuring at the point of maximal displacement.
肱骨内上髁骨折在儿童中很常见。手术或非手术治疗的决策通常取决于骨折移位的程度。本研究旨在评估不同培训水平的骨科医生在 X 光片上测量这些骨折移位的测量结果的观察者内和观察者间的一致性。
我们对 38 例肱骨内上髁骨折患者的 X 光片进行了回顾性研究。每位受累肘部的数字前后位、侧位和斜位 X 光片在就诊时呈现给 5 位不同培训水平的独立评估者，包括 2 位初级住院医师（初级住院医师 1 和 2）、1 位研究员、1 位初级主治医生和 1 位高级主治医生。每位评估者记录了感知到的移位量（以毫米为单位）。测量值之间的差异>2 毫米代表评估者之间的临床分歧。通过计算组内相关系数和评分之间临床分歧的百分比来评估观察者内和观察者间的一致性。
初级住院医师 1 测量前后位 X 光片的观察者内一致性的组内相关系数为 0.24（95%置信区间，0.00 至 0.68），初级住院医师 2 为 0.82（95%置信区间，0.41 至 0.95），高级主治医生为 0.83（95%置信区间，0.46 至 0.96），初级主治医生为 0.92（95%置信区间，0.69 至 0.98），研究员为 0.98（95%置信区间，0.92 至 1.00）。观察者内一致性的综合组内相关系数为 0.76。评估者平均有 26%的时间不同意自己的测量结果。该组前后位 X 光片测量的观察者间可靠性的组内相关系数为 0.80（95%置信区间，0.64 至 0.89），评估者之间平均有 54%的时间不同意。观察者间一致性的组内相关系数为 0.28（95%置信区间，0.03 至 0.76），用于测量侧位 X 光片，0.62（95%置信区间，0.34 至 0.89），用于测量斜位 X 光片，评估者之间平均有 87%的时间不同意侧位 X 光片的测量结果，有 64%的时间不同意斜位 X 光片的测量结果。
肱骨内上髁骨折移位测量的观察者内一致性因评估者而异，但总体较低。前后位 X 光片的观察者间一致性最好，但总体也较低。这些发现令人怀疑感知到的移位量是否应该作为选择肱骨内上髁骨折手术或非手术治疗的标准。通过采用一套标准的测量指南，包括在可能的情况下使用前后位 X 光片并始终在最大移位点进行测量，可能会提高到可接受的一致性水平。
