ORIGINAL ARTICLE

Joo Carlos Belloti Marcel Jun Sugawara Tamaoki Carlos E uar o a Sil!eira "rancio#i Joo Ba$tista Gomes os Santos %aniel Bal&ac'e!sk( E uar o C'a$ C'a$ )alter Manna Al&ertoni "l*!io "alo$$a

Are distal radius fracture classifications reproducible? Intra and interobserver agreement Department of Orthopedics and Traumatology,
Universidade Federal de So Paulo Escola Paulista de $ra%il edicina !Unifesp"EP #, So Paulo,

ABSTRACT
CONTEXT AND OBJECTI E! +arious classi,ication s(stems 'a!e &een $ro$ose ,or ,ractures o, t'e istal ra ius. &ut t'e relia&ilit( o, t'ese classi,ications is sel om a resse / "or a ,racture classi,ication to &e use,ul. it must $ro!i e $rognostic signi,icance. intero&ser!er relia&ilit( an intrao&ser!er re$ro uci&ilit(/ T'e aim 'ere was to e!aluate t'e intrao&ser!er an intero&ser!er agreement o, istal ra ius ,racture classi,ications/ DE"I#N AND "ETTIN#! T'is was a !ali ation stu ( on intero&ser!er an intrao&ser!er relia&ilit(/ It was e!elo$e in t'e %e$artment o, Ort'o$e ics an Traumatolog(. 0ni!ersi a e "e eral e So 1aulo 2 Escola 1aulista e Me icina/ $ET%OD! 3-ra(s ,rom 45 cases o, is$lace istal ra ius ,racture were e!aluate &( ,i!e o&ser!ers6 one t'ir -(ear ort'o$e ic resi ent 7R89. one si:t'-(ear un ergra uate me ical stu ent 70G;9. one ra iologist $'(sician 73R19. one ort'o$e ic trauma s$ecialist 7OT9 an one ort'o$e ic 'an surger( s$ecialist 7O<S9/ T'e ra iogra$'s were classi,ie on t'ree i,,erent occasions 7times T=. T> an T89 using t'e 0ni!ersal 7Coone(9. Ar&eitsgemeinsc'a,t ,?r Osteos(nt'ese,ragen@ Association ,or t'e Stu ( o, Internal "i:ation 7AO@ASI"9. "r(kman an "ern*n e# classi,ica- tions/ T'e ka$$a coe,,icient 7A9 was a$$lie to assess t'e egree o, agreement/ &E"'(T"! Among t'e t'ree occasions. t'e 'ig'est mean intrao&ser!er k was o&ser!e in t'e 0ni!er- sal classi,ication 7B/;=9. ,ollowe &( "ern*n e# 7B/C49. "r(kman 7B/CC9 an AO@ASI" 7B/D49/ T'e intero&ser!er agreement was unsatis,actor( in all classi,ications/ T'e "ern*n e# classi,ication s'owe t'e &est agreement 7B/DD9 an t'e worst was t'e "r(kman classi,ication 7B/>;9/ CONC('"ION! T'e low agreement le!els o&ser!e in t'is stu ( suggest t'at t'ere is still no classi,ication met'o wit' 'ig' re$ro uci&ilit(/ )E* +O&D"! CollesE ,racture/ Ra ius ,ractures/ Classi,ication/ Re$ro uci&ilit( o, results/ +ali ation stu ies/

INTRO%0CTION %istal ra ius ,ractures 'a!e an a$$ro:imate inci ence o, =6=B.BBB $eo$le an re$resent =;F o, skeletal an GDF o, ,orearm ,ractures/= T'e( are more $re!alent among ,emales an $resent a $rogressi!e increase in com$lications wit' age. as osteo$enia an osteo$orosis &ecome more $re!alent/> T'e most common trauma mec'anism is ,alling o!er onto t'e 'an /8 T'e c'aracteristics o, suc' ,ractures 7trace location. $ossi&le Hoint in!ol!ement. comminution an egree o, so,t- $art lesion9 are irectl( relate to t'e ,orce o, t'e trauma. wrist angle at t'e moment o, t'e trauma an &one 'ealt'/> S(stems 'a!e &een e!elo$e to 'el$ surgeons in classi,(ing ,ractures into i,,erent an clinicall( use,ul grou$s ,or treatment e,inition/ Colles. Smit'. 1outeau. an ot'ers escri&e ,racture mor$'olog( wit' a !iew to treatment/8-C )it' t'e a !ent o, ra iolog(. it &ecame $ossi&le to escri&e inHuries more $recisel(. inclu ing &ot' t'e egree o, is- $lacement an t'e $resence o, Hoint inHuries/ In =4C=. Garlan an )erle(; create a clas- si,ication &ase on t'e $resence or a&sence o, Hoint in!ol!ement. meta$'(seal comminution an @or angular e,ormit(/ In =4C4. Lin strom e:$an e t'ese criteria to si: grou$s. escri&- ing t'e ,ragment is$lacement in ,urt'er etail. along wit' Hoint in!ol!ement/G In =4;G. "r(kman esta&lis'e a rating s(stem t'at consi ere t'e ra iocar$al an @or istal ra ius-ulna Hoints. an also t'e $resence or a&sence o, t'e ulnar st(loi /5 E!en t'us. t'is was a limite rating s(stem6 it i not consi er ,actors like t'e e:tent o, ,ragment is$lace- ment. $resence or a&sence o, comminution an insta&ilit( ,actors/ In =45D. Melone4 $u&lis'e a rating s(s- tem ,or istal ra ius Hoint ,ractures &ase on ,our $arts6 ra ius st(loi . ra ius

s'a,t. orsal ,ragment an T'is rating s(s-

$almar ra ius/

tem 'as &een use to e,ine surgical ,i:ation met'o s. &ut its accurac( an re$ro uci&ilit( ,or i enti,(ing t'e ,our ,ragments on con- !entional :-ra(s 'a!e not &een !ali ate (et &( clinical trials. an t'e s(stem still $resents isagreements/=B T'e Ar&eitsgemeinsc'a,t ,?r Osteo- s(nt'ese,ragen@Association ,or t'e Stu ( o, Internal "i:ation 7AO@ASI"9 rating s(stem was create in =45; an re!iewe in =44B/ It consi ers &one inHur( se!erit( an is a &asis ,or treatment an results e!aluation/ T'ere are t'ree &asic lesion t($es in t'is s(stem6 e:traar- ticular. $artial articular an com$lete

articular/ T'e t'ree grou$s are organi#e into increasing or er o, se!erit( o, mor$'ological com$le:it(. treatment i,,icult( an $rognostics/ It is one o, t'e most com$lete ratings a!aila&le. &ut its intra an intero&ser!er re$ro uci&ilit( 'as &een a $ro&lem w'en e!aluating grou$s an su&grou$s/==.=> T'e 0ni!ersal rating s(stem escri&e &( Coone(=8 is c'aracteri#e &( sim$licit(. classi,(ing ,ractures as intra or e:tra-articular. is$lacement $resent or a&sent. an accor ing to t'e egree o, sta&ilit( an $ossi&ilities o, re uction/ It t'us acts as a gui e ,or treatment $atterns/ T'e rating s(stem $ro$ose &(

"ern*n e# is &ase on t'e trauma mec'anism/=D T'is rat- ing was create to &e $ractical. $re ict sta&il- it(. c'eck on associate ,ractures o, t'e ulna st(loi $rocess. i enti,( eIui!alent lesions in c'il ren an make general recommen ations ,or treatment/ To &e consi ere goo . a rating s(stem must &e !ali . relia&le an re$ro uci&le/ "urt'ermore. an i eal rating s(stem s'oul stan ar i#e a trustwort'( communication language t'at $ro!i es gui elines ,or treatment. in icates t'e $ossi&ilities o, com$lications. e!aluates ,racture sta&ilit( an ena&les ,rac- ture $rognosis/ T'is i eal s(stem s'oul also

Sao 1aulo Me J/ >BB5J=>;7896=5B-C/

=5=

$ro!i e a mec'anism t'at allows com$arison o, t'e results o&taine wit' treatments un- ertaken on similar ,ractures in ot'er centers. re$orte at i,,erent times in t'e literature/=C +ariation in e!aluatorsE e:$ertise ma( 'a!e in,luence e!aluations carrie out on intrao&ser!er an intero&ser!er agreement/ Stu ies 'a!e s'own t'at less e:$erience o&ser!ers attain lower rates o, intrao&ser!er agreement t'an o e:$ert $'(sicians/=>.=; <owe!er. in a com$arison o, one grou$ in w'ic' t'e o&ser!ers were more e:$erience in rating assessments wit' anot'er grou$ w'ose e:$ertise was lower. no signi,icant i,,erence in intero&ser!er agreement was ,oun /=> It woul also &e e:$ecte t'at. as o&ser!ers stu ( an &ecome accustome to using a gi!en rating s(stem. t'e agreement &etween t'em. an wit'in t'eir own o&ser!ations. woul increase/ Ket. it was o&ser!e t'at re$eate a$$lication. i/e/ at i,,erent moments in time. o, t'e same rating s(stem. 'a no im$act on intrao&ser!er an intero&ser!er re$ro uci&ilit(/=B Consi ering t'e 'ig' $re!alence o, t'ese kin s o, ,racture an t'e nee to $ro$erl( an re$ro uci&l( classi,( t'em. we e!elo$e t'e $resent stu (/ Its aim was to e!aluate t'e re$ro uci&ilit( o, t'e ,our most wi el( use rating s(stems in our ,iel /=; OBJECTI+E T'is o&Hecti!e o, t'is stu ( was to e!aluate t'e intrao&ser!er an intero&ser!er agreement o, t'e 0ni!ersal. AO@ASI". "r(kman an "ern*n e# rating s(stems ,or ,ractures wit' regar to is$lacement o, t'e ra ius istal e:tremit(/ MATERIAL AN% MET<O%S T'is was a ratings re$ro uci&ilit( stu ( using t'e ka$$a in e:/ Ninet(-eig't is$lace istal ra ius ,ractures in 4; $atients o!er t'e age o, DB (ears w'o 'a &een treate at t'e <an Institute o, 0ni!ersi a e "e eral e So 1aulo 2 Escola 1aulista e Me icina 70ni,es$- E1M9 were retros$ecti!el( e!aluate ,rom t'e ra iogra$'ic arc'i!es/ "i!e o&ser!ers were in!ol!e 6 one t'ir (ear ort'o$e ic resi ent 7R89. one si:t'(ear un ergra uate me ical stu ent 70G;9. one ra iologist $'(sician 73R19. one ort'o$e ic trauma s$ecialist 7OT9 an one ort'o$e ic 'an surger( s$ecialist 7O<S9/ T'ese o&ser!ers use ,our classi,ication s(stems to la&el eac' case using sim$le :-ra(s in two inci ence $lanes 7$osteroanterior an lateral to t'e wrist9/

an illustrate &roc'ure s'owing escri$tions o, egrees an t($es o, inHur(/ At t'e ,irst e!aluation 7time T=9. all t'e :-ra(s were assesse in numerical seIuence/ T'ree weeks later. at t'e secon e!aluation 7time T>9. t'e initial :-ra( or er was ran- oml( c'ange to generate a new seIuence/ A ,urt'er ran omi#ation o, t'e seIuence was $er,orme ,or t'e t'ir e!aluation 7time T89. a,ter si: weeks/ T'e :ra(s were scanne an anal(#e in com$uters/ %ata were collecte on s$rea s'eets an t'e ka$$a 7A9 coe,,icient was use to assess agreements/ k was a$$lie using t'e met'o $ro$ose &( "leiss et al/=G. an t'e ran om e:$ecte agreement calculation escri&e &( Scott=5 an Co'en=4 was also use / T'e latter two met'o s ena&le calculation o, agreements ,or multi$le 7more t'an two9 o&ser!ers wit' regar to e!aluations o, nominal !ariances/ T'e( 'a!e t'ere,ore ,reIuentl( &een use in

stu ies to e!aluate intrao&ser!er an intero&ser!er relia&ilit( an re$ro uci&ilit(/ T'e ka$$a agreement coe,,icient $ro!i es a $arallel rating o, t'e agreement among t'e o&ser!ers t'at is ran oml( correct/ La$$a !alues range ,rom -= to M=J !alues &etween -= an B in icate t'at t'e o&ser!e agreement was lower t'an w'at was ran oml( e:$ecte . B in icates t'e ran om agreement le!el. an M= in icates total agreement/=G In general. ka$$a !alues o, less t'an B/C are consi ere unsatis,actor(J !alues &etween B/C an B/GC are consi ere satis,ac- tor( an a$$ro$riate. an !alues a&o!e B/GC are consi ere e:cellent/>B T'is $roHect was a$$ro!e &( t'e Researc' Et'ics Committee o, 0ni,es$E1M. un er No/ =BG;-B;. on August D. >BB;/ RES0LTS Out o, t'e initial 45 ,ractures. eig't were e:clu e 6 ,our $resente $oor Iualit( :-ra(s

Table 53 Intrao&ser!er ka$$a !alues &etween t'e t'ree times 7T=. T> an
Observer O<S OT 3R1 R8 0G; $ean /appa Classification 'niversal B/;C;5 B/;DC> B/8C=8 B/GC54 B/;DB; 2345264 AO,A"IB/;8;> B/;8D B/8=== B/D58C B/8GC= 23789:8 -r./man B/;8GC B/;;8> B/8B44 B/CD4 B/C5>4 236786

T89
-ern0nde1 B/G==C B/C>GD B/>55> B/GD=> B/;5=> 2368::

&' ( third"year orthopedic resident) U*+ ( si,th"year medical student) -&P ( radiologist physician) O.S ( orthopedic hand surgery specialist) OT ( orthopedic trauma specialist) /O0/S1F ( /r2eitsgemeinschaft f3r Osteosynthesefragen0/ssociation for the Study of 1nternal Fi,ation4

Table ;3 Intrao&ser!er ka$$a !alues &etween times T= an

Observer

T>

Classification

T'e classi,ications use were t'e 0ni!ersal 7Coone(9. AO@ASI". "r(k- man an "ern*n e#. an t'ese were $re!iousl( $resente an e:$laine to t'e e!aluators. wit'

Sao 1aulo Me J/ >BB5J=>;7896=5B-C/

=5>
' n i v e r s a l A O , A " I r . / m a n e r n 0 n d e 1 O<S B/;4=D B/;>5D B/;=>= B/G85 OT B/CG5D B/;>8 B/;BGC B/D488 3R1 B/>DG5 B/>=DD B/>4G= B/>;85 R8 B/GB54 B/D8D= B/;BG; B/G;44 0G; B/C5>= B/85C B/CB8; B/;>; $ean 236459; 23764:8 236;668 23698; &' ( third"year resident) U*+ ( Sao 1aulo Me orthopedic J/ >BB5J=>;7896=5B-C/ /appa
si,th"year medical student) -&P ( radiologist physician) O.S ( orthopedic hand surgery specialist) OT ( orthopedic trauma specialist) /O0/S1F ( /r2eitsgemeinschaft f3r Osteosynthesefragen0/ssociation for the Study of 1nternal Fi,ation4

Table <3 Intrao&ser!er ka$$a !alues &etween times T> an

Observer O<S OT 3R1 R8 0G; $ean /appa 'niversal B/;C4G B/;4BC B/DC>8 B/54B4 B/;;=C 23492:8 AO,A"IB/GBG; B/;;=5 B/D85= B/;4>G B/CCBD 234525;

T8
-r./man B/;54; B/G==> B/8==; B/C84G B/GB>D 236:2: -ern0nde1 B/GG>= B/DD88 B/8GGC B/5B>8 B/5==G 23475<8

Classification

&' ( third"year orthopedic resident) U*+ ( si,th"year medical student) -&P ( radiologist physician) O.S ( orthopedic hand surgery specialist) OT ( orthopedic trauma specialist) /O0/S1F ( /r2eitsgemeinschaft f3r Osteosynthesefragen0/ssociation for the Study of 1nternal Fi,ation4

Table 73 Intero&ser!er ka$$a !alues at eac' time 7T=. T>. T89

Classification Time T= T> T8 'niversal B/84;8 B/DBBD B/D==5 AO,A"IB/>GB> B/>455 B/8==G -r./man B/>D>G B/>C54 B/>;B5 -ern0nde1 B/8D B/DB5G B/D8DD

/O0/S1F ( /r2eitsgemeinschaft f3r Osteosynthesefragen0 /ssociation for the Study of 1nternal Fi,ation4

Table 63 Anal(sis o, intero&ser!er ka$$a !alues ,or $airs at time = 7T=9

Classification

=airs O<S !ersus OT O<S !ersus 3R1 O<S !ersus R8 O<S !ersus 0G; OT !ersus 3R1 OT !ersus R8 OT !ersus 0G; 3R1 !ersus R8 3R1 !ersus 0G; R8 !ersus 0G;

'niversal B/CD>4 B/>B4G B/CD;C B/8;58 B/8D;8 B/C4D B/DDC8 B/>;54 B/=4C5 B/CG>;

AO,A"IB/D4== B/=;8C B/DC8> B/=;DD B/>=C5 B/D>G> B/>D8= B/=D4G B/>=C5 B/>5G>

-r./man B/DBBG B/=G88 B/>444 B/B4CD B/>D;5 B/D=G8 B/>>>C B/>C=8 B/=;5; B/>D

-ern0nde1 B/8;CD B/8B8; B/;5D4 B/D8BD B/>=5; B/8CBC B/8=55 B/=CD5 B/BC5D B/;B>4

an anot'er ,our $resente :-ra(s $ro uce wit' t'e ,orearm immo&ili#e in $laster/ T'us. t'e sam$le si#e was re uce to 4B ,ractures/ T'e 'ig'est mean intrao&ser!er A. taking all t'ree o&ser!ation times. was ,rom t'e 0ni!ersal classi,ication 7A N B/;=9. ,ollowe &( "ern*n e# 7A N B/C49. "r(kman 7A N B/CC9 an AO@ASI" 7A N B/D49 7Ta&le =9/ E!aluation o, t'e intrao&ser!er k &etween t'e times T= an T> s'owe t'at t'e 'ig'est mean was ,rom t'e "ern*n e# classi,ication 7A N B/C59. ,ollowe &( t'e 0ni!ersal 7A N B/C;9. an t'e lowest mean was ,rom t'e AO@ASI" 7A N B/D;9 7Ta&le >9/ Between times T> an T8. t'e mean intrao&ser!er A was greater. ranging ,rom A N B/C4 ,or "r(kman classi,ication to A N B/;G ,or t'e t'e 0ni!ersal classi,ication 7Ta&le 89/ All t'e mean intero&ser!er k !alues ,or t'e classi,ications were 'ig'er at time 8. suc' t'at t'e( were 7in ecreasing or er9 "ern*n e# A N B/DD. 0ni!ersal A N B/D=. AO@ASI"
&' ( third"year orthopedic resident) U*+ ( si,th"year medical student) -&P ( radiologist physician) O.S ( orthopedic hand surgery specialist) OT ( orthopedic trauma specialist) /O0/S1F ( /r2eitsgemeinschaft f3r Osteosynthesefragen0/ssociation for the Study of 1nternal Fi,ation4

&' ( third"year orthopedic resident) U*+ ( si,th"year medical student) -&P ( radiologist physician) O.S ( orthopedic hand surgery specialist) OT ( orthopedic trauma specialist) /O0/S1F ( /r2eitsgemeinschaft f3r Osteosynthesefragen0/ssociation for the Study of 1nternal Fi,ation4

Table 43 Anal(sis o, intero&ser!er ka$$a !alues ,or $airs at time > 7T>9
=airs O<S !ersus OT O<S !ersus 3R1 O<S !ersus R8 O<S !ersus 0G; OT !ersus 3R1 OT !ersus R8 OT !ersus 0G; 3R1 !ersus R8 3R1 !ersus 0G; R8 !ersus 0G; Classification 'niversal B/CGC= B/>885 B/D48D B/CC; B/>G;4 B/C>5C B/CD>5 B/>==> B/>=5G B/D8;5 AO,A"IB/D554 B/>=4= B/D;B> B/8;4C B/=5B5 B/C>5C B/88D> B/==GD B/=>G> B/8;D; -r./man B/844 B/=8G8 B/8B5 B/=D4C B/>DDD B/D==G B/>4D4 B/>>>C B/>GD5 B/>D>> -ern0nde1 B/D=B> B/8>5; B/G;4= B/D454 B/>G8G B/D=48 B/D=C8 B/884G B/>BC B/D4>;

&' ( third"year orthopedic resident) U*+ ( si,th"year medical student) -&P ( radiologist physician) O.S ( orthopedic hand surgery specialist) OT ( orthopedic trauma specialist) /O0/S1F ( /r2eitsgemeinschaft f3r Osteosynthesefragen0/ssociation for the Study of 1nternal Fi,ation4

Table 93 Anal(sis o, intero&ser!er ka$$a !alues ,or $airs at time 8 7T89

=airs O<S !ersus OT O<S !ersus 3R1 O<S !ersus R8 O<S !ersus 0G; OT !ersus 3R1 OT !ersus R8 OT !ersus 0G; 3R1 !ersus R8 3R1 !ersus 0G; R8 !ersus 0G; Classi,ication 'niversal B/CDD= B/>;4> B/C8> B/CB== B/8D5= B/CD4= B/C=D> B/>DG= B/>>DD B/C==5 AO,A"IB/C85> B/>=GC B/D45C B/D;=5 B/>>> B/D8B; B/88>5 B/=CC= B/=BBC B/D=D8 -r./man B/DC=> B/>4G B/8>GG B/=>;C B/D8;= B/>;85 B/>8=> B/=GC4 B/>88G B/>=BC -ern0nde1 B/DG5= B/8D4> B/;DG= B/C88G B/>48 B/DC;D B/DG;4 B/885= B/8CBC B/C8D

A N B/8= an "r(kman A N B/>; 7Ta&le D9/ E!aluation o, t'e intero&ser!er k &( com- $aring $airs o, o&ser!ers at time = s'owe t'at t'e 'ig'est agreement was &etween t'e o&- ser!ers R8 an 0G; 7B/;B9 in t'e "ern*n e# classi,ication/ On t'e ot'er 'an . t'e lowest agreement was &etween 3R1 an 0G; 7B/B;9. in t'e same classi,ication s(stem 7Ta&le C9/ At time >. t'e 'ig'est agreement was o&taine &etween O<S an R8 7B/GG9 in t'e "ern*n e# classi,ication. w'ile t'e lowest was &etween 3R1 an R8 7B/=>9 in t'e AO@ASI" s(stem 7Ta&le ;9/ At time 8. t'e 'ig'est A was &etween O<S an R8 7B/;9 in t'e "ern*n e# classi,ica- tion. w'ile t'e lowest was &etween 3R1 an 0G; 7B/=9 in t'e AO@ASI" s(stem 7Ta&le G9/ %ISC0SSION T'e ,our classi,ication s(stems e!aluate in t'e $resent stu ( were c'osen &ecause t'e( are t'e ones t'at are most wi el( stu ie an use in our ,iel to classi,( istal ra ius ,ractures/>= In t'e "r(kman classi,ication. t'e general mean ka$$a !alue ,or intrao&ser!er agreement was satis,actor( 7B/CC9. alt'oug' t'e ra iolo- gist $'(sician 73R19 $resente an unsatis,ac- tor( !alue 7B/8=9 t'at was ,ar ,rom t'e ot'er ,our o&ser!ers/ A,ter recalculating t'e intrao- &ser!er ka$$a wit'out t'e me ical stu ent 70G;9 an t'e ort'o$e ic resi ent 7R89. w'o were less e:$erience e!aluators. t'e ka$$a !alue ecrease to B/CD/ T'is s'owe t'at t'e $ro,essionalEs e:$ertise le!el 'a no signi,icant im$act on t'e intrao&ser!er agreement/ +ari- ance anal(sis &etween t'e o&ser!ation times

s'owe t'at 0G; $resente relati!el( 'ig' !ariance 7B/C= to B/GB9 t'at was 84F greater t'an among t'e ot'er o&ser!ers/ T'is $ro&a&l( resulte ,rom t'e learning $rocess reIuire to &ecome accustome to t'is classi,ication s(stem/ T'is assum$tion is rein,orce &( t'e o&ser!ation t'at t'ere was relati!el( lower !ariance among t'e more e:$erience o&ser!- ers at t'e same times/ T'is suggests t'at t'e o&ser!erEs con itioning an knowle ge. s$e- ci,ic to t'e "r(kman s(stem. 'a a signi,icant im$act on t'e re$ro uci&ilit( o&taine / It is im$ortant to make it clear t'at t'e $ro,es- sional e:$ertise le!el was i,,erent ,rom t'e le!el o, e:$erience relating to t'e classi,ication/ T'e k-!alue ,or t'e intrao&ser!er agreement in t'e "r(kman classi,ication e!aluate &( An ersen et al/=B in =44; was B/D5/ In =445. Illarramen i et al/>> in =445 ,oun A N B/;=. an in >BB8. Oli!eira "il'o et al/=; ,oun A N B/CC/ T'ese coe,,icients re$orte in literature were in line wit' t'e results ,rom t'e $resent stu ( 7A N B/CC9/ )it' regar to t'e o&ser!erEs e:$erience. t'e stu ( $u&lis'e &( Oli!eira "il'o et al/=; 'a similar conclusions to ours. t'us emonstrating t'e $ositi!e e,,ect o, e:$ertise on t'e agreement rate/ T'e intero&ser!er agreement rate ,or t'e "r(kman classi,ication was unsatis,actor(. al&eit wit' a $rogressi!e increase ,rom T= 7B/>D>G9 to T8 7B/>;B59/ <owe!er. t'is increase was relati!el( lower t'an w'at was o&- ser!e ,rom t'e ot'er classi,ication s(stems/ T'e anal(sis s'owe t'at. in com$arison wit' t'e most e:$erience o&ser!ers 7O<S an OT9. t'e 3R1 o&ser!er $resente lower agreement rates/ T'is suggests t'at alt'oug' t'e 3R1 o&ser!er 'a $ro,essional e:$erience wit' ra iogra$'ic e!aluations. t'is o&ser!er was not using t'ese classi,ication met'o s routinel(/ T'is emonstrates t'at $ro,essional e:$erience o, ra iogra$'ic e!aluation is not. on its own. a etermining ,actor ,or a 'ig'er agreement rate using t'ese classi,ication s(s- tems/ )e also saw t'is w'en anal(#ing t'e ot'er classi,ication met'o s/ In our stu (. t'e intero&ser!er re$rouci&ilit( o, t'e "r(kman classi,ication was unsatis,actor( 7B/>; at T89. an t'e k !alue was relati!el( lower t'an ,oun in t'e stu ies &( An ersen et al/=B an Illarramen i et al/>>. w'ic' $resente k o, B/8C an B/D8 res$ec- ti!el(/ Our unsatis,actor( result ,rom t'e "r(kman classi,ication $ro&a&l( results ,rom t'e low agreement rate &etween 3R1 an t'e ot'er e!aluators/

T'e 0ni!ersal classi,ication e!aluates t'e ,ollowing !aria&les o, istal ra ius ,ractures.

e:clusi!el( &ase on ra iogra$'ic criteria6 in!ol!ement or non-in!ol!ement o, t'e ra io- car$al Hoint. $resence or a&sence o, islocation. ,racture re uci&ilit( an sta&ilit(/ T'e &iggest i,,icult( ,oun in a$$l(ing t'is classi,ication was in assessing t'e egree o, insta&ilit( o, t'e ,racture/ T'e literature i not emon- strate an( consensus regar ing t'e &est wa( to $re ict s$eci,ic insta&ilit( criteria on t'e initial :-ra(. an t'ere are se!eral stu ies wit' iscor- ant results concerning suc' criteria/>8->; In t'e 0ni!ersal classi,ication. t'e a!erage intrao&ser!er in e: was satis,actor( 7B/;=BC;9/ )'en t'e intrao&ser!er ka$$a was recalcu- late wit'out t'e less e:$erience o&ser!ers 7R8 an 0G;9. t'ere was a re uction in ka$$a to B/CC==/ T'is emonstrate t'at t'e egree o, e:$ertise i not in,luence t'e results. since an increase ka$$a woul &e e:$ecte w'en e:clu ing t'e less e:$erience e!alu- ators/ On t'e ot'er 'an . anal(sis o, 'ow t'e agreement e!ol!e ,rom time T= to M8 s'owe t'at 0G; $resente an increase o, =8F. w'ic' was lower t'an w'at was o&ser!e ,or R8 7increase o, >C/GF9 an 3R1 7increase o, 5>/CF9/ T'e intrao&ser!er agreement ,or t'e 0ni!ersal classi,ication was also satis,ac- tor( in anot'er stu (.=; w'ic' ,oun A N B/CD/ <owe!er. t'at stu ( emonstrate t'at t'e o&ser!erEs e:$erience was a ,actor t'at mo i- ,ie t'e agreement/ T'e intero&ser!er agreement ,or t'e 0ni!ersal classi,ication was unsatis,actor(. &ut $resente a $rogressi!e increase ,rom T= 7B/84;89 to T8 7B/D==59/ T'e 3R1 e!aluator $resente a lower agreement rate t'an w'at woul &e e:$ecte / <owe!er. we ,oun t'at t'is o&ser!erEs agreement rate increase in relation to t'e OT an O<S e!aluators/ T'is suggests t'at con itioning to t'e 0ni!ersal classi,ication 7i/e/ t'e e!olution ,rom T= to T89 was a ,actor t'at acte $ositi!el( on t'e re$ro uci&ilit(/ T'e same i,,icult( escri&e a&o!e ,or t'e 0ni!ersal classi,ication was ,oun in t'e AO@ASI" a$$lication. e!en consi ering t'at in t'e latter. e!aluation o, t'e comminution location is e:tremel( im$ortant ,or e,ining t'e grou$s/>G It is $ossi&le t'at t'is i,,icult( is t'e limiting ,actor ,or unsatis,actor( agree- ment rates t'at 'a!e &een ,oun in $re!ious stu ies/=B.=; Assuming t'at t'e $resence an location o, comminution are etermining !aria&les wit' regar to ,racture sta&ilit(. t'ere&( e,ini- ti!el( gui ing t'e t'era$(. etaile in!estiga- tion o, t'e re$ro uci&ilit( o, t'ese !aria&les on t'e ra iogra$' &ecomes necessar(/ In t'e AO@ASI" classi,ication. we use

grou$s an su&grou$s 7nine t($es9 an t'e mean intrao&ser!er !alue was unsatis,actor( 7B/D49/ T'ere was a signi,icant i,,erence &etween t'e !alues ,or t'e more e:$erience o&ser!ers 7O<S A N B/;D an OT A N B/;D9 an t'ose ,or t'e less e:$erience ones 7R8 A N B/D58C an 0G; A N B/8GC=9/ T'is suggests t'at t'e e:$ertise le!el 'a an in,lu- ence/ Onl( t'e 3R1 o&ser!er $resente a !alue at o s wit' w'at was e:$ecte 7A N B/8D9 ,or t'e more e:$erience e!aluators/ )'en t'e intrao&ser!er ka$$a was recalculate wit'out t'e less e:$erience o&ser!ers 7R8 an 0G;9. t'ere was an increase in A to B/C8. w'ic' rein,orces t'e '($ot'esis t'at t'e $ro,essional e:$ertise le!el 'a a signi,icant im$act on t'e intrao&ser!er agreement/ T'e anal(sis o, !ariation &etween t'e times T= an T8 emonstrate t'at t'e 0G; o&ser!er 7less e:$erience 9 'a an increase in agreement o, D8F. 3R1 increase &( C4/;F9 an R8 increase &( =BD/8F/ T'is emonstrate t'at con itioning to t'e classi,ication 'a a signi,i- cant im$act on intrao&ser!er re$ro uci&ilit(. $articularl( among t'e in i!i uals wit' less e:$ertise in using it/ In t'e literature. we saw t'at A range ,rom B/8G to B/;B in i,,erent stu ies.=B.=>.=;.>> t'us suggesting t'at t'e intrao&ser!er re$ro- uci&ilit( o, AO@ASI" s'oul &e close to B/C/ In t'e $resent stu (. t'e mean A was B/D5. wit' a range ,rom B/8= to B/;8/ It was onl( in t'e stu ( &( An ersen et al/=B. t'at t'e $ro,essional e:$ertise le!el 'a no signi,icant im$act on intrao&ser!er re$ro uci&ilit(/ T'is coul &e e:$laine &( t'e $resence o, ra iologist an ort'o$e ist o&ser!ers w'o were working in similar ,iel s an ,reIuentl( a$$lie t'e AO@ASI" classi,ication. in t'e same wa( as in our stu (/ In t'e ot'er stu ies.=>.=;.>> e:$ertise $la(e a mo i,(ing role in relation to intrao- &ser!er re$ro uci&ilit(/ T'e intero&ser!er agreement ,or t'e AO@ ASI" classi,ication was also unsatis,actor(. &ut $resente $rogressi!e increase ,rom T= 7B/>G9 to T8 7B/8=9/ T'e 3R1

e!aluator $resente increase agreement wit' OT an O<S. &( B/5F an 8/BF res$ecti!el(. an t'e 0G; o&ser!er $resente increase agreement wit' OT an O<S. &( 8;/4F an =5B/4F/ T'is suggests t'at con itioning was a ,actor acting $ositi!el( towar s intero&ser!er re$ro uc- i&ilit(. $articularl( ,or t'e less e:$erience in i!i uals/ In t'e literature.=B.=>.=;.>> we saw t'at t'e intero&ser!er A range ,rom B/8 to B/C/ T'is suggests t'at t'e AO@ASI" ka$$a is close to B/D. im$l(ing unsatis,actor( re$ro uci&ilit(/ It also suggests t'at t'e $ro,essional e:$ertise

le!el 'a no im$act on intero&ser!er re$ro uc- i&ilit( in t'is classi,ication. in t'e same wa( as seen in our stu (/ In t'e "ern*n e# classi,ication. t'e mean intrao&ser!er A was satis,actor( 7A N B/C49/ )'en t'e intrao&ser!er ka$$a was recalculate wit'out t'e less e:$erience o&ser!ers. t'ere was a re uction in A 7B/C=9. t'us emonstrat- ing t'at $ro,essional e:$ertise i not 'a!e an( in,luence on intrao&ser!er agreement/ Likewise. $ro,essional e:$erience was not seen to 'a!e an( $ositi!e in,luence on intero&ser!er agreement &etween t'e times T= an T8/ Con itioning 7t'roug' e!olution ,rom T= to T89 was seen to &e a ,actor acting $ositi!el( on intrao&ser!er re$ro uci&ilit(. ,or t'e "ern*n e# classi,ication/ T'ere are no eIui!alent stu ies on t'is classi,ication in t'e literature. w'ic' makes it im$ossi&le to make com$arisons wit' t'e $resent results/ Regar ing t'e intero&ser!er agreement ,or t'is classi,ication. it coul &e seen t'at

t'ere was a $rogressi!e increase in agreement &etween T= 7A N B/8D9 an T8 7A N B/DD9/ T'is was relati!el( greater t'an w'at was seen in t'e ot'er classi,ications/ T'is suggests t'at t'e con itioning in t'is classi,ication 'a a greater im$act on re$ro uci&ilit( t'an i t'e con itioning in ot'er classi,ications/ It is im$ortant to mention t'at t'e $resent stu ( was limite to e!aluating t'e agree- ment &etween t'e o&ser!ersE o$inions/ T'e stu ( was una&le to measure t'e accurac( o, eac' o&ser!erEs o$inion/ To clari,( t'e accurac( issue. stu ies in w'ic' clinical-ra iogra$'ic iagnoses ma e &( eac' o&ser!er were com- $are wit' an e:amination result or a stan ar $roce ure. i/e/ one wit' 'ig' sensiti!it( an s$eci,icit(. woul &e nee e in or er to $ro!e t'e $ro$ose iagnosis/ CONCL0SIONS T'e agreement rates o&ser!e in t'e $resent stu ( s'ow t'at currentl( t'ere is

still no classi,ication met'o t'at is ,ull( re$ro uci&le/ T'e &est intero&ser!er re$ro uci&ilit( rate was o&ser!e in t'e "ern*n e# classi,ication 7B/D89 an t'e worst was in t'e "r(kman classi,ication 7B/>;9/ T'e intrao&ser!er re$ro uci&ilit( was satis,actor( in t'e 0ni!ersal 7B/;=9. "ern*n e# 7B/C49 an "r(kman 7B/CC9 classi,ications. an it was unsatis,actor( in t'e AO@ASI" classi,ication 7B/D49/ Im$lications ,or ,urt'er researc' T'ere is a nee to $er,orm new stu ies aime at clari,(ing w'ic' classi,ication !aria&les $resent t'e 'ig'est isagreement rates &etween o&ser!ers. wit' conseIuent limits to re$ro uci&ilit(/ In t'e continuing searc' ,or an i eal classi,ication. $ros$ecti!e stu ies to escri&e w'ic' !aria&les can $re ict t'e insta&ilit( ,actors in suc' ,ractures t'roug' ra iogra$'ic e:amination are necessar(/

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>D/

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"ources of funding! None Conflict of interest! None Date of first submission! Octo&er =C. >BBG (ast received! A$ril =G. >BB5 Accepted! A$ril =5. >BB5/

A0T<OR IN"ORMATION
Jo>o Carlos Belloti? $D? $"c? =@D3 Atten ing $'(sician in t'e Traumatolog( Sector. %e$artment o, Ort'o$e ics an Traumatolog(. 0ni!ersi a e "e eral e So 1aulo 2 Escola 1aulista e Me icina 70ni,es$-E1M9. So 1aulo. Bra#il/ $arcel Jun "ugaAara Tamao/i3 T'ir -(ear resi ent in t'e %e$artment o, Ort'o$e ics an Traumatolog(. 0ni!ersia e "e eral e So 1aulo 2 Escola 1aulista e Me icina 70ni,es$-E1M9. So 1aulo. Bra#il/ Carlos Eduardo da "ilveira -rancio1i3 T'ir -(ear resi ent in t'e %e$artment o, Ort'o$e ics an Traumatolog(. 0ni!ersi a e "e eral e So 1aulo 2 Escola 1aulista e Me icina 70ni,es$-E1M9. So 1aulo. Bra#il/ Jo>o Baptista #omes dos "antos? $D? =@D3 A Hunct $ro,essor an 'ea o, <an Surger( Clinic. %e$artment o, Ort'o$e ics an Traumatolog(. 0ni!ersi a e "e eral e So 1aulo 2 Escola 1aulista e Me icina 70ni,es$-E1M9. So 1aulo. Bra#il/ Daniel Balbac@evs/.? $D3 Atten ing $'(sician in t'e Trauma- tolog( Sector. %e$artment o, Ort'o$e ics an Traumatol- og(. 0ni!ersi a e "e eral e So 1aulo 2 Escola 1aulista e Me icina 70ni,es$-E1M9. So 1aulo. Bra#il/ Eduardo C@ap C@ap3 Si:t'-(ear un ergra uate. 0ni!ersi a e "e eral e So 1aulo 2 Escola 1aulista e Me icina 70ni,es$-E1M9. So 1aulo. Bra#il/ +alter $anna Albertoni? $D? =@D3 Titular $ro,essor o, t'e %e$artment o, Ort'o$e ics an Traumatolog(. 0ni!ersia e "e eral e So 1aulo 2 Escola 1aulista e Me icina 70ni,es$-E1M9. So 1aulo. Bra#il/ -l0vio -aloppa? $D? =@D3 Titular $ro,essor an 'ea o, t'e %e$artment o, Ort'o$e ics an Traumatolog(. 0ni!ersia e "e eral e So 1aulo 2 Escola 1aulista e Me icina 70ni,es$-E1M9. So 1aulo. Bra#il/ Address for correspondence! Joo Carlos Belloti &ua $orges de 5agoa, 67' 8o andar So Paulo !SP# $rasil 9EP :;:'7":'< Tel40Fa, !=88 >># 886>"++<> E"mail? @2ellotiAterra4com42r 9opyright B <::7, /ssociaCo Paulista de edicina

RES0MO
As classificaBCes das fraturas do r0dio distal s>o reprodutDveis? ConcordEncia intra e inF terobser vadores
CONTEXTO E OBJETI O! 1ara Iue as classi,icaUVes as ,raturas $ossam ser Xteis. elas e!em $ro!er o $rognYstico. a$resentar concor Zncia intero&ser!a or e re$ro uti&ili a e intrao&ser!a or/ O o&Heti!o ,oi a!aliar a concor Zncia intra e intero&ser!a ores as classi,icaUVes as ,raturas o r* io istal/ TI=O DE E"T'DO E (OCA(! Estu o e !ali aUo 7concor Zncia intra e intero&ser!a ores9. esen!ol!i o no %e$artamento e Orto$e ia e Traumatologia a 0ni!ersi a e "e eral e So 1aulo 2 Escola 1aulista e Me icina 70ni,es$-E1M9. So 1aulo. Brasil/ $GTODO! "oram a!alia as 4B ,raturas o r* io istal com es!io $or meio e ra iogra,ias $or cinco o&ser!a ores 7um mO ico resi ente e Orto$e ia o terceiro ano. um gra uan o o se:to ano e me icina. um mO ico ra iologista. um orto$e ista es$eciali#a o em trauma e um orto$e ista es$eciali#a o em cirurgia a mo9 em tr[s momentos i,erentes. em$regan o as classi,icaUVes 0ni!ersal 7Coone(9. AO@ASI" 7Osteos(nt'es,ragen@Association ,or t'e Stu ( o, Internal "i:ation9. "r(kman e "ern*n e#/ A$licou-se o coe,iciente e concor Zncia ka$$a 7A9 $ara a!aliaUo as classi,icaUVes/ &E"'(TADO"! O maior A intrao&ser!a or mO io. se consi erarmos os tr[s momentos. ,oi a classi,icaUo 0ni!ersal 7A N B.;=9. segui a a "ern*n e# 7A N B.C49. "r(kman 7A N B.CC9 e AO@ASI" 7A N B.D49/ A concor Zncia intero&ser!a or ,oi insatis,atYria em to as as classi,icaUVes/ A classi,icaUo e "ern*n e# mostrou a mel'or concor Zncia 7A N B.DD9 e a $ior ,oi a e "r(kman 7A N B.>;9/ CONC('"HO! Os &ai:os n\!eis e concor Zncia o&ser!a os neste estu o sugerem Iue atualmente ain a no '* um mOto o e classi,icaUo $lenamente re$ro ut\!el/ =A(A &A"FC%A E! "ratura Estu os e !ali aUo/ e Colles/ "raturas o r* io/ Classi,icaUo/ Re$ro uti&ili a e os testes/