Statistical analysis on the concordance of the radiological evaluation of fractures of the distal radius subjected to traction Work performed in the Orthopedics and Traumatology Service, Hospital Central da Polícia Militar do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.

ABSTRACT

OBJECTIVE:

The objective of this study was to evaluate the current classifications for fractures of the distal extremity of the radius, since the classifications made using traditional radiographs in anteroposterior and lateral views have been questioned regarding their reproducibility. In the literature, it has been suggested that other options are needed, such as use of preoperative radiographs on fractures of the distal radius subjected to traction, with stratification by the evaluators. The aim was to demonstrate which classification systems present better statistical reliability.

RESULTS:

In the Universal classification, the results from the third-year resident group (R3) and from the group of more experienced evaluators (Staff) presented excellent correlation, with a statistically significantp-value (p < 0.05). Neither of the groups presented a statistically significant result through the Frykman classification. In the AO classification, there were high correlations in the R3 and Staff groups (respectively 0.950 and 0.800), withp-values lower than 0.05 (respectively <0.001 and 0.003).

CONCLUSION:

It can be concluded that radiographs performed under traction showed good concordance in the Staff group and in the R3 group, and that this is a good tactic for radiographic evaluations of fractures of the distal extremity of the radius.

Keywords:
Fractures of the radius; Radiography; Traction

RESUMO

OBJETIVO:

Avaliar as classificações atuais da fratura da extremidade distal do rádio, pois as classificações feitas em radiografias tradicionais nas incidências anteroposterior e perfil têm sido questionadas quanto a sua reprodutibilidade e é sugerida pela literatura a necessidade de outras opções, com o uso das radiografias pré-operatórias submetidas a tração de fraturas de rádio distal, estratificados pelos avaliadores, com vistas a demonstrar quais classificações apresentam melhor confiabilidade estatística.

RESULTADOS:

Na classificação Universal os resultados dos grupos de R3 e Staff apresentaram uma ótima correlação, com um p-valor estatisticamente significativo (p < 0,05). Quando avaliada a classificação de Frykman, nenhum grupo apresentou um resultado estatisticamente significativo. Na classificação AO, nos grupos R3 e Staff, a correlação foi alta (respectivamente 0,950 e 0,800) com um p-valor abaixo de 0,05 (respectivamente < 0,001 e 0,003).

CONCLUSÃO:

A tração para feitura das radiografias se mostrou com uma boa concordância principalmente nos grupos avaliadores de maior experiência (Staff) e no residente de 3 o ano e é uma boa tática na avaliação radiográfica da fratura da extremidade distal do rádio.

Palavras-chave:
Fraturas do rádio; Radiografia; Tração

Introduction

Fractures of the distal extremity of the radius are very frequent injuries nowadays and this, along with technological advances, has led to much debate among orthopedists with regard to improvement of their treatment.11. Belloti JC, dos Santos JB, de Moraes VY, Wink FV, Tamaoki MJ, Faloppa F. The IDEAL classification system: a new method for classifying fractures of the distal extremity of the radius - description and reproducibility. Sao Paulo Med J. 2013;(4): 252-6.

The different approaches and outcomes have stimulated authors to seek classification systems that would guide diagnosis and treatment.22. Neuhaus V, Bot AG, Guitton TG, Ring DC. Influence of surgeon, patient, and radiographic factors on distal radius fracture treatment. J Hand Surg Eur Vol. 2015;40(8):796-804. Classifications for the distal extremity of the radius have the aims of ranking the injuries, enabling better knowledge and serving as facilitators in the decision-making process, either for conservative treatment or for surgical treatment, and with regard to the latter, determining which technique would be best. A wide variety of methods for treating the distal extremity of the radius exists,33. Makhni EC, Ewald TJ, Kelly S, Day CS. Effect of patient age on the radiographic outcomes of distal radius fractures subject to nonoperative treatment. J Hand Surg Am. 2008;33(8):1301-8. going from conservative to surgical treatment, using different techniques (fixation using Kirschner wires; ligamentotaxis using an external fixator with or without associated Kirschner wires; open reduction using rigid internal fixation; and absolute stabilization by means of osteosynthesis using a plate and screws with or without grafting). Use of imaging technology for classifications within orthopedics has been analyzed by researchers,44. Silva CFB, Câmara EKB, Vieira LA, Adolphsson F, Rodarte RRP. Radiographic assessment of the opening wedge proximal tibial osteotomy. Rev Bras Ortop. 2010;45(4):439-43. in relation to radiography,55. Herzberg G. Acute distal radius fracture: PAF analysis. J Wrist Surg. 2012;1(1):81-2.and66. Machado DG, Cerqueira SAdaC, Rodarte RRP, Netto A, Souza CA, Mathias MB. Análise estatística dos resultados funcionais e radiográficos após utilizaç ão de placa volar bloqueada nas fraturas da extremidade distal do rádio. Rev Bras Ortop. 2012;47(3):297-303. computed tomography or magnetic resonance imaging.77. Kümmel A, Ebner L, Kraus M, Mauch F, Geyer T, Mentzel M, et al. Magnet resonance imaging in common injuries of the wrist. Unfallchirurg. 2014;117(3):221-6. The reproducibility of fracture evaluations through using classification systems is extremely important for reliability. Use of such systems is an important stage in quantifying the severity of the injury and this demonstrates the safety of using certain classifications.88. Andersen DJ, Blair WF, Steyers CM Jr, Adams BD, el-Khouri GY, Brandser EA. Classification of distal radius fractures: an analysis of interobserver reliability and intraobserver reproducibility. J Hand Surg Am. 1996;21(4):574-82.,99. Avery DM 3rd, Matullo KS. Distal radial traction radiographs: interobservera nd intraobserver reliability compared with computed tomography. J Bone Joint Surg Am. 2014;96(7):582-8.,1010. Kural C, Sungur I, Kaya I, Ugras A, Ertürk A, Cetinus E. Evaluation of the reliability of classification systems used for distal radius fractures. Orthopedics. 2010;33(11):801.and1111. Gradl G, Neuhaus V, Fuchsberger T, Guitton TG, Prommersberger KJ, Ring D. Science of Variation Group Radiographic diagnosis of scapholunate dissociation among intra-articular fractures of the distal radius: interobserver reliability. J Hand Surg Am. 2013;38(9):1685-90. Inter and intraobserver consistency is a prerequisite for efficient use of any classification system.

Classifications that are made using traditional radiographs in posteroanterior and lateral views have been questioned regarding their reproducibility. IN the literature, it has been suggested that there is a need for other options, such as computed tomography.99. Avery DM 3rd, Matullo KS. Distal radial traction radiographs: interobservera nd intraobserver reliability compared with computed tomography. J Bone Joint Surg Am. 2014;96(7):582-8. However, among the limitations of computed tomography is its greater cost and higher radiation dose in relation to radiography. Radiography performed under traction is among the other options of lower cost and greater practicality, and this may increase the reliability of analyses on joint fractures.1212. Goldwyn E, Pensy R, O&apos;Toole RV, Nascone JW, Sciadini MF, LeBrun C, et al. Do traction radiographs of distal radial fractures influence fracture characterization and treatment? J Bone Joint Surg Am. 2012;94(22):2055-62.

The objective of this study was to evaluate the current classification systems for fractures of the distal radius by means of preoperative radiographs produced under traction, with stratification by the evaluators, with a view to demonstrating which classification systems present the best statistical reliability.

Methodology

A retrospective observational study was conducted in our institution based on 30 radiographs on patients who had been admitted to the orthopedics and traumatology service and who underwent surgical procedures to treat fractures of the distal extremity of the radius.

The authors declare that this study was in accordance with the Declaration of Helsinki.

Radiographs on these patients were produced preoperatively, at the time of admission, and these were performed under traction in order to evaluate the fracture, as part of the established routine within our service. Two radiographs were produced on each patient: in anteroposterior and lateral views.

After this, the images were evaluated. The evaluators were grouped according to their year of residency or position as a member of the hospital staff.

Universal classification (Cooney)

I. extra-articular without displacement II. extra-articular with displacement

A. stable and reducible B. unstable and reducible C. irreducible

III. intra-articular without displacement IV. intra-articular with displacement

A. stable and reducible B. unstable and reducible C. irreducible D. complex

Frykman classification

I. extra-articular II. extra-articular + fracturing of the distal ulna III. intra-articular (radiocarpal joint) IV. intra-articular (radiocarpal joint) + fracturing of the distal ulna V. intra-articular (distal radioulnar joint) VI. intra-articular (distal radioulnar joint + fracturing of the distal ulna VII. intra-articular (radiocarpal and distal radioulnar joints) VIII. intra-articular (radiocarpal and distal radioulnar joints) + fracturing of the distal ulna

AO classification

A - extra-articular

A1 - ulna and radius intact A2 - simple and impacted fractures of the radius A3 - multifragmented fracture of the radius

B - partial intra-articular

B1 - sagittal facture of the radius B2 - frontal and dorsal edge fracture of the radius B3 - frontal and volar edge fracture of the radius

C - complete intra-articular fracture of the radius

C1 - simple at joint and simple in metaphysis C2 - simple at joint and multifragmented in metaphysis C3 - multifragmented at joint

Each group according to year of residency comprised three residents. Thus, three evaluators were first-year residents, three were second-year residents and three were third-year residents. Three staff physicians also formed part of the group, as a reference group.

Statistical analysis

The results from analyzing the radiographs with regard to the different classification systems (Frykman, AO and Universal) were tabulated and the SPSS statistical package (IBM), version 13.0, was used for the concordance analysis.

First stage: exploratory analysis of the central trend and dispersion measurements on the variables obtained.

Second stage: evaluation of the intra and inter-group inter-examiner concordance (R1/R2/R3 and Staff) by means of the intraclass correlation (ICC).

Third stage: identification of concordance between the control group (Staff) and R3 in the universal classification with and without the subtypes.

Results

The three classifications presented very different results in correlations that were made with the aim of examining the consistency of the evaluations between the groups of evaluators.

In evaluating the universal classification proposed by Cooney,1313. Cooney WP. Fractures of the distal radius A modern treatment-based classification. Orthop Clin North Am. 1993;24(2):211-6. the groups of evaluators presented behavior that differed greatly.

The group of first-year residents presented low concordance (0.236), with low statistical significance (p-value = 0.278).

The group of second-year residents presented greater concordance, although still at an intermediate level (0.566), with a p-value of 0.064, which was at the limit of significance.

The results from the R3 and Staff groups presented excellent correlations, with statistically significant p-values (p < 0.05). When the Cooney classification was used without evaluating the criterion of stability of position (full Staff versus Staff), the concordance was seen to increase (from 0.725 to 0.786), with a significant p-value (p < 0.05). When the R3 and Staff groups were compared, this showed high concordance between the groups (Table 1).

Table 1
Analysis on the intraclass correlation between the groups of evaluators using Cooney's universal classification system.

When the Frykman classification was evaluated, none of the groups presented a statistically significant result (all of them presented p-values >0.05), although the Staff group presented an adequate correlation (0.885) (Table 2).

Table 2
Analysis on the intraclass correlation between the groups of evaluators using Frykman's classification system.

Analysis on the AO classification showed that the groups presented behavioral differences (Table 3).

Table 3
Analysis on the intraclass correlation between the groups of evaluators using the AO classification system.

The R1 group presented low concordance and also a p-value with low statistical significance.

The R2 group presented good correlation, with a p-value of 0.032 (statistically significant).

For the R3 and Staff groups, the correlations were high (respectively 0.950 and 0.800), with p-values less than 0.05 (respectively <0.001 and 0.003).

Discussion

Fractures of the distal extremity of the radius are among the most frequent types of fractures of the skeleton, according to Reis et al.,1414. Reis FB, Faloppa F, Saone RP, Boni JR, Corvelo MC. Fraturas do terç o distal do rádio: classificaç äo e tratamento. Rev Bras Ortop. 1994;29(5):326-30. and account for up to 10% of skeletal fractures. Paksima et al.1515. Paksima N, Panchal A, Posner MA, Green SM, Mehiman CT, Hiebert R. A meta- analysis of the literature on distal radius fractures: review of 615 articles. Bull Hosp Jt Dis. 2004;62(1-2):40-6. stated that they are responsible for one in six emergency orthopedic cases attended.

The concern for observing radiographic results in relation to functional outcomes has been evaluated recently.1616. Xavier CRM, Dal Molin DC, Santos RMM, Santos RDT, Ferreira Neto JC. Surgical treatment of distal radius fractures with a volar locked plate: correlation of clinical and radiographic results. Rev Bras Ortop. 2011;46(5):505-13.

The initial status of the fracture,33. Makhni EC, Ewald TJ, Kelly S, Day CS. Effect of patient age on the radiographic outcomes of distal radius fractures subject to nonoperative treatment. J Hand Surg Am. 2008;33(8):1301-8.along with the comminution, is considered to be a factor that contributes toward the outcome from the fracture.

The existence of various classifications demonstrates that there is a need to obtain a single ideal classification that would be very wide-ranging and would provide support for therapeutic and prognostic conduct.1717. Jeong GK, Kaplan FT, Liporace F, Paksima N, Koval KJ. An evaluation of two scoring systems to predict instability in fractures of the distal radius. J Trauma. 2004;57(5):1043-7. More than 20 classification systems for fractures of the distal extremity of the radius have been described. If a classification system has fulfilled all the premises for supplying support, it will still need to present intra and interobserver reproducibility. Several authors have stated that choosing the ideal treatment for stabilizing the fracture is of fundamental importance.33. Makhni EC, Ewald TJ, Kelly S, Day CS. Effect of patient age on the radiographic outcomes of distal radius fractures subject to nonoperative treatment. J Hand Surg Am. 2008;33(8):1301-8.,1010. Kural C, Sungur I, Kaya I, Ugras A, Ertürk A, Cetinus E. Evaluation of the reliability of classification systems used for distal radius fractures. Orthopedics. 2010;33(11):801.and1515. Paksima N, Panchal A, Posner MA, Green SM, Mehiman CT, Hiebert R. A meta- analysis of the literature on distal radius fractures: review of 615 articles. Bull Hosp Jt Dis. 2004;62(1-2):40-6. According to Downing and Karantana,1818. Downing ND, Karantana A. A revolution in the management of fractures of the distal radius? J Bone Joint Surg Br. 2008;90(10):1271-5. no other fracture treatment has been influenced by technology in the way that treatments for fractures of the distal extremity of the radius have.1818. Downing ND, Karantana A. A revolution in the management of fractures of the distal radius? J Bone Joint Surg Br. 2008;90(10):1271-5.and1919. Karantana A, Downing ND, Forward DP, Hatton M, Taylor AM, Scammell BE, et al. Surgical treatment of distal radial fractures with a volar locking plate versus conventional percutaneous methods: a randomized controlled trial. J Bone Joint Surg Am. 2013;95(19):1737-44. Therefore, the prospect of making an appropriate diagnosis, classifying the fracture with greater reproducibility and reliability and choosing the most appropriate technique have become the pillars for achieving the best result possible.2020. Sink EL, Leunig M, Zaltz I, Gilbert JC, Clohisy J. Academic Network for Conservational Hip Outcomes Research Group Reliability of a complication classification system for orthopaedic surgery. Clin Orthop Relat Res. 2012;470(8):2220-6.,2121. Siripakarn Y, Niempoog S, Boontanapibul K. The comparative study of reliability and reproducibility of distal radius&apos; fracture classification among: AO frykman and Fernandez classification systems. J Med Assoc Thai. 2013;96(1):52-7.and2222. Küç ük L, Kumbaraci M, Günay H, Karapinar L, Ozdemir O. Reliability and reproducibility of classifications for distal radius fractures. Acta Orthop Traumatol Turc. 2013;47(3):153-7. Recognizing the characteristics of the fracture is extremely important,2323. Arealis G, Galanopoulos I, Nikolaou VS, Lacon A, Ashwood N, Kitsis C. Does the CT improve inter- and intra- observer agreement for the AO, Fernandez and Universal classification systems for distal radius fractures? Injury. 2014;45(10):1579-84.,2424. Koval K, Haidukewych GJ, Service B, Zirgibel BJ. Controversies in the management of distal radius fractures. J Am Acad Orthop Surg. 2014;22(9):566-75.and2525. Beumer A, Adlercreutz C, Lindau TR. Early prognostic factors in distal radius fractures in a younger than osteoporotic age group: a multivariate analysis of trauma radiographs. BMC Musculoskelet Disord. 2013;14:170. since certain factors that predict instability, as described by Lafontaine et al.,2626. Lafontaine M, Hardy D, Delince P. Stability assessment of distal radius fractures. Injury. 1989;20(4):208-10.need to be well recognized in making the radiographic assessment.

In a study on radiographic assessment without traction, Flinkkilä et al.2727. Flinkkilä T, Raatikainen T, Hämäläinen M.A.O. Frykman&apos;s classifications of Colles&apos; fracture No prognostic value in 652 patients evaluated after 5 years. Acta Orthop Scand. 1998;69(1):77-81. suggested that the AO and Frykman classifications presented low value and that this was accompanied by low concordance regarding the clinical outcome. The percentage concordance between different evaluators through using the complete AO classification has ranged from 17 to 40% from radiographs and from 17 to 50% from tomography. In the study by Kreder et al.,2828. Kreder HJ, Hanel DP, McKee M, Jupiter J, McGillivary G, Swiontkowski MF. Consistency of AO fracture classification for the distal radius. J Bone Joint Surg Br. 1996;78(5):726-31. the interobserver concordance values from the AO classification was 0.67 between residents and 0.86 between surgeons, through evaluating the major types (A, B and C). When all the subtypes were used, the concordance decreased to 0.25 and 0.42, respectively. Use of additional tools such as computed tomography has the aim of improving the classification. Better results with regard to identifying the presence or absence of six specific fragments of the fracture (radial column, dorsal wall, dorsoulnar corner, volar-ulnar corner, volar edge and central impaction), so as to make treatment recommendations are found through radiography under traction and computed tomography.99. Avery DM 3rd, Matullo KS. Distal radial traction radiographs: interobservera nd intraobserver reliability compared with computed tomography. J Bone Joint Surg Am. 2014;96(7):582-8. In our study, we observed a good correlation through the universal classification. The Frykman classification showed a low level of concordance in the present study, and this was in line with the literature. On the other hand, the AO classification presented excellent concordance. According to Küçük et al.,2222. Küç ük L, Kumbaraci M, Günay H, Karapinar L, Ozdemir O. Reliability and reproducibility of classifications for distal radius fractures. Acta Orthop Traumatol Turc. 2013;47(3):153-7. the classification systems for evaluating fractures of the distal extremity of the radius presented inconsistent results and they suggested that there was a need to create new classifications. In the study by Evans et al.,2929. Evans S, Taithongchai A, Machani B, David M. Are plain radiographs useful in accurately classifying distal radius fractures? Int J Surg. 2013;11(8):707.and3030. Evans S, David M, Quraishi MK, Hanif U-K, Sadique H, Machani B. The use of plain radiographs in the classification of distal radius fractures. J Orthop. 2014;11(3):142-4. the sensitivity of radiographs for making classifications using the Frykman and AO systems was only 12.5%. These authors stated that evaluations using radiographs alone were insufficient and suggested that there was a need for other types of examinations in order to increase the reliability and reproducibility, as we found in the presented study, in which we achieved good concordance using the universal and AO classification systems.

Conclusion

In the present study, it was observed that evaluations on radiographs produced under traction presented high concordance through the AO and universal classification systems.

Regarding the Frykman classification, we did not find good reliability from this evaluation, even on radiographs produced under traction.

We conclude that radiographs produced under traction showed good concordance, especially in the groups with greater experience that were evaluated (staff and third-year residents), and that this is a good tactic in making radiographic assessments of fractures of the distal extremity of the radius through Cooney's universal classification and the AO classification.

References

  • 1
    Belloti JC, dos Santos JB, de Moraes VY, Wink FV, Tamaoki MJ, Faloppa F. The IDEAL classification system: a new method for classifying fractures of the distal extremity of the radius - description and reproducibility. Sao Paulo Med J. 2013;(4): 252-6.
  • 2
    Neuhaus V, Bot AG, Guitton TG, Ring DC. Influence of surgeon, patient, and radiographic factors on distal radius fracture treatment. J Hand Surg Eur Vol. 2015;40(8):796-804.
  • 3
    Makhni EC, Ewald TJ, Kelly S, Day CS. Effect of patient age on the radiographic outcomes of distal radius fractures subject to nonoperative treatment. J Hand Surg Am. 2008;33(8):1301-8.
  • 4
    Silva CFB, Câmara EKB, Vieira LA, Adolphsson F, Rodarte RRP. Radiographic assessment of the opening wedge proximal tibial osteotomy. Rev Bras Ortop. 2010;45(4):439-43.
  • 5
    Herzberg G. Acute distal radius fracture: PAF analysis. J Wrist Surg. 2012;1(1):81-2.
  • 6
    Machado DG, Cerqueira SAdaC, Rodarte RRP, Netto A, Souza CA, Mathias MB. Análise estatística dos resultados funcionais e radiográficos após utilizaç ão de placa volar bloqueada nas fraturas da extremidade distal do rádio. Rev Bras Ortop. 2012;47(3):297-303.
  • 7
    Kümmel A, Ebner L, Kraus M, Mauch F, Geyer T, Mentzel M, et al. Magnet resonance imaging in common injuries of the wrist. Unfallchirurg. 2014;117(3):221-6.
  • 8
    Andersen DJ, Blair WF, Steyers CM Jr, Adams BD, el-Khouri GY, Brandser EA. Classification of distal radius fractures: an analysis of interobserver reliability and intraobserver reproducibility. J Hand Surg Am. 1996;21(4):574-82.
  • 9
    Avery DM 3rd, Matullo KS. Distal radial traction radiographs: interobservera nd intraobserver reliability compared with computed tomography. J Bone Joint Surg Am. 2014;96(7):582-8.
  • 10
    Kural C, Sungur I, Kaya I, Ugras A, Ertürk A, Cetinus E. Evaluation of the reliability of classification systems used for distal radius fractures. Orthopedics. 2010;33(11):801.
  • 11
    Gradl G, Neuhaus V, Fuchsberger T, Guitton TG, Prommersberger KJ, Ring D. Science of Variation Group Radiographic diagnosis of scapholunate dissociation among intra-articular fractures of the distal radius: interobserver reliability. J Hand Surg Am. 2013;38(9):1685-90.
  • 12
    Goldwyn E, Pensy R, O&apos;Toole RV, Nascone JW, Sciadini MF, LeBrun C, et al. Do traction radiographs of distal radial fractures influence fracture characterization and treatment? J Bone Joint Surg Am. 2012;94(22):2055-62.
  • 13
    Cooney WP. Fractures of the distal radius A modern treatment-based classification. Orthop Clin North Am. 1993;24(2):211-6.
  • 14
    Reis FB, Faloppa F, Saone RP, Boni JR, Corvelo MC. Fraturas do terç o distal do rádio: classificaç äo e tratamento. Rev Bras Ortop. 1994;29(5):326-30.
  • 15
    Paksima N, Panchal A, Posner MA, Green SM, Mehiman CT, Hiebert R. A meta- analysis of the literature on distal radius fractures: review of 615 articles. Bull Hosp Jt Dis. 2004;62(1-2):40-6.
  • 16
    Xavier CRM, Dal Molin DC, Santos RMM, Santos RDT, Ferreira Neto JC. Surgical treatment of distal radius fractures with a volar locked plate: correlation of clinical and radiographic results. Rev Bras Ortop. 2011;46(5):505-13.
  • 17
    Jeong GK, Kaplan FT, Liporace F, Paksima N, Koval KJ. An evaluation of two scoring systems to predict instability in fractures of the distal radius. J Trauma. 2004;57(5):1043-7.
  • 18
    Downing ND, Karantana A. A revolution in the management of fractures of the distal radius? J Bone Joint Surg Br. 2008;90(10):1271-5.
  • 19
    Karantana A, Downing ND, Forward DP, Hatton M, Taylor AM, Scammell BE, et al. Surgical treatment of distal radial fractures with a volar locking plate versus conventional percutaneous methods: a randomized controlled trial. J Bone Joint Surg Am. 2013;95(19):1737-44.
  • 20
    Sink EL, Leunig M, Zaltz I, Gilbert JC, Clohisy J. Academic Network for Conservational Hip Outcomes Research Group Reliability of a complication classification system for orthopaedic surgery. Clin Orthop Relat Res. 2012;470(8):2220-6.
  • 21
    Siripakarn Y, Niempoog S, Boontanapibul K. The comparative study of reliability and reproducibility of distal radius&apos; fracture classification among: AO frykman and Fernandez classification systems. J Med Assoc Thai. 2013;96(1):52-7.
  • 22
    Küç ük L, Kumbaraci M, Günay H, Karapinar L, Ozdemir O. Reliability and reproducibility of classifications for distal radius fractures. Acta Orthop Traumatol Turc. 2013;47(3):153-7.
  • 23
    Arealis G, Galanopoulos I, Nikolaou VS, Lacon A, Ashwood N, Kitsis C. Does the CT improve inter- and intra- observer agreement for the AO, Fernandez and Universal classification systems for distal radius fractures? Injury. 2014;45(10):1579-84.
  • 24
    Koval K, Haidukewych GJ, Service B, Zirgibel BJ. Controversies in the management of distal radius fractures. J Am Acad Orthop Surg. 2014;22(9):566-75.
  • 25
    Beumer A, Adlercreutz C, Lindau TR. Early prognostic factors in distal radius fractures in a younger than osteoporotic age group: a multivariate analysis of trauma radiographs. BMC Musculoskelet Disord. 2013;14:170.
  • 26
    Lafontaine M, Hardy D, Delince P. Stability assessment of distal radius fractures. Injury. 1989;20(4):208-10.
  • 27
    Flinkkilä T, Raatikainen T, Hämäläinen M.A.O. Frykman&apos;s classifications of Colles&apos; fracture No prognostic value in 652 patients evaluated after 5 years. Acta Orthop Scand. 1998;69(1):77-81.
  • 28
    Kreder HJ, Hanel DP, McKee M, Jupiter J, McGillivary G, Swiontkowski MF. Consistency of AO fracture classification for the distal radius. J Bone Joint Surg Br. 1996;78(5):726-31.
  • 29
    Evans S, Taithongchai A, Machani B, David M. Are plain radiographs useful in accurately classifying distal radius fractures? Int J Surg. 2013;11(8):707.
  • 30
    Evans S, David M, Quraishi MK, Hanif U-K, Sadique H, Machani B. The use of plain radiographs in the classification of distal radius fractures. J Orthop. 2014;11(3):142-4.

  • Work performed in the Orthopedics and Traumatology Service, Hospital Central da Polícia Militar do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.

Publication Dates

  • Publication in this collection
    jan-feb 2016

History

  • Received
    03 Nov 2014
  • Accepted
    29 Dec 2014
Sociedade Brasileira de Ortopedia e Traumatologia Al. Lorena, 427 14º andar, 01424-000 São Paulo - SP - Brasil, Tel.: 55 11 2137-5400 - São Paulo - SP - Brazil
E-mail: rbo@sbot.org.br