Diagnostic imaging concordance study: Are traction radiographs necessary in a hip fracture?

ABSTRACT Introduction: Hip fractures are a pathology that have emerged as a major subject over the years, due to increased prevalence and the multiple surgical treatments involved. The characterization and classification of the lesion is essential for proper surgical planning, with anteroposterior (AP), lateral and traction radiograph of the hip, paramount for decision-making. Patients and methods: This is a retrospective concordance study of 64 patients with hip fracture who consulted the hospital between January and July 2017. Four radiographs were taken of each: AP, AP with traction, lateral and lateral with traction. This set of images was evaluated by 9 observers, with different levels of experience, to answer questions regarding the classification, emphasize in potential instability and requirement of other images. A statistical analysis of concordance between and within observers was performed using Cohen's kappa coefficient. Results: Of the 64 patients, 70.6% were women; the average age was 69.5 years. 82.8% presented a secondary fracture from falling from their own height. As the observer's experience increases, the need for traction radiograph decreases; interobserver kappa goes from 0.98 in experts to 0.01 in students. Traction radiograph is important in the diagnosis of potentially unstable fractures. Of the 1,503 radiographs with traction, 636 (42.38%) were classified as potentially unstable. And of the 708 without traction, 560 (79.1%) were classified as potentially unstable. Conclusions: Traction hip radiograph continues to be a useful tool in training environments to adequately classify an intertrochanteric fracture, considering it is a low-cost, minimal morbidity intervention, and is easily accessible. In similar studies, we found similar findings regarding the usefulness of traction to perform an adequate classification in people in training or in young orthopedists. It also influences to determine the potential instability, and this would modify the choice of the implant 1 Hip fractures represent a major economic burden on the health system. They are a frequent public health problem, closely related to osteoporosis and increased age. Orthopedists need to use inexpensive but useful elements for the proper diagnosis of hip fractures 2 Selecting the proper management of hip fractures requires the most accurate classification possible, which entails having the images necessary to identify the bone injury. The complex anatomy of the hip, associated with the potential displacement that the fracture, impaction and angulation may present, creates challenges for the accurate classification of the fracture, so tools such as traction radiograph tend to be used for proper diagnosis, classification and surgical planning. 3 Traction radiograph is a useful tool in training environments to adequately classify an intertrochanteric fracture, considering it is a low-cost, minimal morbidity intervention, and is easily accessible.