How accurate and reliable are doctors in estimating fracture angulation?

By J.S.H. Gaskin, M.K. Pimple, R. Wharton, C. Fernandez, D. Gaskin, and D.M. Ricketts
Article reprinted with permission from INJURY, International Journal of the Care of the Injured (2007) 38, 160-162.

Summary
This study assessed the accuracy of doctors in estimating fracture angulations. Radiographs of fractured wrist and forearm of varying angulations were shown to all grades of doctors in the specialty of trauma and orthopaedics. They were asked to estimate the angulation at the fracture site without using a goniometer. The estimates were analyzed for accuracy and variability. This study showed that doctors have a mean error of 8° to 9° and had poor agreement with themselves and others. We recommend the use of a goniometer to assess fracture angulation.

Key words: fracture angulation, forearm, wrist, accuracy, inter-observer variability, intra-observer variability, goniometer

Introduction
Children frequently present with fractures of the forearm and wrist. The angulation of the fracture is important in deciding management. Doctors often estimate fracture angulation without a goniometer and use the result to plan treatment. In the literature, the accuracy of doctors in estimating metaphyseal-diaphyseal angle (Auerbach, Radomisli, Simoncini, & Ulin, 2004) in tibia vara and Cobb's angle
(Loder, Spiegel, Gutknecht, et al., 2004) in scoliosis has been assessed. However, no literature exists on the estimation of fracture angulation.

The aim of this study was to determine the accuracy and variability of doctors in estimating the angulation of fractures of the forearm and wrist.

Material and methods

Groups studied
We assessed consultants, registrars, senior house officers (SHOs) and pre-registration house officers (PRHOs) from the department of trauma and orthopaedics at a district general hospital. Four staff from each group was included in the study. The PRHOs had no previous experience in orthopaedics or accident and emergency. The SHOs had a minimum of six months' experience and the registrars had a minimum of two years' experience in trauma and orthopaedics.

Radiographs used
We used 40 radiographs in this study. Of these, 20 radiographs were of fractured distal radii and 20 were radiographs of fractured forearms in the age group five to 12 years. To simplify the study, only lateral radiographs were used. Varying degrees of angulation from 0° to 50° were included (mean 22.2°).

The angles were evenly distributed so that there were five radiographs each in the range of 0° to 10°, 11° to 20°, 21° to 30° and over 30°.