Hip fracture is a common serious injury in the elderly. Between 1982 and 1998 the number of hip fractures reported annually in Scotland in patients over 55 years rose from 4,000 to 5,700. The optimum method of treatment for the various fracture types remains in contention.

We compare outcome measures between displaced, intracapsular fractures in patients over 70 years fixed with cannulated screws and sliding hip screw with side plate.

Between 1998 and 2005 a total of 30,482 patients were reviewed by the Scottish Hip Fracture Audit (SHFA). Of these 15,823(53.3% of the total) had sustained intracapsular fractures. 13,587 of these occurred in patients aged 70 or over. Of these 2,428 had undisplaced and 11,159 displaced fractures. Chi test statistical analysis compare outcome measures in this group of displaced intracapsular fractures with respect to aspects of early failure.

534(3.9%) of patients were treated conservatively. 509 (4.7%) fractures were fixed using cannulated screws and 499 (4.6%) using a sliding hip screw. Readmission within 120 days for any cause occurred in 62 patients(14.1%) treated with cannulated screw fixation and in 63 patients(15.7%) for those treated with a sliding hip screw(P=0.509). Of these 36 patients(8.2%) in the former and 23 patients(5.7%) in the latter group were readmitted for complications related to hip fracture(P=0.033). Mortality within this period included 69 patients(13.5%) in the CS and 98(19.6%) in the SHS group. In terms of re-operation within 120 days of the original admission, 53 patients(10.6%) receiving cannulated screws compared to 24 patients(4.8%) treated with a sliding hip screw requiring further surgery(P=0.0006). The fracture was seen to displace in 12(22.6%) patients originally treated with cannulated screws compared to 6 patients(25%) treated with sliding hip screw(P=0.156). More significantly the fixation device was seen to have migrated in 24(45.3%) of the cannulated screw as compared to 7(29.2%) patients in the sliding hip screw group(P=0.002). Periprosthetic fractures were recorded in 4(7.5%) of the former and 3(12.5%) in the latter group(P=0.708). Wound infection was higher in the SHS group(2 patients) as compared to the screw fixation group(1 patient)(P=0.565).

Statistical analysis demonstrates a dramatic difference exists between these 2 fixation types in terms of re-operation within 120 days of the original admission for which published literature has previously only recorded biomechanical, in vitro comparisons.

Data regarding specific implant factors such as number of screws, position, configuration, starting point, thread length and use of washers in cannulated screws, and position, tapping, supplementary screw and compression screw in sliding hip screws was not recorded and may be considered to bias our results.

For any fracture classification, a high level of intraobserver reproducibility and interobserver reliability is desirable. We compare the consistency of the AO and Neer classifications for proximal humerus fractures with an assessment of the digitised radiographs of 100 fractures by 10 orthopaedic surgeons and 5 radiologists using the General Electric Picture Archiving and Communications System (PACS), allowing manipulation of the image. This process repeated 1 month later.

Reproducibility and reliability moderate for both the AO and Neer systems. Reproducibility using the AO/ ASIF system was slightly greater. The assessor’s level of experience and specialty did affect accuracy. The ability to electronically manipulate images does not improve reliability and their sole use in describing these injuries and comparing similarly classified fractures from different centres is not recommended.

Fractures of the proximal humerus are common. Most undisplaced or minimally displaced, and treated conservatively. Up to one fifth may benefit from surgery. As decisions regarding treatment are based on the fracture type, a radiological classification should be easy to use and have a high degree of reliability and reproducibility to serve as a useful discriminator, creating standards by which treatment can be recommended and outcomes compared.

Radiographs of 100 fractures of the proximal humerus selected. A true anteroposterior, scapular lateral, and axillary radiograph taken for each fracture. 10 orthopaedic surgeons and 5 radiologists recruited as assessors, including 5 specialist registrars. Each given a printed description of both Neer and AO classifications, a goniometer and ruler. The assessment preceeded by short lecture. Radiographs could be manipulated digitally for size, contrast, brightness, orientation and the negative image displayed. We did not require assessors to determine subgroups for reasons of simplicity. Reproducibility and reliability analysed using Kappa statistical methods. Coefficients for agreement compared using the Student t test incorporating the standard errors of kappa for these groups. A comparison made between radiologists and surgeons, and then consultant orthopaedic surgeons and trainees.

In each case the AO/ASIF system was statistically (p< 0.01) more accurate.

Agreement was greater for less complex (one and two part, and type A) fractures.

Level of experience produced a statistically (p< 0.01) significant difference in accuracy. Specialty did not.

Our analysis comparing the Neer and AO systems uses the largest group of assessors reviewing the largest number of radiographs reported in the literature.

We concur with others in concluding that using these systems in isolation in determining treatment and comparing results following treatment cannot be recommended

For any fracture classification, a high level of intraobserver reproducibility and interobserver reliability is desirable. We compare the consistency of the AO and Frykman classifications for distal radius fractures using digitised radiographs of 100 fractures by 15 orthopaedic surgeons and 5 radiologists using a Picture Archiving and Communications System (PACS). The process was repeated 1 month later. Reproducibility moderate for both the AO and Frykman systems, reliability only fair for both the AO and Frykman systems. In each case reproducibilty using the Frykman system was slightly greater. The assessor’s level of experience and specialty was not seen to influence accuracy. The ability to electronically manipulate images does not appear to improve reliability compared to the use of traditional hard copies, and their sole use in describing these injuries is not recommended.

These fractures are common, approximately one sixth of all fractures and the most commonly occurring fractures in adults. Their multitude of eponyms hint at the difficulty in formulating a comprehensive and useable system. The Frykman classification is most popular, but limited- does not quantify displacement, shortening or the extent of comminution. The more comprehensive AO system is limited in its complexity with 27 possible subdivisions. Computerised tomography shown to give only marginal improvement in consistency of classification.

Radiographs of 100 fractures selected. Anteroposterior and lateral view for each. 15 orthopaedic surgeons and 5 radiologists recruited as assessors, including 5 specialist registrars. Each given a printed description of Frykman and AO classifications. Radiographs could be manipulated digitally. Intra and inter-observer reproducibility analysed. A comparison made comparing reproducibility between radiologists and surgeons, consultant orthopaedic surgeons and trainees. Statistical methods; analysis involves adjustment of observed proportion of agreement between observers by correction for the proportion of agreement that could have occurred by chance. Kappa coefficients compared using the Student t test incorporating standard errors of kappa for these groups.

Median interobserver reliability was fair for both the AO (kappa = 0.31, range 0.2 to 0.38) and Frykman (kappa = 0.36, range 0.30 to 0.43) systems. Median intraobserver reproducibility was moderate for both the AO (kappa = 0.45, range 0.42 to 0.48) and Frykman (kappa = 0.55, range 0.51 to 0.57) systems. In each case the Frykman system was statistically (p< 0.01) more accurate. Level of experience, or specialty was not seen to influence accuracy (p< 0.01).

Our results demonstrate that using them in isolation in determining treatment and comparing results following treatment cannot be recommended