Evaluating the Clinical Value of Oblique-View Radiographs in the Initial Intervention of Closed Distal Radius Fractures: An External Survey of Hand Surgeons

Abstract

Traditionally, an acute wrist radiograph series comprises posteroanterior, oblique, and lateral projections. There is controversy within the field of orthopedics, however, over the value of the oblique view in determining a plan of care for a given fracture. An external survey of practicing hand surgeons was conducted to evaluate whether the addition of the oblique view to a 2-view (posteroanterior and lateral) series resulted in a difference in the initial intervention plan for closed distal radius fractures (DRFs). Participants, licensed and practicing hand surgeons in the United States, reviewed 30 sets of wrist radiograph studies twice (once as a complete 3-view series and again with the oblique omitted) in a randomized order. Cases were randomly selected to include 10 pediatric, 10 geriatric, and 10 intermediate/adult DRFs. After reviewing the films and demographic information, the participants selected their preferred initial intervention from the following list: (1) treatment using a cast or orthosis without reduction, (2) closed reduction under or without fluoroscopy with treatment using a cast or orthosis, (3) closed reduction and percutaneous fixation with treatment using a cast or orthosis, and (4) open reduction internal fixation and subsequent treatment in a cast or orthosis. A calculated Cohen kappa for the entire sample revealed a statistically significant and strong association between 2- and 3-view survey answers (κ= 0.81, P < .001). Each pairing was examined separately, and 90% of the questions had a statistically significant (P < .05) Cohen kappa pairing; however, many were in the 0.5-0.75 range. The data support the hypothesis that the addition of an oblique view radiograph to a posteroanterior and lateral series does not change surgical decision-making in the initial evaluation of acute closed DRF in many situations. However, although most cases had a statistically significant (P < .05) agreement between the surveys, the oblique view did result in some meaningful intervention changes. Therefore, the elimination of the oblique view cannot be supported by our findings. This is a decision analysis survey study designed to investigate how the oblique-view radiograph influences DRF surgical decision-making.