Reliability of classification of fractures of the tibial plafond according to a rank-order method.

BACKGROUND: Many orthopedic classification systems, including those for tibial plafond fractures, are either unvalidated or have demonstrated problems with interobserver reliability. Classification of tibial plafond fractures according to a rank-order method has shown excellent interobserver reliability with several observers. The purpose of this study is to determine the reliability of a rank order classification of plafond fractures with a large number of observers.
METHODS: A radiographic review study was completed by 69 orthopedists of varying training levels. Observers ranked 10 fractures of the tibial plafond based on anteroposterior and lateral ankle radiographs. Fractures were ranked in increasing severity from 1 to 10. No instructions were given regarding determination of severity. Agreement between rankings was analyzed by the intraclass correlation coefficient (ICC).
RESULTS: Rankings were performed by viewing prints at the annual Orthopaedic Trauma Association meeting and through the Orthopaedic Trauma Association website using digital images. The overall ICC was 0.62. There was no difference in the ICC between traumatologists and general orthopedists (p > 0.5). Eleven observers commented that the radiographs did not represent the full spectrum of injury severity.
CONCLUSIONS: The interobserver reliability of the rank-order classification in this study was fair to good, which is better than previously reported for plafond fracture classification systems. It remains to identify and validate a series of tibial plafond fractures that represent a full spectrum of injury and can be ranked with excellent interobserver reliability. A series of cases such as this may then serve a measurement standard for severity of bony injury against which individual cases may be reliably compared.