The use of internal rotation traction radiographs in improving radiographic assessment of Extracapsular femoral fractures at Muhimbili Orthopedic Institute

Abstract

ABSTRACT Background: The incidence of complex extracapsular proximal femoral fractures is rising globally, necessitating prompt and accurate diagnosis. While internal rotation traction radiographs have demonstrated higher reliability in other settings, their effectiveness in the clinical environment at Muhimbili Orthopedic Institute has not yet been assessed. This study aimed at assessing this phenomenon. Objective: This study aimed to assess the use of internal rotation traction radiographs in improving radiographic assessment of extracapsular femoral fractures at Muhimbili Orthopedics Institute. Methods: A cross-sectional study was conducted at Muhimbili Orthopedics Institute, involving 46 participants with extracapsular proximal femoral fractures who were attended at the emergency department between July 2023 and December 2023. Data on fracture pattern, routine and traction internal rotation radiographs were taken from the participants. 5 senior residents who were randomly selected, evaluated the radiographs. Descriptive statistics was used to assess the pattern of extracapsular femoral fractures while Fleiss kappa statistics was used to analyze the interobserver reliability for the routine and traction internal rotation radiographs among senior residents. Results: The mean age was 63.8 ± 17.6 years. The majority of participants were females (55%), and most fractures resulted from slipping on a slippery surface (34.8%). The fractures were predominantly intertrochanteric (58.7%) and occurred more frequently on the right side (69.6%). The overall interobserver reliability among senior residents using routine radiographs was moderate (κ = 0.593, SE = 0.03, Z = 203.608, p < 0.001). Individual evaluations showed substantial agreement for diagnosing intertrochanteric (κ = 0.626, SE = 0.013, Z = 48.386, p = 0.015) and pertrochanteric fractures (κ = 0.611, SE = 0.013, Z = 47.890, p < 0.001), and excellent agreement for subtrochanteric fractures (κ = 1.00, SE = 0.013, Z = 77.340, p < 0.001). There was fair agreement for diagnosing unstable fractures (κ = 0.214, SE = 0.013, Z = 16.529, p < 0.001) and substantial agreement for stable fractures (κ = 0.630, SE = 0.013, Z = 48.744, p < 0.001). vi In contrast, the overall interobserver reliability using internal rotation traction radiographs was excellent (κ = 0.943, SE = 0.04, Z = 262.928, p < 0.001). Evaluations of individual variables indicated nearly excellent agreement on the evaluability of radiographs (κ = 0.990, SE = 0.013, Z = 76.587, p < 0.001), and for diagnosing intertrochanteric (κ = 0.904, SE = 0.013, Z = 69.871, p < 0.001), pertrochanteric (κ = 0.995, SE = 0.013, Z = 76.965, p < 0.001), and subtrochanteric fractures (κ = 1.00, SE = 0.013, Z = 77.330, p < 0.001). There was nearly perfect agreement for assessing unstable fractures (κ = 0.995, SE = 0.013, Z = 76.960, p < 0.001) and stable fractures (κ = 0.950, SE = 0.013, Z = 73.455, p < 0.001). Conclusions: This study demonstrates that internal rotation traction radiographs significantly enhance the interobserver reliability of fracture assessment compared to routine radiographs, highlighting their potential utility in improving diagnostic accuracy and patient’s outcome in clinical practice. It is recommended that clinical protocols be updated to include internal rotation traction radiographs for the assessment of extracapsular femoral fractures. Furthermore, preventive measures should be implemented to prevent falling among elderly individuals which would lead to extracapsular proximal femoral fractures.