Introduction: Gap and step-off measurements are generally used in the surgical decision-making process of distal radius fractures. Unfortunately, there is no consensus on treatment choice as these measurements are prone to inter- and intraobserver variability. In this study, we aim to introduce a new 3D fracture quantification method and compare it to conventional fracture analysis.
Methods: Forty patients with a minimally displaced intra-articular distal radius fracture that was treated nonoperatively between 2008-2015 were included. 2D-CT images were reassessed by three orthopedic trauma surgeons who performed gap and step-off measurements. Subsequently, 3D models were created and a 3D measurement method for fracture displacement was developed. For each fracture, the '3D gap area' (3D surface between all fracture fragments) was determined by three observers. Interobserver agreements were calculated for all measurements, and the intraobserver agreement was calculated for the new 3D measurement. All patients completed two questionnaires in order to link our measurements to functional outcome.
Results: The interobserver agreement of the 2D measurements was fair (ICC = 0.54) for the gap and poor (ICC = 0.21) for the step-off. The median gap was 2.8 (IQR: 1.9-3.5) mm and step-off was 0.9 (IQR: 0.0-1.6) mm. Interobserver agreement on 3D gap area measurements was excellent (ICC = 0.81), with a median difference between measurements of 6.0 (IQR: 2.0-19.0) mm2, which indicates reliable assessment of 3D fracture displacement. Intraobserver agreement was also excellent (ICC = 0.98), with a median difference of 4.0 (IQR: 1.5-5.5) mm2. No significant differences in clinical outcome were found between the above and below 2mm displacement groups. The score of the DASH was 3.4 (IQR: 0.4-8.8) versus 4.2 (IQR: 0.0-11.6) respectively. Results from the PRWE questionnaire shows a similar result of 3.5 (IQR: 0.0-12.6) versus 5.0 (IQR: 0.0-25.5).
Conclusion: 3D gap area is a more objective measurement method compared to the conventional gap and step-off measurements to quantify the level of fracture displacement of distal radius fractures. 3D fracture assessment can be used in addition to the currently used classification systems of distal radius fractures.