A simplified classification of proximal femoral fractures improves accuracy, confidence, and inter-reader agreement of hip fracture classification by radiology residents

Emerg Radiol. 2019 Apr;26(2):179-187. doi: 10.1007/s10140-018-1660-5. Epub 2018 Nov 23.


Purpose: To demonstrate the effect of teaching a simplified treatment-based classification of proximal femoral fractures on the accuracy, confidence, and inter-reader agreement of radiology residents. The authors hypothesize that these measures will improve after viewing an educational presentation.

Materials and methods: Three radiology residents independently classified 100 operative proximal femoral fractures, both before and after viewing a 45-min educational video describing the simplified classification scheme, with a washout period of at least 12 weeks between sessions. Based on the gold standard established by consensus of two radiologists and an orthopedic trauma surgeon utilizing intraoperative fluoroscopic imaging, operative reports, and pre-procedural imaging, accuracy of classification was calculated for each reader before and after viewing the educational video. Reader confidence was recorded on a 0-10 scale, and inter-reader agreement was calculated with Fleiss's kappa. McNemar's test was used to compare accuracy, a paired t test was used to compare confidence, and the Z-test was used to compare kappa values after bootstrapping to determine the standard error of the mean.

Results: The study cohort included 60/100 females, with a mean age of 76.6 years. The pooled classification accuracy was initially 65%, which improved to 80% in the second reading session after viewing the educational video (p < 0.0001). Confidence improved from 6.9 initially to 8.6 (p < 0.0001). Inter-reader agreement improved from a kappa of 0.45 (moderate agreement) to 0.74 (substantial agreement) (p < 0.0001).

Conclusions: A simplified treatment-based classification of proximal femoral fractures is easily taught to radiology residents and resulted in increased accuracy, increased inter-reader agreement, and increased reader confidence.

Keywords: Education; Fracture classification; Hip fracture.

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Female
  • Femoral Fractures / classification*
  • Femoral Fractures / diagnostic imaging*
  • Hip Fractures / classification*
  • Hip Fractures / diagnostic imaging*
  • Humans
  • Internship and Residency*
  • Male
  • Middle Aged
  • Radiology / education*
  • Retrospective Studies