Boehler's angle and the critical angle of Gissane are of limited use in diagnosing calcaneus fractures in the ED

Jason R. Knight, Eric Gross, Gail H. Bradley, Curt Bay, Frank LoVecchio

Research output: Contribution to journalArticle

21 Citations (Scopus)

Abstract

Study Objectives: The aim of this study was to determine the use of Boehler's angle (BA) and the critical angle of Gissane (CAG) in diagnosing calcaneus fractures in the ED. Design: The study was conducted as a randomized, blinded, case-control trial. Cases: One hundred thirty-three patients older than 15 years were included in the study. Sixty-five patients with computed tomography-verified calcaneus fractures (gold standard) and 68 ED patients with lateral foot or ankle x-rays without calcaneus fractures were included in the study. Methods: One second-year emergency medicine resident, 1 third-year emergency medicine resident, 2 board-certified emergency medicine attending physicians, and 1 board-certified radiologist prospectively reviewed all films using the Picture Archival and Communication System digital radiology system. Cases and controls were randomized and the participants were blinded to final radiographic diagnoses. Participants determined whether there was a fracture on each x-ray and measured BA and the CAG using the digital angle tool in the Picture Archival and Communication System. Results: Emergency physicians were 97.9% accurate in diagnosing calcaneus fractures (range, 97% to 99%). The mean κ value for emergency physicians was 0.96 (range, 0.94-0.985). Receiver operating characteristic curves were constructed for BA and the CAG. When compared with the gold standard, the area under the curve for BA ranged from 0.82 to 0.88. The area under the curve for the CAG ranged from 0.45 to 0.67. BA had an interclass correlation coefficient of 0.84 (95% confidence interval, 0.79-0.87). The CAG interclass correlation was 0.52 (95% confidence interval, 0.43-0.60). One fracture was missed by the radiologist and all of the emergency physicians because it was only visible on computed tomography. Conclusion: BA is somewhat helpful and the CAG is not useful in diagnosing calcaneus fractures in the ED. Interrater reliability for BA is excellent, but for the CAG, it is poor. Emergency physicians were 97.9% accurate in making the diagnosis by reviewing the plain films without "assistance" of the angle measurements.

Original languageEnglish (US)
Pages (from-to)423-427
Number of pages5
JournalAmerican Journal of Emergency Medicine
Volume24
Issue number4
DOIs
StatePublished - Jul 1 2006
Externally publishedYes

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Calcaneus
Emergency Medicine
Physicians
Emergencies
Area Under Curve
Communication
Tomography
X-Rays
Confidence Intervals
Motion Pictures
Radiology
Ankle
ROC Curve
Foot

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Boehler's angle and the critical angle of Gissane are of limited use in diagnosing calcaneus fractures in the ED. / Knight, Jason R.; Gross, Eric; Bradley, Gail H.; Bay, Curt; LoVecchio, Frank.

In: American Journal of Emergency Medicine, Vol. 24, No. 4, 01.07.2006, p. 423-427.

Research output: Contribution to journalArticle

Knight, Jason R. ; Gross, Eric ; Bradley, Gail H. ; Bay, Curt ; LoVecchio, Frank. / Boehler's angle and the critical angle of Gissane are of limited use in diagnosing calcaneus fractures in the ED. In: American Journal of Emergency Medicine. 2006 ; Vol. 24, No. 4. pp. 423-427.
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abstract = "Study Objectives: The aim of this study was to determine the use of Boehler's angle (BA) and the critical angle of Gissane (CAG) in diagnosing calcaneus fractures in the ED. Design: The study was conducted as a randomized, blinded, case-control trial. Cases: One hundred thirty-three patients older than 15 years were included in the study. Sixty-five patients with computed tomography-verified calcaneus fractures (gold standard) and 68 ED patients with lateral foot or ankle x-rays without calcaneus fractures were included in the study. Methods: One second-year emergency medicine resident, 1 third-year emergency medicine resident, 2 board-certified emergency medicine attending physicians, and 1 board-certified radiologist prospectively reviewed all films using the Picture Archival and Communication System digital radiology system. Cases and controls were randomized and the participants were blinded to final radiographic diagnoses. Participants determined whether there was a fracture on each x-ray and measured BA and the CAG using the digital angle tool in the Picture Archival and Communication System. Results: Emergency physicians were 97.9{\%} accurate in diagnosing calcaneus fractures (range, 97{\%} to 99{\%}). The mean κ value for emergency physicians was 0.96 (range, 0.94-0.985). Receiver operating characteristic curves were constructed for BA and the CAG. When compared with the gold standard, the area under the curve for BA ranged from 0.82 to 0.88. The area under the curve for the CAG ranged from 0.45 to 0.67. BA had an interclass correlation coefficient of 0.84 (95{\%} confidence interval, 0.79-0.87). The CAG interclass correlation was 0.52 (95{\%} confidence interval, 0.43-0.60). One fracture was missed by the radiologist and all of the emergency physicians because it was only visible on computed tomography. Conclusion: BA is somewhat helpful and the CAG is not useful in diagnosing calcaneus fractures in the ED. Interrater reliability for BA is excellent, but for the CAG, it is poor. Emergency physicians were 97.9{\%} accurate in making the diagnosis by reviewing the plain films without {"}assistance{"} of the angle measurements.",
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AB - Study Objectives: The aim of this study was to determine the use of Boehler's angle (BA) and the critical angle of Gissane (CAG) in diagnosing calcaneus fractures in the ED. Design: The study was conducted as a randomized, blinded, case-control trial. Cases: One hundred thirty-three patients older than 15 years were included in the study. Sixty-five patients with computed tomography-verified calcaneus fractures (gold standard) and 68 ED patients with lateral foot or ankle x-rays without calcaneus fractures were included in the study. Methods: One second-year emergency medicine resident, 1 third-year emergency medicine resident, 2 board-certified emergency medicine attending physicians, and 1 board-certified radiologist prospectively reviewed all films using the Picture Archival and Communication System digital radiology system. Cases and controls were randomized and the participants were blinded to final radiographic diagnoses. Participants determined whether there was a fracture on each x-ray and measured BA and the CAG using the digital angle tool in the Picture Archival and Communication System. Results: Emergency physicians were 97.9% accurate in diagnosing calcaneus fractures (range, 97% to 99%). The mean κ value for emergency physicians was 0.96 (range, 0.94-0.985). Receiver operating characteristic curves were constructed for BA and the CAG. When compared with the gold standard, the area under the curve for BA ranged from 0.82 to 0.88. The area under the curve for the CAG ranged from 0.45 to 0.67. BA had an interclass correlation coefficient of 0.84 (95% confidence interval, 0.79-0.87). The CAG interclass correlation was 0.52 (95% confidence interval, 0.43-0.60). One fracture was missed by the radiologist and all of the emergency physicians because it was only visible on computed tomography. Conclusion: BA is somewhat helpful and the CAG is not useful in diagnosing calcaneus fractures in the ED. Interrater reliability for BA is excellent, but for the CAG, it is poor. Emergency physicians were 97.9% accurate in making the diagnosis by reviewing the plain films without "assistance" of the angle measurements.

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