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Is Smartphone Technology Reliable and Effective in Assessing Pediatric Elbow Trauma?
Ebrahim Paryavi, MD, MPH; Brandon Schwartz, MPH; Joshua Abzug, MD
Department of Orthopaedics, University of Maryland Medical Center, Baltimore, MD

Hypothesis: The use of mobile imaging has become increasingly prevalent in the clinical setting. Data are not available regarding the reliability of mobile phones in transmitting adequate images of radiographs for establishing a diagnosis and directing treatment. We hypothesized that diagnosis of pediatric elbow fractures from multimedia messaging service (MMS) images would demonstrate low reliability among pediatric orthopaedic surgeons and senior residents. Our secondary hypothesis was that the decision for operative treatment would not be affected by evaluation of images on a mobile device as opposed to standard picture archiving and communication system (PACS).

Methods: AP and lateral radiograph images of 50 pediatric elbow cases were evaluated by 2 pediatric orthopaedic surgeons and 2 senior orthopaedic residents. Raters were asked to classify the case as any of the following fractures/diagnoses: supracondylar humerus, lateral condyle, medial epicondyle, radial neck, posterior fat pad, or normal pediatric elbow. Additionally, raters were asked to choose operative or conservative treatment. After a temporal lag, pictures of the same images were taken from a standardized distance from a computer monitor with an iPhone 5 camera and transmitted by MMS to each rater. The same questions were again posed to raters. Inter and intra-observer reliabilities were calculated by Cohenís kappa statistics with bootstrapped 95% confidence intervals.

Results: Baseline inter-observer reliability of classification of injuries based on PACS images was excellent between residents and attendings with a kappa of 0.85 (95% CI 0.76-0.93). The inter-observer reliability of treatment decision between the two groups was also high with a kappa of 0.79 (95% CI 0.67-0.91). Intra-observer reliability of classification of injuries on PACS compared to MMS images was excellent, with kappa ranging from 0.89 (95% CI 0.80-0.95) to 0.94 (95% CI 0.87-0.99) for residents and attendings, respectively. The overall kappa was 0.91 (95% CI 0.86-0.95) when comparing ratings of all participants on PACS versus MMS. Treatment decision also demonstrated excellent intra-observer reliability (PACS versus MMS) with kappa ranging from 0.80 (95% CI 0.67-0.92) to 0.916 (95% CI 0.84-0.99) for residents and attendings, with an overall kappa of 0.86 (95% CI 0.79-0.93) for all raters.

Conclusion: The diagnosis of pediatric elbow injuries and treatment decisions can be made equally reliably based on either PACS or transmitted MMS images taken with an iPhone from a computer screen. As MMS images become increasingly prevalent in communication between physicians and staff, we have demonstrated that this practice can be effective in establishing a diagnosis and directing treatment.

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