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Radial Head Fractures: Is the Mason Classification Still Effective Today? A Large-Sample Validation of Intra- and

Filippo Calderazzi¹, Davide Donelli², Alessandro Marinelli³

¹Department of Medicine and Surgery, Orthopaedic Clinic, Maggiore Hospital, University of Parma, 43126 Parma, Italy.

Journal of Clinical Medicine

|October 29, 2025

Summary

The Mason-Johnston classification for radial head fractures demonstrates moderate inter-observer reliability and moderate to substantial intra-observer agreement, indicating its clinical utility despite limitations.

Keywords:

inter-observer intra-observer mason classification multicenter study radial head fractures

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Area of Science:

Orthopedic Surgery
Radiology
Medical Imaging Analysis

Background:

Radial head fractures are common elbow injuries.
Existing classifications, like Mason-Johnston, rely on conventional radiographs.
Limitations in radiographic criteria may affect classification reliability.

Purpose of the Study:

To evaluate the reliability and reproducibility of the Mason-Johnston classification system.
To assess both inter-observer and intra-observer agreement for this widely used classification.

Main Methods:

Analysis of 90 elbow X-rays with radial head fractures.
Classification by eight orthopedic surgeons and one radiologist.
Assessment of inter-observer agreement in the first session.
Re-evaluation by the same observers after four months for intra-observer agreement.
Statistical analysis using Fleiss' kappa, Krippendorff alpha, and Cohen's kappa.

Main Results:

Moderate overall inter-observer agreement (Fleiss' κ ≈ 0.50).
Substantial agreement for specific fracture types (Krippendorff's α ≈ 0.73).
Moderate reliability for Types II-III and higher for Type IV.
Moderate to substantial intra-observer agreement observed.

Conclusions:

The Mason-Johnston classification exhibits moderate inter-observer reliability.
Intra-observer agreement is generally moderate to substantial.
Findings support the continued, albeit cautious, use of this classification in clinical practice.