Immunoglobulin G4 (IgG4)-related sclerosing cholangitis (IgG4-SC) is a rare condition with symptoms often mimicking malignancy, infection, or other autoimmune diseases. This case report describes the unique case of a 62-year-old male initially diagnosed with IgG4-SC, followed by subsequent diagnosis of cholangiocarcinoma. Biliary tract cancer in the setting of IgG4 related disease has been previously described; however, this patient course is novel as it encompasses the spectrum of challenges in IgG4-SC management, including diagnostic uncertainty, risk of infection with immunosuppressive agents, and development of malignancy diagnosed shortly following IgG4-SC diagnosis. We review the literature of management, outcomes, and malignancy risk and furthermore, highlight a promising recent therapy in treatment of IgG4 related disease, inebilizumab.

OBJECTIVETo assess the interobserver agreement on Garden classification of fresh femoral neck fracture and management plan based on anteroposterior (AP) view and also assess if the addition of lateral view changes the classification and management plan.

METHODSTen orthopaedic surgeons were asked to classify 35 femoral neck fractures on AP view only and propose the management plan. Then the same films were reshown in conjunction with their lateral view after 10 days. Results were compared with respect to the classification and management plan between two groups. Interobserver agreement was calculated using Fleiss' kappa.

RESULTSThere was only a fair interobserver agreement (kappa value 0.39) on Garden classification on AP view only which improved to moderate agreement (kappa value 0.52) after adding a lateral view. While there was only a slight improvement in the interobserver agreement on the management plan on AP view only (kappa value 0.50) and AP combined with lateral views (kappa value 0.52). Supplementation of the lateral view changed the classification in 15.42% of the cases and altered the management plan in 23.14% of the cases.

CONCLUSIONWe conclude that lateral view should be obtained routinely on all patients with suspected femoral neck fracture as it definitely has a role in planning treatment of femoral neck fracture.

Adolescent ; Adult ; Female ; Femoral Neck Fractures ; surgery ; Humans ; Male ; Middle Aged ; Observer Variation