Diagnostic Accuracy of 2-Dimensional Computed Tomography for Articular Involvement and Fracture Pattern of Posterior Malleolar Fractures

Foot Ankle Int. 2016 Jan;37(1):75-82. doi: 10.1177/1071100715603999. Epub 2015 Sep 29.


Background: Up to 44% of ankle fractures have involvement of the posterior tibial margin. Fracture size and morphology are important factors to guide treatment of these fragments, but reliability of plain radiography in estimating size is low. The aim of the current study was to evaluate the accuracy of 2-dimensional computed tomography (2DCT) in the assessment of posterior malleolar fractures. Additionally, the diagnostic accuracy of 2DCT and its value in preoperative planning was evaluated.

Methods: Thirty-one patients with 31 ankle fractures including a posterior malleolar fragment were selected. Preoperative CT scans were analyzed by 50 observers from 23 countries. Quantitative 3-dimensional CT (Q3DCT) reconstructions were used as a reference standard.

Results: Articular involvement of the posterior fragment was overestimated on 2DCT by factors 1.6, 1.4, and 2.2 for Haraguchi types I, II, and III, respectively. Interobserver agreement on operative management ("to fix, or not to fix?") was substantial (κ = 0.69) for Haraguchi type I fractures, fair (κ = 0.23) for type II fractures, and poor (κ = 0.09) for type III fractures. 2DCT images led to a change in treatment of the posterior malleolus in 23% of all fractures. Surgeons would operatively treat type I fractures in 63%, type II fractures in 67%, and type III fractures in 22%.

Conclusion: Surgeons overestimated true articular involvement of posterior malleolar fractures on 2DCT scans. 2DCT showed some additional value in estimating the involved articular surface when compared to plain radiographs; however, this seemed not yet sufficient to accurately read the fractures. Analysis of the CT images showed a significant influence on choice of treatment in 23% with a shift toward operative treatment in 12% of cases compared to evaluating plain lateral radiographs alone.

Level of evidence: Level III, comparative study.

Keywords: Haraguchi classification; computed tomography; posterior malleolar fracture; quantitative 3-dimensional CT.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Ankle Fractures / classification
  • Ankle Fractures / diagnostic imaging*
  • Ankle Fractures / surgery
  • Female
  • Humans
  • Imaging, Three-Dimensional
  • Male
  • Observer Variation
  • Preoperative Care
  • Reproducibility of Results
  • Sensitivity and Specificity
  • Tomography, X-Ray Computed