title: Guesstimation of posterior malleolar fractures on lateral plain radiographs.
abstract: BACKGROUND
  Accurate assessment of articular involvement of the posterior malleolar fracture fragments in ankle fractures is essential, as this is the leading argument for internal fixation. The purpose of this study is to assess diagnostic accuracy of measurements on plain lateral radiographs.
  
  
  METHODS
  Quantification of three-dimensional computed tomography (Q-3D-CT) was used as a reference standard for true articular involvement (mm(2)) of posterior malleolar fractures. One-hundred Orthopaedic Trauma surgeons were willing to review 31 trimalleolar ankle fractures to estimate size of posterior malleolus and answer: (1) what is the involved articular surface of the posterior malleolar fracture as a percentage of the tibial plafond? and (2) would you fix the posterior malleolus?
  
  
  RESULTS
  The average posterior malleolar fragment involved 13.5% (SD 10.8) of the tibial plafond articular surface, as quantified using Q-3D-CT. The average involvement of articular surface of the posterior malleolar fragment, as estimated by 100 observers on plain radiographs was 24.4% (SD 10.0). The factor 1.8 overestimation of articular involvement was statistically significant (p<0.001). Diagnostic accuracy of measurements on plain lateral radiographs was 22%. Interobserver agreement (ICC) was 0.61. Agreement on operative fixation, showed an ICC of 0.54 (Haraguchi type I=0.76, Haraguchi type II=0.40, Haraguchi type III=0.25).
  
  
  CONCLUSIONS
  Diagnostic accuracy of measurements on plain lateral radiographs to assess articular involvement of posterior malleolar fractures is poor. There is a tendency to misjudge posteromedial involvement (Haraguchi type II).
authors.affiliation: Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, Netherlands. Electronic address: dtmeijer@gmail.com.
authors.forename: D T
authors.initials: DT
authors.lastname: Meijer
authors.affiliation: Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, Netherlands.
authors.forename: J N
authors.initials: JN
authors.lastname: Doornberg
authors.affiliation: Clinical Epidemiologist, Slotervaartziekenhuis, Amsterdam, Netherlands.
authors.forename: I N
authors.initials: IN
authors.lastname: Sierevelt
authors.affiliation: Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, Netherlands.
authors.forename: W H
authors.initials: WH
authors.lastname: Mallee
authors.affiliation: Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, Netherlands.
authors.forename: C N
authors.initials: CN
authors.lastname: van Dijk
authors.affiliation: Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, Netherlands.
authors.forename: G M
authors.initials: GM
authors.lastname: Kerkhoffs
authors.affiliation: Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, Netherlands.
authors.forename: S A
authors.initials: SA
authors.lastname: Stufkens
mesh_terms: D064386:Ankle Fractures / Q000000981:diagnostic imaging* / Q000473:pathology; D006801:Humans; D021621:Imaging, Three-Dimensional; D009426:Netherlands; D015588:Observer Variation; D012015:Reference Standards; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D013639:Tarsal Bones / Q000000981:diagnostic imaging* / Q000293:injuries; D013977:Tibia / Q000000981:diagnostic imaging* / Q000293:injuries; D014057:Tomography, X-Ray Computed / Q000295:instrumentation
keywords: Ankle; Posterior malleolar fragment; Q3DCT; Trauma; X-ray