Skeletal Radiology

, Volume 44, Issue 10, pp 1435–1439 | Cite as

Interobserver variation in classification of malleolar fractures

  • S. M. VerhageEmail author
  • S. J. Rhemrev
  • S. B. Keizer
  • H. M. E. Quarles van Ufford
  • J. M. HoogendoornEmail author
Scientific Article



Classification of malleolar fractures is a matter of debate. In the ideal situation, a classification system is easy to use, shows good inter- and intraobserver agreement, and has implications for treatment or research.

Material and methods

Interobserver study. Four observers distributed 100 X-rays to the Weber, AO and Lauge-Hansen classification. In case of a trimalleolar fracture, the size of the posterior fragment was measured. Interobserver agreement was calculated with Cohen’s kappa. Agreement on the size of the posterior fragment was calculated with the intraclass correlation coefficient.


Moderate agreement was found with all classification systems: the Weber (K = 0.49), AO (K = 0.45) and Lauge-Hansen (K = 0.47). Interobserver agreement on the presence of a posterior fracture was substantial (K = 0.63). Estimation of the size of the fragment showed moderate agreement (ICC = 0.57).


Classification according to the classical systems showed moderate interobserver agreement, probably due to an unclear trauma mechanism or the difficult relation between the level of the fibular fracture and syndesmosis. Substantial agreement on posterior malleolar fractures is mostly due to small (<5 %) posterior fragments. A classification system that describes the presence and location of fibular fractures, presence of medial malleolar fractures or deep deltoid ligament injury, and presence of relevant and dislocated posterior malleolar fractures is more useful in the daily setting than the traditional systems. In case of a trimalleolar fracture, a CT scan is in our opinion very useful in the detection of small posterior fragments and preoperative planning.


Radiological classification Malleolar fractures Ankle fractures Trimalleolar fractures Posterior malleolar fracture 


Conflicts of interest

No conflicts of interest were declared for all authors.

Source of funding

No funding was necessary to complete this study.


  1. 1.
    Lindsjo U. Classification of ankle fractures: the Lauge-Hansen or AO system? Clin Orthop Relat Res. 1985;199:12–6.PubMedGoogle Scholar
  2. 2.
    Thomsen NO, Overgaard S, Olsen LH, Hansen H, Nielsen ST. Observer variation in the radiographic classification of ankle fractures. J Bone Joint Surg (Br). 1991;73(4):676–8.Google Scholar
  3. 3.
    Michelson J, Solocoff D, Waldman B, Kendell K, Ahn U. Ankle fractures. The Lauge-Hansen classification revisited. Clin Orthop Relat Res. 1997;345:198–205.PubMedGoogle Scholar
  4. 4.
    Russo A, Reginelli A, Zappia M, Rossi C, Fabozzi G, Cerrato M, et al. Ankle fracture: radiographic approach according to the Lauge-Hansen classification. Musculoskelet Surg. 2013;97 Suppl 2:S155–60.CrossRefPubMedGoogle Scholar
  5. 5.
    Yde J. The Lauge Hansen classification of malleolar fractures. Acta Orthop Scand. 1980;51(1):181–92.CrossRefPubMedGoogle Scholar
  6. 6.
    Lauge N. Fractures of the ankle; analytic historic survey as the basis of new experimental, roentgenologic and clinical investigations. Arch Surg. 1948;56(3):259–317.CrossRefPubMedGoogle Scholar
  7. 7.
    Lauge-Hansen N. Fractures of the ankle. IV. Clinical use of genetic roentgen diagnosis and genetic reduction. AMA Arch Surg. 1952;64(4):488–500.CrossRefPubMedGoogle Scholar
  8. 8.
    Lauge-Hansen N. Fractures of the ankle. III. Genetic roentgenologic diagnosis of fractures of the ankle. Am J Roentgenol Radium Ther Nucl Med. 1954;71(3):456–71.PubMedGoogle Scholar
  9. 9.
    Lauge-Hansen N. Fractures of the ankle. II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg. 1950;60(5):957–85.CrossRefPubMedGoogle Scholar
  10. 10.
    Barbosa P BFKK. AO foundation. www2 aofoundation org 2013Google Scholar
  11. 11.
    Langenhuijsen JF, Heetveld MJ, Ultee JM, Steller EP, Butzelaar RM. Results of ankle fractures with involvement of the posterior tibial margin. J Trauma. 2002;53(1):55–60.CrossRefPubMedGoogle Scholar
  12. 12.
    De Vries JS, Wijgman AJ, Sierevelt IN, Schaap GR. Long-term results of ankle fractures with a posterior malleolar fragment. J Foot Ankle Surg. 2005;44(3):211–7.CrossRefPubMedGoogle Scholar
  13. 13.
    Mingo-Robinet J, Lopez-Duran L, Galeote JE, Martinez-Cervell C. Ankle fractures with posterior malleolar fragment: management and results. J Foot Ankle Surg. 2011;50(2):141–5.CrossRefPubMedGoogle Scholar
  14. 14.
    Xu HL, Li X, Zhang DY, Fu ZG, Wang TB, Zhang PX, et al. A retrospective study of posterior malleolus fractures. Int Orthop. 2012;36(9):1929–36.PubMedCentralCrossRefPubMedGoogle Scholar
  15. 15.
    Cohen J. Weighted kappa: nominal scale agreement with provision for scaled disagreement or partial credit. Psychol Bull. 1968;70(4):213–20.CrossRefPubMedGoogle Scholar
  16. 16.
    Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159–74.CrossRefPubMedGoogle Scholar
  17. 17.
    Cohen J. A coeffecient of agreement for nominal scales. 20[Educational and Psychological Measurement], 37-46. 1960. Ref Type: Generic.Google Scholar
  18. 18.
    Dias JJ, Dhukaram V, Abhinav A, Bhowal B, Wildin CJ. Clinical and radiological outcome of cast immobilisation versus surgical treatment of acute scaphoid fractures at a mean follow-up of 93 months. J Bone Joint Surg (Br). 2008;90(7):899–905.CrossRefGoogle Scholar
  19. 19.
    Ferries JS, DeCoster TA, Firoozbakhsh KK, Garcia JF, Miller RA. Plain radiographic interpretation in trimalleolar ankle fractures poorly assesses posterior fragment size. J Orthop Trauma. 1994;8(4):328–31.CrossRefPubMedGoogle Scholar
  20. 20.
    Buchler L, Tannast M, Bonel HM, Weber M. Reliability of radiologic assessment of the fracture anatomy at the posterior tibial plafond in malleolar fractures. J Orthop Trauma. 2009;23(3):208–12.CrossRefPubMedGoogle Scholar
  21. 21.
    Malek IA, Machani B, Mevcha AM, Hyder NH. Inter-observer reliability and intra-observer reproducibility of the Weber classification of ankle fractures. J Bone Joint Surg (Br). 2006;88(9):1204–6.CrossRefGoogle Scholar
  22. 22.
    Viera AJ, Garrett JM. Understanding interobserver agreement: the kappa statistic. Fam Med. 2005;37(5):360–3.PubMedGoogle Scholar
  23. 23.
    O’Connor TJ, Mueller B, Ly tv, Jacobson AR, Nelson ER, Cole PA. "A to P" Screw vs Posterolateral Plate for Posterior Malleolus Fixation in Trimalleolar Ankle Fractures. J Orthop Trauma 2014.Google Scholar
  24. 24.
    Berkes MB, Little MT, Lazaro LE, Pardee NC, Schottel PC, Helfet DL, et al. Articular congruity is associated with short-term clinical outcomes of operatively treated SER IV ankle fractures. J Bone Joint Surg Am. 2013;95(19):1769–75.CrossRefPubMedGoogle Scholar
  25. 25.
    Brorson S, Olsen BS, Frich LH, Jensen SL, Sorensen AK, Krogsgaard M, et al. Surgeons agree more on treatment recommendations than on classification of proximal humeral fractures. BMC Musculoskelet Disord. 2012;13:114.PubMedCentralCrossRefPubMedGoogle Scholar
  26. 26.
    Hartford JM, Gorczyca JT, McNamara JL, Mayor MB. Tibiotalar contact area. Contribution of posterior malleolus and deltoid ligament. Clin Orthop Relat Res. 1995;320:182–7.PubMedGoogle Scholar
  27. 27.
    Macko VW, Matthews LS, Zwirkoski P, Goldstein SA. The joint-contact area of the ankle. The contribution of the posterior malleolus. J Bone Joint Surg Am. 1991;73(3):347–51.PubMedGoogle Scholar
  28. 28.
    Fitzpatrick DC, Otto JK, McKinley TO, Marsh JL, Brown TD. Kinematic and contact stress analysis of posterior malleolus fractures of the ankle. J Orthop Trauma. 2004;18(5):271–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Irwin TA, Lien J, Kadakia AR. Posterior malleolus fracture. J Am Acad Orthop Surg. 2013;21(1):32–40.CrossRefPubMedGoogle Scholar
  30. 30.
    Fu S, Zou ZY, Mei G, Jin D. Advances and disputes of posterior malleolus fracture. Chin Med J (Engl). 2013;126(20):3972–7.Google Scholar

Copyright information

© ISS 2015

Authors and Affiliations

  • S. M. Verhage
    • 1
    • 4
    Email author
  • S. J. Rhemrev
    • 1
  • S. B. Keizer
    • 2
  • H. M. E. Quarles van Ufford
    • 3
  • J. M. Hoogendoorn
    • 1
    • 4
    Email author
  1. 1.Department of SurgeryMC HaaglandenThe HagueThe Netherlands
  2. 2.Department of Orthopaedic SurgeryMC HaaglandenThe HagueThe Netherlands
  3. 3.Department of RadiologyMC HaaglandenThe HagueThe Netherlands
  4. 4.MC Haaglanden, locatie WesteindeSecretariaat HeelkundeThe HagueThe Netherlands

Personalised recommendations