• Leonard Lisitano, Timon Röttinger, Andreas Wiedl, Kim Rau, Sönke Helling, Jairo Cifuentes, Bertram Jehs, Mark Härting, Laura-Marie Feitelson, Johannes Gleich, Sophia Kiesl, Daniel Pfeufer, Carl Neuerburg, Edgar Mayr, and Stefan Förch.
• Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany. leonard.lisitano@uk-augsburg.de.
• Eur J Trauma Emerg Surg. 2023 Dec 1; 49 (6): 233923452339-2345.

PurposeTibial shaft spiral fractures and fractures of the distal third of the tibia (AO:42A/B/C and 43A) frequently occur with non-displaced posterior malleolus fractures (PM). This study investigated the hypothesis that plain X-ray is not sufficient for a reliable diagnosis of associated non-displaced PM fractures in tibial shaft spiral fractures.Methods50 X-rays showing 42A/B/C and 43A fractures were evaluated by two groups of physicians, each group was comprised of a resident and a fellowship-trained traumatologist or radiologist. Each group was tasked to make a diagnosis and/or suggest if further imaging was needed. One group was primed with the incidence of PM fractures and asked to explicitly assess the PM.ResultsOverall, 9.13/25 (SD ± 5.77) PM fractures were diagnosed on X-ray. If the posterior malleolus fracture was named or a CT was requested, the fracture was considered "detected". With this in mind, 14.8 ± 5.95 posterior malleolus fractures were detected. Significantly more fractures were diagnosed/detected (14 vs. 4.25/25; p < 0.001/14.8 vs. 10.5/25; p < 0.001) in the group with awareness. However, there were significantly more false positives in the awareness group (2.5 vs. 0.5; p = 0.024). Senior physicians recognized slightly more fractures than residents (residents: 13.0 ± 7.79; senior physicians: 16.5 ± 3.70; p = 0.040). No significant differences were demonstrated between radiologists and trauma surgeons. The inner-rater reliability was high with 91.2% agreement. Inter-rater reliability showed fair agreement (Fleiss-Kappa 0.274, p < 0.001) across all examiners and moderate agreement (Fleiss-Kappa 0.561, p < 0.001) in group 2.ConclusionOnly 17% of PM fractures were identified on plain X-ray and awareness of PM only improved diagnosis by 39%. While experiencing improved accuracy, CT imaging should be included in a comprehensive examination of tibial shaft spiral fractures.Level Of EvidenceII. Diagnostic prospective cohort study.Trail Registration NumberDRKS00030075.© 2023. The Author(s).

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