An evaluation of the Herscovici classification for fractures of the medial malleolus

Despite its use in the literature, the application of the Herscovici classification system for medial malleolus fractures has not been evaluated.

We aimed to determine the reliability and accuracy of the Herscovici classification. The blinded radiographs of 130 patients were independently classified by four orthopaedic trauma surgeons. We held a consensus meeting where observers agreed on a final classification and this served as our reference standard. We used weighted kappa (κ) coefficients of agreement.

Twenty-four fractures (18%) were deemed unclassifiable. The classification system demonstrated moderate inter-observer reliability (κ=0.54, 95% CI 0.40-0.68) but substantial reproducibility (κ=0.64, 95% CI 0.51-0.79). Accuracy, when compared with the reference standard, was κ=0.54 (95% CI 0.40-0.66).

The obliquity of the fracture line, and fracture extension, created difficulty in classification in 26% of cases. 18% of our cases could not be classified by majority decision. Our results emphasise the challenges faced in classifying these fractures. Future work should focus on refining the Herscovici classification.