Vol. 11, Issue 4 (2025)

Background: Complex intra-articular fractures are challenging to classify and plan for using plain radiographs. Two-dimensional CT (2D CT) adds detail, but may not fully capture fracture geometry. Three-dimensional CT (3D CT) can improve visualization and influence surgical decision-making.

Methods: Prospective observational study of 60 patients with complex intra-articular fractures (tibial plateau n = 32; distal radius intra-articular n = 18; calcaneus intra-articular n = 10). Each case was evaluated using plain radiographs, 2D CT, and 3D CT reconstructions by three independent orthopaedic observers. We assessed interobserver reliability (kappa), reclassification after 3D CT, changes in surgical plan, and concordance with intraoperative findings.

Results: Interobserver agreement (κ) improved from 0.42 on radiographs to 0.61 on 2D CT and 0.82 on 3D CT. 19/60 (31.7%) cases were reclassified after 3D CT. Surgical plans changed in 23/60 (38.3%) after 3D CT, most frequently for calcaneal fractures. Concordance with intraoperative findings was 61.7% (radiographs), 75.0% (2D CT), and 91.7% (3D CT).

Conclusion: 3D CT substantially improves classification reliability and assists surgical planning for complex intra-articular fractures. It should be considered an adjunct in preoperative assessment, particularly for tibial plateau and calcaneal injuries.