EN : ankle fracture, malleoli fracture

DE : Die Sprunggelenkfraktur

FR : une fracture de la cheville


Slideshows :

Malleola Frakuteren bei Dr J.Peltzer (Hôpital du Jura)

Links :

Ankle fracture on AOfoundation
Ankle fracture on Wheelessonline (with reference)
Ankle fracture in emergency medicine on Medscape
Ankle fracture on OrthopaedicsOne
Ankle fracture on Wikipedia EN
Sprunggelenkfraktur on Wikipedia DE
Malleoli anatomy on AOfoundation
Ankle fracture on www.ombroecotovelo.net
Ankle fracture - Weber and Lauge Hansen Classification on the radiology assistant

Anatomy :

Syndesmosis :

  • anterior : anterior inferior tibio-fibular ligament (AITFL)
    • from the anterolateral prominence of the Tibia (tubercle of Tillaux-Chaput)
    • to the anteromedial prominence of the Fibula (tubercle of Lefort-Wagstaffe)

  • posterior : postero inferior tibio-fibular Ligament (PITFL)
    • from posterior Malleoli (Wolkmann's tubercle), very strong

Ligaments :

  • medial : Deltoid ligament
    • deep anterior talofibular
    • superficial posterior talotibial
    • superficial naviculotibial ligament
    • superficial calcaneotibial

  • lateral :
    • anterior talofibular ligament
    • posteriro talofibular ligament
    • fibulocalcaneal ligament


Classification :

Pott's classification :
This classification is somehow archaic, but quite simple
First degree Pott's fracture : one malleolus is fractured
Second degree Pott's fracture : bimalleolar fracture
Third degree Pott's fracture : trimalleolar fracture (bimalleolar + fracture of the posterior part of the inferior articular surface of the tibia)


Lauge - Hansen classification
This biomechanic classification is great because it is based on 1. the position of the foot during the trauma 2. the direction of the force creating the fracture.
It will help you understand the fracture. To understand this classification it is important to understand the anatomy of the ankle, especially the ligaments holding the bones together. Keep those structures in mind while looking at the X-rays and try to imagin what mechanism of the fracture could have been.
external image tnz_lauge.png

Lauge Hansen Supination external roatation (eversion) SER

Stage 1 (SER1): - Rupture of anterior inferior tibiofibular ligament (AITFL)
Stage 2 (SER2): - Oblique fracture of the lateral malleolus with classical long posterior spike OR- Spiraloid fracture of the lateral malleolus = Danis-Weber/AO B1 type fracture
Stage 3 (SER3): - Rupture of posterior inferior tibiofibular (PITLF) ligament (Danis-Weber/AO B2.1) OR - fracture of posterior malleolus of Tibia (Danis-Weber/AO B3.)=

Stage 4 (SER4): Transverse (sometimes oblique) fracture of Tibial malleolus.

external image tnz_lauge2.jpg








Lauge Hanse Supination external roatation (eversion) SER
type injury often creates a :

Danis - Weber / AO classification Type B





Lauge Hansen Supination adduction (SAD) = supination lateral rotation (SLR) type injury
often creates a :
Danis - Weber / AO classification Type A
- fibula lesion below the syndesmosis
- syndesmosis typically intact
  • 44-A1 medial malleolus intact | isolated lateral lesion below syndesmosis
  • 44-A1.1 : medial malleolus intact | rupture of collateral ligament
  • 44-A1.2 : medial malleolus intact | avulsion of tip of lateral malleolus
  • 44-A1.3 : medial malleolus intact | transverse avulsion fracture of the fibula below the syndesmosis
  • 44-A2 vertical > oblique medial malleolus fracture | fibula lesion below syndesmosis
  • 44-A2.1 : vertical > oblique medial malleolus fracture | rupture of collateral ligament
  • 44-A2.2: vertical > obliquemedial malleolus fracture | avulsion of tip of lateral malleolus
  • 44-A2.3 : vertical > obliquemedial malleolus fracture | transverse avulsion fracture of the fibula below the syndesmosis
(+/- chondral impaction at medial aspect of tibial roof)

  • 44-A3 posteromedial fracture | fibula lesion below syndesmosis
  • 44-A3.1 : posteromedial fracture | rupture of collateral ligament
  • 44-A3.2 : posteromedial fracture | avulsion of tip of lateral malleolus
  • 44-A3.3 : posteromedial fracture | transverse avulsion fracture of the fibula below the syndesmosis



Danis - Weber / AO classification

external image tnz_ao.jpg external image a5097976767734_TAB-Weber-and-LH-2.png



Lauge Hansen Supination adduction (SAD) = supination lateral rotation (SLR)
  • foot inverts (supination)
  • overall adduction of talus (torque convertor effect > external rotation > countered by impact to the forefoot)
  1. if small trauma > partial tear of collateral ligament (ankle sprain)
    if trauma increases > complete tear of collateral ligament (44-A1.1) or avulsion of tip (44-A1.2) or transverse or avulsion fracture of fibula (44-A1.3)
  2. if talus adducts more, it will strike the medial malleolus creating a vertical or high oblique fracture of medial malleolus (pushed off) (44-A2.X)
    sometimes, it can be a compression fracture of the angle of the medial aspect tibial roof
    sometimes, medial malleolus can break without lateral ligament injury

external image tnz_lauge1.jpg




Summary :

collateral ligament
tip of fibula
transverse fibula

intact mm
44-A1.1
44-A1.2
44-A1.3
Lauge - Hansen SA stage 1
vertical > oblique mm♯
44-A2.1
44-A2.2
44-A2.3
Lauge - Hansen SA stage 2
postero - medial mm♯
44-A3.1
44-A3.2
44-A3.3
Lauge - Hansen SA stage 2






Lauge Hansen Pronation abduction
Stage 1: Rupture of the deltoid ligament or transverse fracture of the medial malleolus.Stage 2: Rupture of the anterior and posterior inferior tibiotalofibular ligaments or bony avulsion.Stage 3: Oblique fracture of the fibula at the level of the syndesmosis.
Less than 5% of ankle fractures.
external image tnz_lauge3.jpg











Lauge Hansen Pronation eversion
Pronation-Eversion
Stage 1: Rupture of the deltoid ligament or transverse fracture of the medial malleolus.Stage 2: Rupture of the anterior nferior tibiotalofibular ligaments or bony avulsion.Stage 3: Spiral/Oblique fracture of the fibula above the level of the syndesmosis.Stage 4: Rupture of the posterior inferior tibiofibular ligament or fracture of the posterior malleolus.
external image tnz_lauge4.jpg










Lauge Hansen Pronation dorsiflexion
Pronation-Dorsiflexion
Stage 1: Fracture of the medial malleolus.Stage 2: Fracture of the anterior lip of the tibial.Stage 3: Fracture of the supramalleolar aspect of the fibulaStage 4: Rupture of the posterior inferior tibiofibular ligament or fracture of the posterior malleolus.

Eponyms :


Maisonneuve fracture :
high fibular fracture + medial malleolus fracture
high fibular fracture + deltoid ligament tear

Tillaux - Chaput fragment :
avulsion fracture of anterior tibial margin by the anterior syndesmosis (anterior tibio-fibular ligament)

Le Fort - Wagstaffe fragment :
avulsion fracture of anterior margin of distal fibula at insertion of anterior syndesmosis (anterior tibio-fibular ligament)

Volkmann's triangle :
bony avulsion of the tibia pulled by the posterior syndesmosis (posterior tibio-fibular ligament)

Dupuytren fracture (Wikiradiography) a.k.a Pott's fracture (Wikipedia EN) :
as described in 1819 by Baron Dupuytren, equals a Lauge-Hansen pronation-eversion injury stages III and IV
  1. disruption of medial structures (medial=deltoid ligament or traction fracture of medial malleolus)
  2. total rupture of inferior tibio-fibular joint
  3. indirect fracture of fibula above syndesmosis