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Ankle fracture - Weber and Lauge-Hansen

Classification
Robin Smithuis

Radiology Department of the Rijnland Hospital, Leiderdorp, the Netherlands


Publicationdate August 23, 2012

Classification of ankle fractures is important in


order to estimate the extent of the ligamentous
injury and the stability of the joint.
The Weber classification focuses on the integrity
of the syndesmosis, which holds the ankle mortise together.
The Lauge-Hansen system focuses on the trauma mechanism.
Adding the stages of Lauge-Hansen to the Weber system will help you to predict ligamentous
injury and instability.
This article will help you to correctly stage ankle
injuries and to detect fractures, that are not obvious at first sight.

Short overview

Basically there are three main types of ankle


fractures.
Weber classified them as:
type A - infrasyndesmotic
type B - transsyndesmotic
type C - suprasyndesmotic

These fractures are identical to the fractures described by Lauge-Hansen as supination-adduction, supination-exorotation and pronation-exorotation.
We will first give a short overview of these fractures and then discuss them in more detail.

Once you understand the trauma mechanism as


described by Lauge-Hansen and the sequence
of events that take place in stages, then you
know where to look for fractures and ligamentous injuries.

Weber A
Occurs below the syndesmosis, which is intact.
According to Lauge-Hansen, it is the result of an
adduction force on the supinated foot.
Stage 1 - Tension on the lateral collateral
ligaments results in rupture of the
ligaments
or avulsion of the lateral malleolus below
the syndesmosis.
Stage 2 - Oblique fracture of the medial
malleolus.

Scroll through the images.


Notice that the fibular fracture is transverse,
because it is an avulsion or pull-off fracture.
The tibial fracture is vertical or oblique, because
it is a push-off fracture.

Weber B

This is a transsyndesmotic fracture with usually


partial - and less commonly, total - rupture of
the syndesmosis.
According to Lauge-Hansen, it is the result of an
exorotation force on the supinated foot.
Stage 1 - Rupture of the anterior
syndesmosis
Stage 2 - Oblique fracture of the fibula
(this is the true Weber B fracture)
Stage 3 - Rupture of the posterior
syndesmosis
or - fracture of the malleolus tertius
Stage 4 - Avulsion of the medial
malleolus
or - rupture of the medial collateral bands

Scroll through the images.


Notice the oblique or vertical orientation of the
push-off fibular fracture.

Weber C

This is a fracture above the level of the syndesmosis. Usually there is a total rupture of the
syndesmosis with instability of the ankle.
According to Lauge-Hansen, it is the result of an
exorotation force on the pronated foot.
Stage 1 - Avulsion of the medial
malleolus
or - ligamentous rupture
Stage 2 - Rupture of the anterior
syndesmosis
Stage 3 - Fibula fracture above the level
of the syndesmosis (this is the true Weber
C fracture)
Stage 4 - Avulsion of the malleolus
tertius
or - rupture of the posterior syndesmosis

Scroll through the images

Exorotation injury

Weber A fractures are usually not a problem.


Weber B and C are more difficult and it is essential to understand the sequence of events in
these injuries, which are both exorotation injuries.
This implies that 75-80% of ankle injuries are
exorotation injuries.
Weber B starts anterolaterally and the sequence
is:
1.
2.
3.
4.

Anterior syndesmosis
Fibula
Posterior syndesmosis
Medial malleolus

Weber C starts medially and the sequence is:


1.
2.
3.
4.

Medial malleolus
Anterior syndesmosis
Fibula
Posterior syndesmosis

Ligamentous rupture or Avulsion

Another important thing to remember is, that a


ligament can rupture or cause an avulsion fracture at the insertion.
Every ligamentous rupture has it's avulsion
fracture counterpart.

Weber and Lauge-Hansen summary


Weber A = Infrasyndesmotic
1. Avulsion of the lateral malleolus
2. Oblique fracture of the medial
malleolus (uncommon)
Weber B = Transsyndesmotic
1. Rupture of the anterior syndesmosis
2. Oblique fracture of the fibula
3. Rupture of the posterior
syndesmosis
or - fracture of the malleolus tertius
4. Avulsion of the medial malleolus or - rupture of the medial bands
Weber C = Suprasyndesmotic
1. Avulsion of the medial malleolus
or - ligamentous rupture
2. Rupture of the anterior syndesmosis
3. Fibula fracture above the level of the
syndesmosis
4. Avulsion of the malleolus tertius
or - rupture of the posterior
syndesmosis

Instability is seen in:


Weber A stage 2
Weber B stage 3 -4
Weber C stage 3-4

Weber and Lauge-Hansen combined


How does it work when we combine the Weber
classification to the stages of Lauge-Hansen?

In daily practice most use the Weber system,


which is easy to memorize, while the LaugeHansen seems rather difficult at first glance.
Combining the simplicity of Weber with the ex-

planation of the trauma mechanism given by


Lauge-Hansen has the advantage that you still
use a simple system, but now you really know
what is going on.

For instance if you see a fracture that is a stage


2 in the Lauge-Hansen system, then you know
that there also is a stage 1 injury and you will
study the radiographs with a high suspicion for
signs of stage 3 and 4.
This can best be demonstrated by giving an example.

First impression
The radiographs show a fracture of the
malleolus tertius.
If you would just report this as - a
fracture of the malleolus tertius - you
would miss the point.
This is probably an unstable ankle
fracture.
A malleolus tertius fracture as an isolated
finding is very uncommon.

Unstable ankle fracture

Looking at the classification system


When we look at the scheme we will
notice that a fracture of the malleolus
tertius in most cases is part of a Weber B
or a Weber C fracture.
A tertius fracture is either Weber B stage
3
or - due to Weber C stage 4 (arrows).
We have to re-examine the films to look
for additional findings.
Since we now know where to look, it will
be easier to detect additional findings.

Re-examination
On the ankle films there was no sign of an
oblique fracture of the lateral malleolus,
so we can exclude a Weber B fracture.
There is still the possibility of a Weber C
fracture stage 4, i.e. medial rupture or
avulsion, high fibular fracture and finally a
malleolus tertius fracture.
At reexamination you notice the subtle
avulsion of the medial malleolus (red
arrow), which is stage 1.
Notice also the soft tissue swelling on the
medial side (blue arrow)
PE stage 1

Additional radiographs of the lower extremity


were ordered and they demonstrate a high fibular fracture, i.e. Weber C stage 3 also known as
a Maisonneuve fracture.
Final report
Weber C fracture stage 4.

This is un unstable ankle injury that needs surgical repair.


PE stage 3
Understanding the fracture mechanism and the
stages according to Lauge-Hansen helps you to
make the right diagnosis

This example is an every day case.


The point that I want to make is, that when you
understand the sequence of injuries to the ankle, then you know where to look for fractures
and soft tissue swelling indicating ligamentous
injury.

Weber A in detail

We will now discuss the Weber classification and


add the stages of the Lauge-Hansen system.

Weber A is seen in 20-25% of all ankle fractures.


The diagnosis as well as the treatment is usually no problem.
According to Lauge-Hansen the fracture results
from an adduction force on the supinated foot.
The lateral side is under extreme tension with
stretch on the ligaments which results in an
avulsion fracture.
Almost always the avulsion is seen as a horizontal fracture.
This is called a pull off type of fracture in contrast to a push off type, which is seen as an
oblique or vertical fracture.

Stage 1
The images show the usual Weber type A fractures.
These are all stage-1 fractures.
Stage-2 is extremely uncommon.

Notice the horizontal orientation of the fracture


lines.
These are pull off type fractures as a result of
avulsion.
Weber-A stage I

Weber A - stage 2

Stage 2

Stage 2 is uncommon and easy to detect.


More adduction force results in the medial
malleolus being pushed off in a vertical or
oblique way.
Stage 2 is unstable because the ring of the ankle is broken in two places.

Notice the horizontal orientation of the lateral


malleolus fracture and the vertical orientation of
the fracture of the medial malleolus.
Enormous forces must have pushed off the medial malleolus.
More on the ring of the ankle and instability

Stage 1: Rupture of anterior tibiofibular ligament or avulsion fracture (Tilleaux)

Weber B in detail
Stage 1-2

Weber B is the most common type of ankle fracture and occurs in about 60 %.
According to Lauge-Hansen the fracture results
from an exorotation force on the supinated foot.

Stage 1 is usually not visible on x-rays.


What we normally see is a stage 2 oblique fracture through the syndesmosis and we have to
assume that there is also a rupture of the anterior tibiofibular ligament, which is stage 1.
According to Lauge Hansen the first injury is on
the lateral side, which is under maximum tension.
In stage 2 the talus exorotates further and
since the foot is in supination, the lateral malleolus is held tightly in place by the lateral collateral ligaments.
The lateral malleolus cannot move away without
breaking.
As a result more rotation of the talus will fracture the fibula in an oblique or spiral fashion because the lateral malleolus is pushed off from
anteromedially to posterolaterally.

The images show a Weber B fracture.


The oblique course of the fracture is typical for
Weber B and results from the exorotation of the
talus that pushes against the fixed lateral malleolus.
The malleolar fracture usually starts medially at
the level of the talar dome, but can also start a
few centimeters above this level.

Weber B - stage 3 and 4

Weber B fracture

Stage 3-4

Stage 3 More posterior displacement of the lateral malleolus fragment by the talus results in
tension on the posterior syndesmosis with rupture or avulsion of the malleolus tertius.

Stage 4 Further posterior movement of the


talus will result in extreme tension on the medial side and the deltoid ligament will either rupture or pull off the medial malleolus in the
transverse plane.

The sequences in a Weber B fracture or LaugeHansen supination exorotation injury take place
in a clockwise manner:
1. Rupture of the anterior tibiofibular
ligament
2. Oblique fracture of the distal fibula
3. Avulsion of the posterior malleolus or
rupture of the posterior tibiofibular
ligament
4. Avulsion of the medial malleolus or
rupture of the medial collateral ligament

Immediately after the injury the injured parts


may again align, which can make it difficult to
detect the injuries.

The radiographs show a typical Weber B fracture.


First study the images and then continue reading.
Do you see what stage this is?
This is a Weber B stage 4 injury.
Notice that all 4 stages are visible:
1. Rupture of the anterior syndesmosis seen as widening of the space between
the distal tibia and fibula (lateral clear
space).
2. Oblique fibula fracture at the level of the
syndesmosis - i.e. Weber B fracture.
3. Tertius fracture - seen on AP view (red
arrow) and on lateral view (yellow arrow).
4. Rupture of the medial collateral ligaments
- seen as widening of the space between
the medial malleolus and the talus (medial
clear space)

These images show another typical Weber B


fracture stage 4.
There is an oblique fracture of the fibula.
There is an avulsion of the malleolus tertius and
an avulsion of the medial malleolus.

Here another typical Weber B fracture stage 4.


First notice the oblique fibular fracture, which is
best seen on the lateral view.
This is stage 2 and we have to assume, that the
anterior syndesmosis is ruptured.
On the lateral view a small tertius fragment is
seen indicating stage 3.
Now you start looking for stage 4 and you will
notice the subtle lucency in the medial malleolus on the AP view (green arrow).
Knowing the stages of Lauge Hansen this must
be a fracture.
Here a more subtle case.
At first impression there is a Weber B fracture
stage 2.
Now we start looking for stage 3, which is a tertius fracture.
The small linear density on the AP-view is
enough to diagnose a tertius fracture.
The soft tissue swelling on the medial side is
probably a rupture of the medial collateral band
, i.e. stage 4.

Weber C in detail

Stage 1

Weber C is seen in approximately 20% of ankle


fractures.
It is the most difficult fracture to diagnose and
the Lauge-Hansen system will help you to understand the fracture-mechanism, as this will be
an enormous help.
According to Lauge-Hansen the fracture results
from an exorotation force on the pronated foot.

Stage 1 The first injury will occur on the medial


side, which is under maximum tension due to
the pronation.
It will lead to rupture of the medial collateral
ligament or avulsion of the medial malleolus.

Now the injury can stop and there will only be a


rupture of the medial collateral ligaments or
avulsion of the medial malleolus.
Lauge Hansen calls this PE stage 1.
We can not cathegorize this in the Weber classification, since there is no fibular fracture.
In many cases the injury progresses to a higher
stage.

Stage 2-3

The talus rotates externally and moves laterally


because it is free from its medial attachment.
Due to the pronation, the lateral ligaments are
not under tension and the fibula can move away
from the tibia.
This causes rupture of the anterior syndesmosis. This is stage 2.

Continuous force will twist the fibula and displace it distally, while proximally it is fixed to
the tibia.
Finally the interosseus membrane will rupture
up to the point where the fibular shaft fractures.
This is stage 3.
This is always above the level of the syndesmosis.
In many cases it is visible on the radiographs of
the ankle, but in some cases the fracture is lo-

cated high and will only be visible on a radiograph of the lower leg.
This last type of fracture is also called Maisonneuve fracture.
Here we see the different stages in the axial
plane.
1. Medial avulsion fracture or rupture of the
collateral band
2. Rupture of the anterior syndesmosis
3. Suprasyndesmotic rupture of the fibula
due to rotation
4. Malleolus tertius fracture or rupture of the
posterior syndesmosis
Scroll through the images.

The radiographs shows a Weber C fracture.


There is an avulsion fracture of the medial
malleolus and a fibula fracture above the level
of the syndesmosis.
According to Lauge-Hansen this is stage 3
pronation exorotation injury and so the anterior
syndesmosis (stage 2) must also be ruptured.

We do not see a tertius fracture, which would


indicate stage 4, but there may be a rupture of
the posterior syndesmosis.
Weber C fracture - stage 3

Weber C fracture - at least stage 3

Here an example of a Weber C fracture with a


proximal fibula fracture.
Notice that on the radiograph of the ankle no
fracture is seen.
You might misdiagnose this as only some soft
tissue swelling.
In fact this is an unstable ankle fracture, since
there also must be a rupture of the medial collateral ligament (stage 1) , so the ring is broken
in two places leading to instability.
According to Lauge Hansen we are probably
dealing with:
1.
2.
3.
4.

Medial collateral band rupture


Rupture of the anterior syndesmosis
High fibula fracture
and possibly a rupture of the posterior
syndesmosis

Stage 4

Finally the posterior syndesmotic ligament ruptures, or there is an avulsion of the posterior
malleolus, also known as malleolus tertius fracture (red arrow).

The medial clear space is only slightly widened,


but based on the stages of Lauge Hansen there
must be a collateral band rupture.

Interpretation and Reporting

Start with a first impression and look for fractures and signs of ligamentous rupture.
This impression will direct you to both a Weber
as well as a Lauge-Hansen classification.
The Lauge-Hansen classification will give you
the fracture mechanism and the preliminary
stage of the ankle injury.

Now re-examine the films to make sure that


you do not overlook a higher grade ankle injury.
After this re-examination you can make a final
report.

In the final report the fracture is described according to Weber and/or Lauge-Hansen.
Describe the number of malleoli involved and
whether there are signs of instability or dislocation.

Example 1
Basic interpretation
There is a medial malleolar fracture.
You interprete this as an avulsion fracture.
Classification
Not possible to classify according to
Weber, but according to Lauge Hansen a
medial avulsion fracture indicates that the
foot probably was in pronation at the
moment of injury.
So this injury is probably a pronation
exorotation injury (PER) stage 1 or higher.
Click to enlarge

Re-examination
You re-examine the x-rays to look for
stage 2 (rupture or avulsion of the
anterior syndesmosis), stage 3 (high
fibular fracture = Weber C) or even stage
4 (rupture or avulsion of posterior
syndesmosis).
So at second look you notice a subtle
widening of the lateral clear space on the
original films, which could indicate but is
definitely no proof of a syndesmotic
rupture.
Although the patient is already in a cast
you order additional films to look for a
possible stage 3.
These films show a high fibular fracture
and a subtle malleolus tertius avulsion.
Final report
Weber C fracture or a PER stage 4
according to Lauge-Hansen. This is an
unstable fracture that needs surgical
repair.
The ankle circle is interrupted at two
places i.e. the medial malleolus and the
syndesmosis.
A syndesmotic screw was inserted.

Example 2
Basic interpretation
Transverse lateral malleolar fracture.
Classification
Weber A and Supination Adduction stage
1.
Re-examination
No sign of SA stage 2 (medial malleolar
fracture)
Final report
Stable Weber A or SA stage 1 fracture.
Patient will be treated conservatively.
Example 3
Basic interpretation
Dislocated bimalleolar fracture. Avulsion
fracture of the medial malleolar.
The lateral malleolus is 'pushed off' from
anterior to posterior.
Classification
The fracture starts at the level of the
ankle joint and extends proximally, i.e. a
Weber B fracture.
According to Lauge Hansen the oblique
fibular fracture indicates Supination
Exorotation injury stage 2 or higher.
Re-examination
Look for stage 3 (posterior syndesmotic
rupture or avulsion of the posterior
malleolus) and stage 4 (rupture of the
deltoid ligament or medial malleolar
avulsion).
Only now you notice the posterior
malleolar fracture on the lateral view.
Final report
Trimalleolar fracture. Weber B. SER stage
4 (Lauge-Hansen).
This is an unstable fracture with
dislocation that needs surgical repair.
The size of the posterior malleolar
fragment is probably less than 25% of the
articular AP-diameter and will need no
separate repair.
Sometimes CT is needed to get a better
impression of the size of the fracture
fragment of the posterior malleolus.

Example 4
Basic interpretation
Fracture of the lateral malleolus starting
anteriorly at the level of the joint
extending proximally posteriorly.
Classification
The fracture is classified according to
Weber as a type B fracture.

Click to enlarge
1. Anatomy of the distal tibiofibular syndesmosis
in adults: a pictorial essay with a multimodality
approach
by John J. Hermans, Annechien Beumer, Ton A.
W. de Jong and Gert-Jan Kleinrensink.
J. Anat. (2010) 217, pp633-645
2. AO-foundation ankle fractures
3. Introduction to Lauge Hansen & Danis Weber
Classifications Ankle Fracture
Animation on YouTube by Dr Glass.

According to Lauge Hansen the oblique


fibular fracture indicates that this is a
Supination Exorotation injury stage 2 or
higher.
Re-examination
Look for stage 3 and stage 4.
There are subtle findings which indicate a
fracture of the malleolus tertius. Normally
you probably would not have noticed
these.
On the lateral view the posterior cortex of
the tibia is interrupted indicating a
fracture (blue arrow).
Even on the AP-view there are subtle
findings that indicate a fracture (red
arrows).
There is a widened medial clear space,
which indicates a rupture of the medial
collateral band, i.e. stage 4.
Final report
Weber B fracture. According to LaugeHansen this is a SER stage 4.
This is an unstable fracture with
dislocation that needs surgical repair.