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Introduction Weber and Lauge-Hansen Normal flexibility of the ankle Position of the foot Pull-off or Push-off fractures Stability

Ottawa Ankle Rules Radiography Mortise view Lateral view Classification Weber A - Lauge Hansen SA Weber B - Lauge Hansen SE Weber C - Lauge Hansen PER Who needs additional radiographs of the lower extremity? Interpretation and Reporting Examples

back to overview print 15-12Publicationdate: 2010 The ankle is the most frequently injured joint. Management decisions are based on the interpretation of the AP and lateral X-rays. Classification of ankle fractures is important in order to estimate the extent of the ligamentous injury and the stability of the joint. In this article we will combine the simplicity of the Weber classification system with the stages of the Lauge-Hansen system. Next we will focus on the interpretation of X-rays of the injured ankle using these classifications. You can enlarge images by clicking on them. This item is not available on the iPhone application.
Introduction
Weber and Lauge-Hansen

On the left an overview of the two most commonly applied classification systems for ankle fractures. The Weber system This system focuses on the integrity of the syndesmosis. It owes its popularity mainly to its simplicity.

Type A occurs below the syndesmosis, which is intact. Type B is a transsyndesmotic fracture with usually partial - and less commonly, total rupture of the syndesmosis. Type C occurs above the

level of the syndesmosis with usually a total rupture of the syndesmosis, and consequently instability of the ankle mortise.

The Lauge-Hansen system This system focuses on the trauma mechanism. Based on the findings on the radiographs you deduce what the trauma mechanism must have been. It stages the severity of the injury, which allows you to predict the ligamentous injury and instability. This system is based on:

Position of the foot at the moment of injury, either in supination (80%) or in pronation (20%) Direction of the force on the foot within the ankle mortise, which is either exorotation (80%) or adduction (20%). We will discuss this system in more detail below.

Normal flexibility of the ankle

The ankle joint has to be flexible in order to deal with the enormous forces applied exerted on the talus within the ankle fork. . The medial side of the joint is quite rigid because the medial malleolus - unlike the lateral malleolus - is attached to the tibia and the medial collateral ligaments are very strong. On the lateral side there is a flexible support by the fibula, syndesmosis and lateral collateral ligaments. This lateral complex allows the

talus to move laterally and dorsally in exorotation during forward motion and subsequently pushes it back into its normal position. The fibula has no weight-bearing function, but merely serves as a flexible lateral support. The syndesmosis is the fibrous connection between the fibula and tibia formed by the anterior and posterior tibiofibular ligaments located at the level of the tibial plafond (French for ceiling) - and the interosseus ligament, which is the thickened lower portion of the interosseus membrane. The anterior and posterior tibiofibular ligaments are often referred to as anterior and posterior syndesmosis.
Position of the foot

There are two positions of the foot in which the flexible ankle joint becomes a rigid and vulnerable system: extreme supination and pronation. In these positions forces applied to the talus within the ankle mortise can result in fractures of the malleoli and rupture of the ligaments. In 80% of ankle fractures the foot is in supination. The injury starts on the lateral side, since that is where the maximum tension is. In 20% of fractures the foot is in pronation with maximum tension on the medial side. The injury starts on the medial side with either a rupture of the medial collateral ligaments or an avulsion of the medial malleolus.

Pull-off or Push-off fractures

The shape of a fracture indicates which forces were involved. An oblique or vertically oriented fracture indicates 'push-off'. A transverse or horizontal fracture is the result of a 'pull-off'. On the left image the lateral malleolus is pushed off by exorotation of the talus. On the right image the medial malleolus is pulled off by the medial collateral ligament due to pronation of the foot.
Stability

The ankle can be thought of as a ring in which bones as well as ligaments play an equally important role in the maintenance of joint stability. If the ring is broken in one place the ring remains stable. When it is broken in two places, the ring is unstable and may dislocate. Now it is easy to say that an ankle is unstable when both the medial and the lateral malleoli are fractured. It becomes more problematic when there is a combination of a fracture and a ligamentous rupture, because the ligamentous rupture may not be detectable on the Xray. In some fractures there may even be a proximal fibular fracture which is not visible on the ankle radiographs - in combination with a medial ligamentous rupture. It is important to realize that the radiographs of an ankle may be normal in cases with an unstable ankle injury.

Stability (2) On the left image a Weber A or SA-fracture. This ankle is stable because there is only an avulsion fracture of the lateral malleolus below the level of the syndesmosis. The ring is broken in only one place. On the right image there is an unstable fracture. The ring of the ankle is broken in two places. There is a lateral fracture and on the medial side there is a rupture of the collateral ligament allowing the talus to dislocate laterally. Stability (3) The medial clear space should not exceed 4 mm and is usually equal to the distance between the tibial plafond and the talus. Widening of the medial joint space up to 6 mm or more requires disruption of the medial collateral ligament. Stability (4) The lateral clear space is measured from the medial border of the fibula to the lateral border of the posterior tibia 1cm above the tibial plafond. It is less well defined because its width varies with positioning. Evident widening of the lateral clear space indicates syndesmotic rupture. Some state that a width of 5.5 mm is abnormal. It is very important to realize that a normal lateral or medial clear space does not exclude ligamentous rupture. It simply means that there is no dislocation, but there can still be instability. The case on the left shows a Weber B fracture. On these images the ankle fork is

normal. Both the medial and lateral clear spaces are prominent, but within normal limits. We can conclude that there is no dislocation, but we do not know if there is rupture of the medial collateral ligaments or of the syndesmosis. Continue with the images post surgery. Following osteosynthesis there is obvious widening of the medial and lateral clear spaces (image on the far left). This indicates that there is a syndesmotic rupture and medial collateral ligament rupture. The ring is still broken in two places. The ankle joint is unstable and dislocated. Resurgery was necessary with placement of a syndesmotic screw to stabilize the ankle joint. Stability (5) On the left another case. There is a Weber B fracture. Both the medial and lateral clear spaces are widened, indicating instability. The talus is displaced laterally. Patient was scheduled for osteosynthesis of the fibular fracture and placement of a syndesmotic screw if necessary. After osteosynthesis of the fibula, the ankle was tested in the operating room and found to be stable. There was no indication for a syndesmotic screw. It was concluded that the syndesmosis was only partially ruptured, as is usually the case in Weber B fractures. The ring was broken in two places and after repairing one of them, the ring was stable.
Ottawa Ankle Rules

These rules are used to determine the need for radiographs in patients with an ankle injury. Ankle X-ray series are only required in case of: Pain in the malleolar zone and any one of the following:

Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus. Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus. Inability to bear weight for 4 steps both immediately and in the emergency department.

Radiography
Mortise view

A basic radiographic examination consists of a Mortise-view and a lateral view. Some add the APview. The Mortise-view is an AP-view taken with a 15-25 endorotation of the foot. The technologist turns the foot inwards until the lateral malleolus is at the same height as the medial malleolus. This view visualizes both the lateral and medial joint spaces.. On a true AP-view the talus overlaps a portion of the lateral malleolus, obscuring the lateral aspect of the ankle joint.

Lateral view

Many think that for a good lateral view the distal fibula should be in the center of the distal tibia. However, since the fibula is positioned more dorsally, the fibula should project over the posterior part of the distal tibia (arrow). The distal fibula should project on the posterior part of the distal tibia
Classification
Weber A - Lauge Hansen SA

This is the most simple ankle fracture. The diagnosis as well as the treatment usually poses no problems. It occurs in about 20-25% of all ankle fractures. The foot is fixed on the ground in supination when an adduction force is applied to the talus. The first injury will occur on the lateral side, which is under tension. Stage 1 Supination results in a tear of the lateral collateral ligament or an avulsion fracture of the lateral malleolus below the level of the tibial plafond, i.e below the level of the syndesmosis. Stage 2 More talar tilt results in the medial malleolus being pushed off in a vertical or oblique way . This second stage is very uncommon and is unstable.

On the left a simple Weber A Lauge Hansen SA fracture. Since the syndesmotic ligaments are intact, the ankle mortise is stable.

Weber A Fracture or SA according to Lauge Hansen VIDEO: Weber A or Supination Adduction injury If the video doesn't play simply push the stop button and the play button again.

Start the video on the left by clicking on the image. Notice that at first the foot is in supination with maximal forces on the lateral side. Subsequently the foot adducts. The result is an SA or Weber A fracture. We can assume that this is the uncommon stage 2. Before we continue with the Weber B and C fractures, it is important to understand that most malleolar fractures have a ligamentous counterpart and vice versa (Table). The Tillaux fracture is an avulsion fracture of the tibia where the anterior syndesmosis attaches. It is an uncommon finding.

Weber B - Lauge Hansen SE

This is the most common type and occurs in about 60-70% of all ankle fractures. The foot is fixed on the ground in supination and an exorotation force is applied to the talus due to an endorotation of the lower leg. Stage 1 The first injury will occur on the lateral side, which is under maximum tension. As the talus exorotates, the anterior tibiofibular ligament ruptures first. Stage 2 Since the foot is in supination, the lateral malleolus is held tightly in place by the lateral collateral ligaments and 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 anterior to posterior. The fracture starts at or only a few cms above the level of the ankle joint and extends proximally. Stage 3 Posterior displacement of the lateral malleolus fragment by the talus results in rupture of the posterior tibiofibular ligament or avulsion of the malleolus tertius. Stage 4 More 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 sequence of events in a Weber B fracture or Lauge-Hansen supination exorotation injury happens in a clockwise sequence: 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

In Weber B or supination exorotation injury the events take place in a clockwise manner

Immediately after the injury the injured parts may again align, which can make it difficult to detect the fractures and ligamentous ruptures. Study the images on the left and try to find out which stage is present. On the left an oblique fibular fracture which is typical for a Weber B or SER (Lauge-Hansen) fracture. According to Lauge-Hansen this is stage 2, so we must assume that there is also a rupture of the anterior syndesmosis, i.e. stage I. Now we look for stage 3 and we notice a subtle irregularity of the posterior aspect of the tibia (black arrow). This is probably the result of an avulsion of the malleolus tertius. Finally, we also notice widening of the medial clear space (red arrow), which indicates a rupture of the medial collateral ligaments, i.e. stage 4. This ankle is unstable and osteosynthesis is necessary.

Weber C - Lauge Hansen PER

This is seen in approximately 20% of ankle fractures. The foot is fixed on the ground in pronation when an exorotation force is applied to the talus. Stage 1 The first injury will occur on the medial side, which is under maximum tension. It will lead to rupture of the medial collateral ligament or avulsion of the medial malleolus . Stage 2 The talus rotates externally and moves laterally because it is free from its medial attachment. Due to the pronation, the lateral side is not under tension and the fibula can move away fron the tibia. This causes rupture of the anterior syndesmotic ligament. Stage 3 The fibula will be twisted distally, while proximally it is fixed in position. Finally the interosseus membrane will rupture up to the point where the fibular shaft fractures above the level of the syndesmosis. The fibular fracture may or may not be visible on the ankle X-rays. Stage 4 Finally the posterior syndesmotic ligament ruptures, or there is an avulsion of the posterior malleolus, also known as the malleolus tertius.

The sequence of events in a Weber C fracture or Lauge-Hansen pronation exorotation injury also happens in a clockwise sequence: 1. Avulsion fracture of the medial malleolus or medial collateral band rupture 2. Rupture of the anterior tibiofibular ligament 3. High transverse fracture of the fibula 4. Avulsion of the posterior malleolus or rupture of the posterior tibiofibular ligament

Weber C or Lauge Hansen SER stage 4.

After the event the pieces may align again and be difficult to detect on the radiographs. Most ligamentous injuries will not be visible on the x-rays unless there is a widened lateral or medial clear space. On the left a typical Weber C fracture above the level of the syndesmosis. Lauge-Hansen has demonstrated that this is the result of an exorotation force on a foot in pronation. The fibular fracture means PER stage 3. This means that there is also: stage 1: rupture of the medial collateral ligaments and stage 2: rupture of the anterior syndesmosis. Now we study the images to look for stage 4. It is not easily seen, but there is also a tertius fracture, which means stage 4. Knowledge of the stages according to Lauge-Hansen helps us to detect fractures which are not easily detected at first glance.

VIDEO: Weber C or Pronation exorotation injury

We also know when the ligaments must be ruptured. Start the video on the left by clicking on the image. Notice that at first the foot is in pronation, with maximum forces on the medial side. Subsequently the foot exorotates. The result is a PER - pronation exorotation injury or Weber C fracture.
Who needs additional radiographs of the lower extremity?

All Weber A and B fractures should be visible on standard radiographs of the ankle. So in these cases there is no need for extra films of the lower leg. In Weber C or pronation exorotation injury the fibular fracture can be located proximally and not visible on radiographs of the ankle. We need to look for a high fibular fracture when there is any of the following:

Isolated fracture of the medial malleolus Isolated fracture of the malleolus tertius without a fracture on the lateral side Any painful swelling or hematoma on the medial side without a fracture on the radiographs

Isolated fracture of the medial malleolus According to Lauge-Hansen this is the first stage of a PER injury. So we have to look for higher stages. The injury can continue to the following:

stage 2: rupture of the anterior syndesmosis stage 3: high fibular fracture stage 4: rupture of the posterior syndesmosis

In all these subsequent stages, purely ligamentous injury will not be visible on the radiographs of the ankle. So even in Weber c fracture or PER stage 4 sometimes only a fracture of the medial malleolus will be visible. Isolated fracture of the malleolus tertius Truly isolated fractures of the posterior malleolus are very uncommon. Most fractures of the posterior malleolus are part of a complex ankle injury, either Weber B (SER) or Weber C (PER). A Weber B fracture is easily detected because of the characteristic oblique fracture. According to Lauge-Hansen, a posterior malleolus fracture is stage 4 of a PER injury. So if we have the following combination:

stage 1: rupture of the medial collateral ligament stage 2: rupture of the anterior syndesmosis

stage 3: high fibular fracture stage 4: tertius fracture

An isolated tertius fracture on an ankle radiograph indicates the presence of an unstable ankle fracture. Any medial painful swelling or hematoma without a visible fracture on ankle radiographs Normal radiographs do not rule out a Weber C fracture or LaugeHansen PER stage 4, which is a serious, often unstable, ankle injury. In that case we have the following combination:

stage 1: rupture of the medial collateral ligament, which causes the swelling and hematoma stage 2: rupture of the anterior syndesmosis stage 3: high fibular fracture - not visible on the radiographs of the ankle stage 4: rupture of the posterior syndesmosis

Interpretation and Reporting

Start with a basic interpretation and look for fractures and signs of ligamentous rupture. This interpretation 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.
Examples

Case 1

Basic interpretation There is a pull-off fracture of the lateral malleolus below the level of the tibial plafond, i.e below the level of the syndesmosis. First impression Weber A fracture or Lauge-Hansen supination adduction injury stage 1. Re-examination Look for the uncommon stage 2, but there is no fracture on the medial side. Final report Weber A fracture or Lauge-Hansen supination adduction injury stage 1. The ankle is stable.

Case 2

Basic interpretation There is a typical oblique fracture of the lateral malleolus (push-off) at the level of the syndesmosis. The medial clear space looks widened. First impression Weber B fracture or Lauge-Hansen supination exorotation injury stage 2 or more, i.e. rupture of the anterior talofibular ligament and oblique fracture of lateral malleolus. Re-examination Look for stage 3, i.e. avulsion of the malleolus tertius or widening of the lateral clear space due to rupture of the posterior syndesmosis. We also look for stage 4, i.e. rupture of the medial collateral ligament or avulsion of the medial malleolus. Re-examination Both the medial and lateral clear spaces are widened. There is a subtle linear lucency in the distal tibia, which indicates a fracture of the malleolus tertius (arrow). Final report Weber B fracture or Lauge-Hansen supination exorotation injury SER stage 4. The ankle is unstable. Osteosynthesis of the fibular fracture is necessary. If this does not restore the

ankle mortise and the medial clear space remains widened, a syndesmotic screw must be inserted and an exploration of the medial ankle joint performed to look for interpositioned ruptured ligaments. Case 3

Basic interpretation This is an AP-view while a Mortise-view is preferable. There is a soft tissue swelling on the lateral side. On the lateral view there is an oblique fracture line. First impression Weber B fracture or Lauge-Hansen supination exorotation injury stage 2 or higher, i.e. rupture of the anterior talofibular ligament and oblique fracture of the lateral malleolus. Re-examination No sign of a posterior malleolus fracture or fracture of the medial malleolus. Based on the radiographs we cannot exclude a rupture of the posterior syndesmosis or a rupture of the medial collateral ligaments. This still can be a LaugeHansen SER stage 4 injury, i.e. an unstable fracture. At physical examination however there was no swelling, tenderness or hematoma on the medial side, so we can exclude a stage 4 injury. A stage 3 injury is still

possible.

Final report Weber B fracture or Lauge-Hansen SER stage 2 or 3. Basic interpretation Oblique fracture at the level of the syndesmosis. First impression Weber B or SER (LaugeHansen) fracture stage 2. Re-examination Widened medial and lateral clear space indicating a stage 4 SER injury. So there also must be a stage 3, i.e. posterior syndesmotic rupture or avulsion of the malleolus tertius. Final report Weber B or SER (LaugeHansen) fracture stage 4. This fracture can be unstable.

Case 4

This patient was scheduled for osteosynthesis of the fibular fracture and placement of a syndesmotic screw if necessary. After osteosynthesis of the fibula, the ankle was tested in the operating room and found to be stable. Thererefore there was no indication for placing a syndesmotic screw. It was concluded that the syndesmosis was only partially ruptured, which is not uncommon in Weber B - SER fractures.

Case 5

Basic interpretation In the images on the left we notice the fracture of the posterior malleolus. First impression Classification is not possible. Since an isolated fracture of the posterior malleolus is uncommon, we have to re-examine the films to look for signs of a Weber B or C fracture. Re-examination 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, i.e. medial rupture or avulsion, high fibular fracture and finally a posterior malleolar fracture. Now we notice the subtle avulsion of the medial malleolus (arrow). Additional radiographs of the lower extremity demonstrate a high fibular fracture, also known as a Maisonneuve fracture.

Final report Weber C fracture or Lauge-Hansen PE stage 4. The lesson learned in this case is that any patient with a hematoma or swelling on the medial side of the ankle may have a Weber C fracture or a Lauge-Hansen PE injury stage 1-4.

Case 6

Basic interpretation On the left images of a patient with a hematoma on the medial side. No signs of a fracture. First impression Classification is not possible. Re-examination We can exclude a Weber A or B fracture, because we see no fracture. A Weber C or LaugeHansen PE injury is still a possibility, i.e. medial ligament rupture, high fibular fracture and finally a posterior syndesmosis rupture. Additional radiographs of the lower leg demonstrate the high fibular fracture, also known as Maisonneuve fracture.

Final report Weber C fracture or Lauge-Hansen PE stage 3 or 4, i.e. medial collateral ligamentous rupture, rupture of the anterior syndesmosis, high fibular fracture and probably a rupture of the posterior syndesmosis. The lesson in this case is that any patient with a hematoma or swelling on the medial side may have a Weber C fracture or a Lauge-Hansen PE injury stage 1-4.

References 1. Fractures of the ankle, combined experimental-surgical and experimentalroentgenologic investigations by N. Lauge-Hansen (1948)

2. Die verletzungen des oberen sprunggelenkes by B.G. Weber (1966) 3. Website of the Ottawa Ankle rules 4. Ankle fractures East Lancashire Foot and Ankle Hyperbook 5. Free AO Surgery Reference The AO Surgery Reference is a huge online repository of surgical knowledge, consisting of more than 7000 pages.

GARZI REZIDENTI LUNA AUGUST 2011


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COORDONATOR PROF. DR. SILVIU A. SFRANGEU