The Radiology Assistant - Ankle Fracture - Weber and Lauge-Hansen Classification

The Radiology Assistant : Ankle fracture - Weber and Lauge-Hansen Classification
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Ankle fracture - Weber and Lauge-Hansen Classification

Robin Smithuis
Radiology Department of the Rijnland Hospital, Leiderdorp, the Netherlands
Short overview
Weber A Publicationdate August 23, 2012
Weber B
Weber C Classification of ankle fractures is
Exorotation injury important in order to estimate the extent
Ligamentous rupture or Avulsion of the ligamentous injury and the stability
Weber and Lauge-Hansen summary of the joint.
Weber and Lauge-Hansen combined The Weber classification focuses on the
Weber A in detail integrity of the syndesmosis, which holds
Stage 1 the ankle mortise together.
Stage 2 The Lauge-Hansen system focuses on the
Weber B in detail trauma mechanism.
Stage 1-2 Adding the stages of Lauge-Hansen to the
Stage 3-4 Weber system will help you to predict
Weber C in detail ligamentous injury and instability.
Stage 1 This article will help you to correctly
Stage 2-3 stage ankle injuries and to detect
Stage 4 fractures, that are not obvious at first
Interpretation and Reporting 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.
http://www.radiologyassistant.nl/en/p420a20ca7196b/ankle-fracture-weber-and-lauge-hansen-classification.html[15/9/19 16:10:43]
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.
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 posterior
malleolus
Stage 4 - Avulsion of the medial
malleolus
or - rupture of the medial collateral
bands

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.
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 posterior
malleolus
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. Anterior syndesmosis
2. Fibula
3. Posterior syndesmosis
4. Medial malleolus
Weber C starts medially and the

sequence is:
1. Medial malleolus
2. Anterior syndesmosis
3. Fibula
4. 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 posterior
malleolus
4. Avulsion of the medial
malleolus -
or - rupture of the medial
bands
Weber C = Suprasyndesmotic
1. Avulsion of the medial
malleolus
or - ligamentous rupture
syndesmosis
3. Fibula fracture above the
level of the syndesmosis
4. Avulsion of the posterior
malleolus
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 Lauge-Hansen seems rather difficult
at first glance.
Combining the simplicity of Weber with

the explanation 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 posterior malleolus.
If you would just report this as - a
fracture of the posterior malleolus -
you would miss the point.
This is probably an unstable ankle
fracture.
A posterior malleolus 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
posterior malleolus 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
posterior malleolus 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
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
Weber A - stage 2
Weber B in detail
Stage 1-2
Weber B is the most common type of

ankle fracture and occurs in about 60 %.
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
Stage 1: Rupture of anterior tibiofibular ligament - or avulsion fracture under maximum tension.
(Tilleaux) 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.
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 posterior malleolus.
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.
Weber B - stage 3 and 4
The sequences in a Weber B fracture or

Lauge-Hansen 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:

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.
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 posterior
malleolus 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.
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 located 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
syndesmosis
3. Suprasyndesmotic rupture of the
fibula due to rotation
4. Posterior malleolus fracture or
rupture of the posterior
syndesmosis
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
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. Medial collateral band rupture

syndesmosis
3. High fibula fracture
4. and possibly a rupture of the
Weber C fracture - at least stage 3 posterior syndesmosis
Stage 4
Finally the posterior syndesmotic

ligament ruptures, or there is an avulsion
of the posterior malleolus, also known as
posterior malleolus 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 posterior
malleolus 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
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
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
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.
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 posterior
Click to enlarge malleolus. 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
Lauge-Hansen this is a SER stage
4.
This is an unstable fracture with
dislocation that needs surgical
repair.
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.
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The Radiology Assistant : Ankle fracture - Weber and Lauge-Hansen Classification

Ankle fracture - Weber and Lauge-Hansen Classification

Basically there are three main types of

These fractures are identical to the

Once you understand the trauma

Occurs below the syndesmosis, which is

Stage 1 - Tension on the lateral

Scroll through the images.

This is a transsyndesmotic fracture with

Stage 1 - Rupture of the anterior

Scroll through the images.

This is a fracture above the level of the

Stage 1 - Avulsion of the medial

Scroll through the images

Weber A fractures are usually not a

Weber B starts anterolaterally and the

Weber C starts medially and the

Another important thing to remember is,

Every ligamentous rupture has it's

Weber and Lauge-Hansen

Instability is seen in:

Weber and Lauge-Hansen

How does it work when we combine the Weber classification to the

Combining the simplicity of Weber with

For instance if you see a fracture that is a

This can best be demonstrated by giving

Unstable ankle fracture

Looking at the classification system

Additional radiographs of the lower

This is un unstable ankle injury that

Understanding the fracture mechanism and the stages according to

We will now discuss the Weber

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

The diagnosis as well as the treatment is

The images show the usual Weber type A

Notice the horizontal orientation of the

Stage 2 is uncommon and easy to detect.

Notice the horizontal orientation of the

More on the ring of the ankle and

Weber B is the most common type of

Stage 1 is usually not visible on x-rays.

The images show a Weber B fracture.

medially at the level of the talar dome,

Stage 3 More posterior displacement of

Stage 4 Further posterior movement of

Weber B - stage 3 and 4

The sequences in a Weber B fracture or

1. Rupture of the anterior tibiofibular

Immediately after the injury the injured

The radiographs show a typical Weber B

First study the images and then continue

This is a Weber B stage 4 injury.

1. Rupture of the anterior

These images show another typical

Here another typical Weber B fracture

Here a more subtle case.

Weber C is seen in approximately 20% of

Stage 1 The first injury will occur on the

Now the injury can stop and there will

The talus rotates externally and moves

Continuous force will twist the fibula and

Here we see the different stages in the