Ankle Fractures

Topics

Lauge-Hansen Classification 
Danis-Weber Classification
Berndt-Hardy Classification
Salter-Harris Classification 
Reudi and Allgower Classification
Supination-Adduction
Supination-External Rotation (SER)
Pronation-Abduction
Pronation-External Rotation (PER)
Pronation-Dorsiflexion
Tillaux-Chaput fracture
Le Fort-Wagstaffe fracture
Maisonneuve fracture
Volkmann's fracture
Pilon fracture
Thurston-Holland Sign


For information about ankle sprains--injury to the soft tissues surrounding the ankle joint, visit our web page by clicking on the X-ray of the ankle below:  

 

 

 


There are several systems to classify fractures of the ankle.  We'll review 3 of the most common classification systems, each of which classifies different sorts of injuries.

  • Lauge-Hansen Classification System

The Lauge-Hansen Classification is the classic way to describe typical ankle fractures.  It's an interesting system because it attempts to describe the mechanism of the injury, by classifying the foot in terms of both the position of the foot and the motion that occurred to create the fracture.  This system predicts locations of soft tissue and bony injuries that may not be easily seen on X-ray, and it allows the user to reverse the mechanism to reduce (correct) the fracture.

There are five types of Lauge-Hansen fractures:  Supination-Adduction, Pronation-Abduction, Supination-External Rotation, Pronation-External Rotation, Pronation-Dorsiflexion, each with progressive stages of injury.   The first name of the Lauge-Hansen fracture is the position of the foot when the fracture occurs.  The second name is the direction of movement responsible for the fracture. 

  • Supination-Adduction 

STAGE I:  Involves either a lateral ligament injury, or a transverse avulsion (pull-off) fracture of the lateral malleolus below or at the level of the ankle mortise.  (*****The transverse fracture of the lateral malleolus is the classic, hallmark finding of the Supination-Adduction injury.)

STAGE II:  Is characterized by a stage I injury coupled with an oblique fracture of the medial malleolus.

Supination-Adduction injuries generally heal favourably.

  • Pronation-Abduction 

STAGE I:   Involves a fracture of the medial malleolus or a tear in the medial malleolus' deltoid ligament.  

STAGE II:  Stage I, plus a rupture of the anerioinferior tibiofibular ligament (the ligament on the front of the ankle, holding the tibia and fibula together), or a small pull-off (avulsion fracture of the anterior (front) portion of the tibia (which is known as a Tillaux-Chaput fracture), or fibula (which is known as a Le Fort-Wagstaffe fracture). 

STAGE III: Stage II, plus an oblique (angled) fracture of the fibula above the malleolus. 

  • Supination-External Rotation (SER)  This is the most common mechanism of ankle fracture.   It begins at the front of the ankle, then rotates around the ankle next affecting the outside of the ankle, then the back, then the inside.    


STAGE I:  Involves either a rupture of the anteroinferior tibiofibular ligament (the ligament on the front of the ankle, holding the tibia and fibula together), or small pull-off (avulsion) fracture of the anterior (front) portion of the tibia (which is known as a
Tillaux-Chaput fracture), or fibula (which is known as a Le Fort-Wagstaffe fracture). 

STAGE II:  Stage I plus a spiral oblique fracture of the lateral malleolus.  (
****This spiral fracture at the level of the lateral malleolus is the classic, hallmark finding of the Supination-External Rotation fracture.)   A good example of this fracture is seen to the right.  While both SER and PER injuries demonstrate spiral fractures, note that this fracture is well below the fracture seen in the PER example below.)

STAGE III:  Stage II plus a fracture of the posterior portion of the tibia (Volkmann's fracture).

STAGE IV:  Stage III plus a fracture of the medial malleolus. 

  • Pronation-External Rotation (PER)     As with the SER fracture, the PER also rotates around the ankle, only this injury begins on the inside of the ankle, then moves to the front, then the outside, then the back of the ankle. 


STAGE I:  A short, transverse fracture of the medial malleolus or a tear of the deltoid ligament (demonstrated well by the picture one the right.)

STAGE II:  Stage I plus a tear of the anteroinferior tibiofibular ligament (the ligament on the front of the ankle holding the tibia and fibula together), or a small pull-off (avulsion fracture of the anterior (front) portion of the tibia (which is known as a Tillaux-Chaput fracture), or fibula (which is known as a Le Fort- Wagstaffe fracture). 

STAGE III:  Stage II plus a tear in the interosseous membrane (the ligament-like sheet holding the tibia and fibula together) and a spiral fracture of the fibula above the lateral malleolus.  (****
This spiral fracture of the fibula well above the lateral malleolus is also known as a Maisonneuve fracture, and is the classic, hallmark finding of the Pronation-External Rotation fracture.)   This fracture is demonstrated well on the picture to the right.

STAGE IV:  Stage III plus a fracture of the posterior tibia

  • Pronation-Dorsiflexion 

        STAGE I:  Involves a fracture of the medial malleolus
        STAGE II:  Stage I plus a fracture on the anterior-inferior portion of the tibia.
        STAGE III:  Stage II plus a transverse fracture of the fibula above the malleolus.
        STAGE IV:  Stage III plus a fracture of the distal tibia (Pilon fracture). 

Reudi and Allgower subdivided these into Grade I (involving a "cleavage" fracture of the distal tibia with no disruption of the internal surface), Grade II (involving internal surface disruption, but no comminution (fragmentation into multiple pieces), and Grade III (involving impaction and comminution).


Danis-Weber Classification System

Another way to describe ankle injuries is the Danis-Weber Classification System.   Less complicated than Lauge-Hansen, Danis-Weber simply describes the location of the injury in relationship to the syndesmosis (the ligament-like sheath between the leg bones (the tibia and fibula)).

TYPE A:    Occurs beneath the level of the syndesmosis.  Corresponds to the Lauge Hansen "Supination-Adduction" fracture, and so, is also associated with a vertical fracture of the medial malleolus.
TYPE B:    Occurs at the level of the syndesmosis.  Corresponds either to the Lauge-Hansen "Supination-External Rotation" or "Pronation-Abduction" fractures.  The posterior portion of the tibia might also be fractured.
TYPE C:   Occurs above the level of the syndesmosis.   Corresponds to the Lauge Hansen "Pronation-External Rotation" fracture.  Associated with an avulsion fracture of the tibia, deltoid ligament rupture and fractures of the posterior malleolus. 

Berndt-Hardy Classification System 

The Berndt-Hardy Classification System only describes fractures of the talar dome--the surface of the ankle bone as it fits in between the leg bones. 

Talar dome fractures typically strike either the the anterior-lateral (front and outside) portion of the bone (44% of cases) or the posterior-medial (back and inside) portion of the bone (56% of cases).  Anterior-lateral injuries are associated with inversion and dorsiflexion motion, and posterior-medial injuries are associated with eversion and plantarflexion motion.   

STAGE ONE:        A small area of compression of the subchondral bone (the bone beneath the joint surface).  This usually has no symptoms and is often simply diagnosed as an ankle sprain.   Treated conservatively with rest, ice, compression, elevation and often, a non-weight-bearing, below-the-knee cast for 6 weeks.  Some degree of bracing of the foot and leg after the cast is removed may be necessary. 

STAGE TWO: 
     The subchondral bone becomes partially detached.  This condition is painful and associated with ankle ligament injury.  Some loss of ankle joint stability is common.  Treatment is usually as with stage 1 injuries. 

STAGE THREE:
  The subchondral bone fragment is completely detached, but still in the same position.  Pain is usually relatively severe.  There may be limitation of ankle motion or a feeling of creaking within the ankle joint.  Often associated with a loss of joint stability.   May respond to conservative treatment or require surgery. 

STAGE FOUR:   
The subchondral bone fragment is detached and displaced from its normal position.  Pain is usually severe.  Often accompanied by limitation of ankle motion, and a creaking or gritty feeling within the ankle with motion.   Often associated with a loss of joint stability.  Treatment is usually surgical, involving removal of the fragment, and when possible, repositioning the fragment, using fixation


Salter-Harris Classification System 

The Salter Harris Classification System describes only injuries that occur around growth plates.  Hence, only children can get Salter-Harris fractures. 

Salter-Harris injuries frequently affect the ankle, but really, this sort of injury may affect any bone with a growth plate. 

To see what a growth plate looks like, take a look at the example to the right.  This is a picture of the proximal phalanx of the great toe--the first bone in the big toe.  The line running across the bone (transversely) is the growth plate.  Because it is composed of growing cartilage and not bone, it looks invisible on X-ray. 

Below you can see growth plates in both the leg bones, the tibia and fibula.


Salter Harris fractures are generally broken down into five categories:

Type I injuries can be thought of as a fracture through the growth plate.  They involve a separation of the two portions of bone, with the growth plate being the area of weakest link, and the area of fracture.  There are frequently no changes seen on X-ray, though the growth plate may look wider than on the other limb. 

These injuries are generally immobilized to allow the tissues to heal.  Prognosis is excellent. 

Type II injuries (the most common type) involve a fracture through the growth plate, but instead of running all the way across the growth plate, a portion of the fracture extends back into the shaft of the bone.  That fragment of bone is known as the "Thurston-Holland" sign.  Prognosis is still excellent. Type III injuries also involve a fracture extending partially through the growth plate, only this time the fracture extends not towards the shaft of the bone, but out towards the joint. 

Type III injuries also consist of a fracture part way across the growth plate, only this time instead of extending into the shaft of the bone, the fracture extends out towards the joint.  Because these injuries may affect the joint, the prognosis is more guarded than with Types I and II, but it is still generally good. 

Type IV injuries extend across the growth plate--from the shaft of the bone, across the growth plate, and into the joint.  Premature arrest (stoppage) of normal growth is common, and surgical repair is usually needed to restore proper anatomical alignment.

Type V injuries involve a compression of the growth plate.  As with Type I, X-rays are generally useless in diagnosing this problem.  Prognosis is variable, with premature arrest (stoppage) of normal growth being the biggest risk. 

Peterson added a Type VI category, which is characterized by a portion of the bones surrounding the growth plate and the growth plate itself is missing.  This is most commonly seen in such traumatic insults as a lawnmower injury.

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