Musculoskelet Surg (2013) 97 (Suppl 2):S155–S160

DOI 10.1007/s12306-013-0284-x

REVIEW

Ankle fracture: radiographic approach according

to the Lauge-Hansen classification
A. Russo • A. Reginelli • M. Zappia •
C. Rossi • O. Fabozzi • M. Cerrato •
L. Macarini • F. Coppolino

Received: 28 May 2013 / Accepted: 11 June 2013

Ó Istituto Ortopedico Rizzoli 2013

Abstract Ankle fractures account for 9 % of fractures the position of the foot at the time of injury and the direction
(Clare in Foot Ankle Clin 13(4):593–610, 1) representing a of the deforming force.
significant portion of the trauma workload; proximal femoral
fractures are the only lower limb fracture to present more Keywords Ankle trauma
Ankle fracture
X-ray
frequently. Ankle fractures have a bimodal age distribution
with peaks in younger males and older females (Arimoto and
Forrester in AJR Am J Roentgenol 135(5):1057–1063, 2). Introduction
There has been threefold increase in the incidence among
elderly females over the past three decades (Haraguchi and Ankle fractures are common among both the general
Armiger in J Bone Joint Surg Am 91(4):821–829, 3). In 1950, population and those who play contact sports. Knowing the
Lauge-Hansen devised a classification of ankle fractures precise mechanism of ankle fractures is important because
based on the position of the foot and the deforming force at the it helps surgeons assess the fracture pattern and soft tissues
time of injury. This has been widely accepted by orthopedists, to determine the sequence of the injury [4]. Identifying a
but is not in general use by radiologists. Identification of the fracture and classifying the type of injury enable diagnosis
fractures and classification of the type of injury allows of otherwise occult ligament injuries [5].
diagnosis of the otherwise occult ligamentous injuries. Three The first classification system for ankle fractures,
radiographic views of the ankle (anteroposterior, mortise, and developed by Percival Pott, describes fractures in terms of
lateral) are necessary to classify an injury with the Lauge- the number of malleoli involved, thus dividing injuries into
Hansen system. Two additional criteria are also necessary: unimalleolar, bimalleolar, and trimalleolar. Although easy
to use, with good intraobserver reliability, it does not dis-
tinguish between stable and unstable injuries.
A. Russo (&)
O. Fabozzi
M. Cerrato Two other common classification systems for rotational
Department of Radiology, S G. Moscati Hospital, Aversa, Italy ankle fractures attempt to aid in this distinction. The Danis-
e-mail: [email protected] Weber classification system [6, 7] categorizes ankle frac-
tures on the basis of the location of the distal fibular fracture
A. Reginelli
C. Rossi
Department of Clinical and Experimental Internistic F. Magrassi, in relation to the syndesmosis. The Lauge-Hansen classifi-
Second University of Naples, Naples, Italy cation describes firstly the position of the foot at the time of
injury and secondly the deforming force on the ankle and
M. Zappia
provides further information about the stability and hence
Department of Health and Science, University of Molise,
Campobasso, Italy the treatment likely to be required. As was previously
described by Arimoto and Forrester, use of an algorithm
L. Macarini may be of great assistance in applying the Lauge-Hansen
Department of Radiology, University of Foggia, Foggia, Italy
classification system. To classify an injury, it is important to
F. Coppolino follow the algorithm for interpreting radiographic findings
Department of Radiology, University of Palermo, Palermo, Italy set forth by Arimoto and Forrester [2].

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Magnetic resonance (MR) imaging provides more them on the basis of the traumatic mechanism [15, 16]
detailed information about the soft-tissue damage associ- Fig. 1.
ated with ankle fractures; however, the Lauge-Hansen
system is useful as an initial assessment tool and treatment
guide because it helps determine which forces to apply to Anatomy and deforming forces
obtain and maintain closed or open reduction of an ankle
fracture, subluxation, or dislocation [8, 9]. The Lauge- Lateral collateral ligament complex
Hansen classification system was developed on the basis of
the mechanism of trauma, and the criteria to determine the The ankle is stabilized by three sets of ligaments: the lat-
appropriate classification consist of two points: the position eral collateral ligament complex, the syndesmotic ligament
of the foot (supination or pronation) at the time of the complex, and the medial collateral (deltoid) ligament
traumatic event and the direction of the deforming force complex. The lateral collateral ligament is the most com-
(abduction, adduction, or external rotation) [10–14]. monly injured ligament in patients with ankle sprain and is
The Lauge-Hansen classification system may be cum- often associated with ligament injury elsewhere in the
bersome and complex, a possible reason why many radi- ankle [16, 17]. The lateral collateral ligament complex has
ologists prefer to describe fractures instead of classifying three components: the anterior talofibular (ATFL),

Fig. 1 The Lauge-Hansen classification system

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posterior talofibular (PTFL), and calcaneofibular ligaments. Pronation external rotation

The syndesmotic ligament complex comprises the anterior
inferior tibiofibular (AITFL), posteroinferior tibiofibular When the foot is in pronation, the deltoid ligament is under
(PITFL), and transverse tibiofibular ligaments and the stress, leading to injury of the medial ankle structures. In
interosseous membrane. The AITFL is one of the most pronation external rotation, the lateral and posterior ankle
commonly injured ligaments in the ankle [18]. The medial structures become involved as the deforming force con-
collateral ligament (MCL) complex lies deep to the medial tinues, usually leading to spiral fracture of the fibula and
flexor tendons and is divided into four components: the posterior malleolus fracture.
anterior and posterior tibiotalar, tibionavicular, tibiospring, Pronation external rotation has four stages. In stage I,
and tibiocalcaneal ligaments. The MCL complex is an rupture of the deltoid ligament, which appears occult or as
important stabilizer against not only valgus forces but medial mortise widening, or fracture of the medial malleolus
anterior and lateral talar excursion, as well as rotatory is seen (Fig. 2). In stage II, in addition to the medial ankle
forces. Although descriptions of the MCL vary widely, structures, involvement of the AITFL with extension into the
there is general agreement that it consists of a deep layer interosseous membrane is seen. As the amplitude of injury
that courses from the medial malleolus to the talus, with a continues, a spiral or oblique fibular fracture ([6 cm) is seen
delta-shaped superficial layer that courses from the medial at the level above the talotibial joint. In stage IV, involve-
malleolus to the navicular, spring ligament, and calcaneus ment of the posterior ankle structures, such as the PITFL, or
[19, 20]. The ankle may be in one of two different positions fracture of the posterior malleolus is seen.
at the time of trauma: pronation (eversion) and supination
(inversion), and three deforming forces may occur: Supination-adduction
abduction, adduction, and external rotation determining
four mechanisms of injury: pronation-abduction, pronation The talus is adducted in the ankle mortise causing a com-
external rotation, supination-adduction, and supination pression force on the medial ankle structures and traction to
external rotation. the lateral ankle (Fig. 3). Only two injuries occur:

Pronation-abduction

With the foot in a pronated attitude, the talus is abducted in

the ankle mortise resulting in traction on the medial ankle
structures and compression laterally. The following injuries
occur to the bones and ligaments in order [21–24]:
Stage I. Transverse fracture of medial malleolus or
rupture of deltoid ligament
Stage II. Rupture of both anterior and posterior
tibiofibular ligaments with fracture of
posterior tibia
Stage III. Bending fracture of the fibula, generally just
above the ankle joint. The short oblique fracture
of the fibula runs upward from medial to lateral Fig. 2 Pronation external rotation stage I. Transverse fracture of
medial malleolus
is not steeply angled and is best seen on the
anteroposterior view. When the medial
malleolus is fractured, it is transverse
An anteroposterior radiograph of the ankle illustrates the
oblique fibular fracture caused by the pronation-abduction
force as it acts on the lateral structures of the ankle.
Widening of the medial ankle mortise establishes the
presence of a deltoid ligament tear. The presence of a short
oblique fibular fracture (often with lateral comminution)
suggests that this is stage III of a pronation-abduction
injury. By inference, then, the posterior tibiofibular liga-
ment is probably torn despite lack of posterior fracture on
the lateral view. Fig. 3 Supination-adduction stage II. Fracture of medial malleolus

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Stage I. Traction fracture of lateral malleolus at or medial structures are ultimately compromised. In stage I,
below the talus rotates laterally and pushes the lateral malleolus
Stage II. Near vertical fracture of medial malleolus posteriorly, stressing the AITFL, and the anterior inferior
tibiofibular ligament ruptures, a mechanism that usually
appears occult at radiography (Fig. 4). Supination external
Supination external rotation rotation stage I is a stable injury. As lateral rotation of the
talus continues, the lateral structures undergo further stress,
Supination external rotation is the most common mecha- leading to stage II, in which the AITFL ruptures, with a
nism of fracture, accounting for 40–70 % of all ankle spiral fracture of the fibular malleolus at the level of the
fractures. In supination external rotation, the lateral struc- joint in a low anterior, high posterior direction (Fig. 5).
tures are under stress, and as the force continues, the This type of fracture is considered stable. In stage III, the

Fig. 4 Supination external rotation stage I. Frontal radiograph shows subtle widening of the fibular space secondary to rupture of the AITFL.
Mortice radiograph shows lateral soft-tissue swelling. Lateral radiograph shows absence of fracture of the third malleolus

Fig. 5 Supination external

rotation stage II. Spiral fracture
of fibula, at the Level of the
plafond. It is not fracture of
medial or posterior malleolus

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Fig. 6 Pronation external rotation stage II. Medial malleolus fracture and the spiral fracture of the proximal fibula

next step in the sequence of supination external rotation Ethical standards The study described in this article did not
injuries, rupture of the PITFL, or fracture of the posterior include any procedures involving humans or animal.
malleolus of the tibia are seen in addition to rupture of the
AITFL and a fibular spiral fracture. To classify an injury as
stage III, rupture of the AITFL and a spiral fracture of the
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