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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

Weber B

Weber C

Exorotation injury

Ligamentous rupture or Avulsion

Weber and Lauge-Hansen summary

Weber and Lauge-Hansen combined

Weber A in detail

Stage 1

Stage 2

Weber B in detail

Stage 1-2

Stage 3-4

Weber C in detail

Stage 1

Stage 2-3

Stage 4

Interpretation and Reporting

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 supinationadduction, 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. 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 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 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.
Unstable ankle fracture

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.

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.
PE stage 1

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 3

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.

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.
Weber-A stage I

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 2

Stage 2

Stage 2 is uncommon and easy to detect.

More adduction force results in the medial malleolus beingpushed 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 B in detail

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

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

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 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.
Weber B fracture

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 oravulsion 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 isstage 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
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.
Weber C fracture - stage 3

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 - 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. Medial collateral band
rupture
2. Rupture of the anterior
syndesmosis
3. High fibula fracture

4. 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.
Click to enlarge

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.

Re-examination
You re-examine the xrays 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.

Basic interpretation
Transverse lateral
malleolar fracture.

Example 2

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.

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

Example 3

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 APdiameter 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.

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

Example 4

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.

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