`

The ankle is the most frequently injured joint.

Management decisions are based on the interpretation of the AP and lateral X-rays.
In this article we will focus on:

Trauma mechanism of ankle injuries

Ottawa ankle rules

Proper positioning of the ankle for radiography

Fracture mechanism and Radiography

by Robin Smithuis

Trauma mechanism in ankle injuries

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.

Vulnerable positions 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.

Ring of stability in the coronal plane

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 anyone can figure out, 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 is not detectable on the X-ray.
In some fractures there may even be a proximal fibular fracture - which is not visible on the
ankle radiographs - in combination with ligamentous ruptures at the level of the ankle.
It is important to realize that in these cases the radiographs of the ankle may be normal, while
there still is an unstable ankle injury.

Ring of stability in the axial plane

There is also an ring of stability in the axial plane.

When the anterior and posterior syndesmosis rupture or avulse, then the ankle mortise is
unstable.


There are many combinations of avulsion fractures and ligamentous ruptures that can produce an
unstable ring in the axial plane.

A
Anteriorly the anterior syndesmosis (or antior tibiofibular ligament) is one of the first structures
to rupture. When the posterior syndesmosis also ruptures, then the ankle is unstable.
B
Less commonly the anterior syndesmosis avulses from the tibial attachment - Tilleaux fracture.
C
On the posterior side frequently the malleolus tertius avulses. Sometimes these fractures are
difficult to detect, as we will discuss in a moment.
D
After the injury the bones frequently align again.

Tilleaux fracture

Stability (2)
It is important to realize, that for the stability of the ankle it doesn't matter whether there is a
rupture of a ligament or an avulsion at the insertion.
Almost every ligamentous rupture has a fracture equivalent.

Stability (3)
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 (4)
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 (5)
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 (6)
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 of the injured ankle consists of an AP-view, a Mortise-view

and a lateral view.
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.

The distal fibula should project on the posterior part of the distal tibia

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).

Malpositioning of the lateral view

Malpositioning of the Lateral view

Malpositioning of the lateral view is the most common mistake in radiography of the injured
ankle.
Because the patient is in pain, the technologist is afraid to let the patient turn the ankle fully
lateral.
This is one of the reasons why we miss so many fractures of the malleolus tertius.

The CT demonstrates a large tertius fracture.

On the lateral view and also on the AP- and Mortise views, which will be shown in the paragraph
on tertius fractures, this fracture was not visible.
The explanation is that on the lateral radiograph the fibula projects in the middle of the tibia.
The x-ray beam is not parallel to the fracture line.
Since the fracture line of a tertius fracture always has this orientation, we must insist on a true
lateral view.


Good positioning of the lateral view - Tertius fracture

On a well positioned lateral view the tertius fracture is obvious (red arrow).
This was the only fracture that was seen on the x-rays of the ankle and this patient turned out to
have an unstable Weber-C fracture and went for surgery.

The x-ray beam has to be centered on the malleoli.
Notice the exorotation of the foot for a proper lateral view.

Videos of severe ankle injuries

The forces in ankle injuries can be enormous.
As was discussed in Ankle fractures 1 the injuries usually take place in a logical sequence.

Ankle - Fractures 1 Weber and Lauge-Hansen classification

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 a Lauge Hansen Supination Adduction injury stage 2.

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.

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 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.


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 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.

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 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 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 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

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 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 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.


Example 2

Basic interpretation
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

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 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.


Click to enlarge

Example 4

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.

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 Lauge-Hansen this is a SER stage 4.
This is an unstable fracture with dislocation that needs surgical repair.
The ankle is the most frequently injured joint.
Management decisions are based on the interpretation of the AP and lateral X-rays.
In this article we will focus on detection of fractures, that may not be so obvious at first sight.
Before you read this article, you need to understand the classification of ankle fractures and
exorotation injuries that were highlighted in Ankle - Fractures 1 and 2.

Malleolus Tertius fracture



Almost all fractures of the malleolus tertius are part of a rotational injury resulting in a Weber B
or Weber C fracture.
The tertius fracture is stage 3 in Weber B and stage 4 in Weber C (figure).
In some cases the tertius fractures are easily seen on the x-rays, but frequently they can be
difficult to detect.
It is important to find these fractures, since a tertius fracture can be the only clue to an unstable
ankle injury.

Ankle - Fractures 2 - Fracture mechanism and Radiography

Linear lucency indicating a fracture of the malleolus tertius

When we study the radiographs of a patient with an ankle injury, we have to study the region of
the malleolus tertius very carefully.
In many cases there is only a small gap between the fracture parts and detection depends on
optimal radiography and a high level of suspicion.
The images show an obvious Weber B fracture.
On the AP-view the linear lucency is the clue to a tertius fracture (red arrow).
It results from subtle malalignment of the fracture fragment.
Likewise in some cases malalignment can result in a linear density.

Trimalleolar Weber B fracture

In this case there is a Weber B fracture with avulsion of the medial malleolus.
The bright line on the AP-view indicates a large tertius fracture fragment.
This tertius fracture can also be seen on the lateral view, but in many cases we need all the
information of both the lateral and AP-view to diagnose a tertius fracture.

Here more examples of the bright line that indicates a tertius fracture.


In some cases a fracture of the malleolus tertius is barely or not visible on the radiographs and
can only be seen on CT.
First study the radiographs and then continue with the CT.
By the way....there are two fractures.
You can enlarge the images by clicking on them.

The CT shows an avulsion of the tertius at the insertion of the posterior syndesmosis (red
arrows).
The alignment is so perfect, that you do not see the fracture on the radiographs.
Maybe the fracture is seen on the AP-view as indicated by the red arrows, but this is
questionable.
Notice that there is also an avulsion at the tibial insertion of the anterior syndesmosis, i.e.
Tilleaux fracture.
This combination of findings implicate that the ankle is unstable.
A syndesmotic screw has to be inserted.

Here we have images of an extremely difficult case.

This woman had a distortion of the ankle and had pain on both medial and lateral side.
She was referred to the radiology department by her general practitioner.
The technician made the standard AP-, Mortise- and lateral view and showed them to the
radiologist, who was a little bit puzzled.
First study the images and then continue reading.

The findings are:

Soft tissue swelling both medial and lateral (red arrows).

Especially the medial swelling should make you consider a pronation exorotation injury
(Weber C).

Lucent line on Mortise view (black arrow) and lateral view. This should make you
consider a tertius fracture.
The radiologist decided first to order a CT to find out if there really was a tertius fracture.
Continue with the CT and be amazed.

Scroll through the images.

It is amazing, that such a large tertius fragment is so difficult to see on the radiographs.
Also notice the soft tissue swelling on the medial side indicating rupture of the medial collateral
ligaments (arrow).

Do you have an idea what kind of injury this is?

Medial soft tissue swelling and a tertius fracture are both indications of a Weber C or Pronation
Exorotation injury.
Since there is no fibula fracture seen on the x-rays of the ankle, there must be a high fibular
fracture.

At physical exam there was some swelling on the medial side and although the patient did not
complain of any pain higher in the lower leg, there was some tenderness when the fibula was
palpated.
This spot was marked and a fracture was found.
This case illustrates the importance of medial soft tissue swelling aswell as the finding of a
tertius fracture.

According to Lauge Hansen we can conclude that this patient first had a rupture of the medial
collateral ligaments (stage 1), followed by a rupture of the anterior syndesmosis (stage 2) and a
high fibula fracture (stage 3) and finally an avulsion of the malleolus tertius, i.e. PE stage 4.

At surgery the ankle was found to be unstable and syndesmosis screws were inserted.
There was an indication for fixing the posterior malleolar fracture, since the fragment involved
more than 25% of the articular surface of the distal tibia.


This patient had a twisted ankle and the only abnormality is seen on the lateral view.
This was thought to be an avulsion of the malleolus tertius.
Knowing that this can be the only clue to a high Weber C, additional radiographs were taken.
Continue with the images of the lower leg.

A subtle high fibula fracture is seen (arrow).

Final diagnosis is a Weber C fracture or according to Lauge Hansen: Pronation Exorotation
injury stage 4.


Isolated Tertius fracture

A fracture of the malleolus tertius as an isolated finding is very uncommon.

It is seen when someone's foot hits the ground and a fragment of the malleolus tertius is pushed
off by the talus.
The size of this fragment depends on the direction of the force (figure).

Salter-Harris fractures

The Salter-Harris classification describes fractures that involve the epiphyseal plate or growth
plate.
The most common is type II, which accounts for 75%.

Type I - transverse fracture through the growth plate or physis

 Type II - fracture through the growth plate and the metaphysis, sparing the epiphysis

Type III - fracture through growth plate and epiphysis, sparing the metaphysis

Type IV - fracture through all three elements of the bone, the growth plate, metaphysis,
and epiphysis

Type V - compression fracture of the growth plate

These Salter-Harris fractures can be easily missed.

In many cases there is only minimal or no displacement.
The fracture through the growth plate is usually obscure and difficult to differentiate from
normal variations of the growth plate. And finally we tend not to look carefully at the epiphysis.

Type I

Type I Salter-Harris fractures tend to occur in younger children (5).

It is a transverse fracture through the cartilage of the growth plate or physis.
Often, x-rays of a child with a type I growth plate fracture will appear normal.
Most type I growth plate injuries are treated with a cast.
Healing of type I fractures tends to be rapid and complications are rare.


Type II

A type II growth plate fracture starts across the growth plate, but the fracture then continues up
through the metaphysis.
This is the most common type of growth plate fracture, and tends to occur in older children.
Often type II growth plate fractures must be repositioned under anesthesia, but healing is usually
quick and complications are uncommon.

Type III

Type III is a fracture through the growth plate and epiphysis sparing the metaphysis.
A type III fracture also starts through the growth plate, but turns and exits through the end of the
bone, and into the adjacent joint.
These injuries can be concerning because the joint cartilage is disrupted by the fracture.
Proper positioning is essential after a type II growth plate fracture.
These injuries also tend to affect older children in whom the growth plate is partially closed.
Study the images and then scroll to the next images.

The fracture through the epiphysis can be easily missed (blue arrow).
The fracture through the growth plate is only seen on CT.
Continue with the CT images.

The CT-images nicely display the fracture through the growth plate and the epiphysis.

Study the images and then scroll to the next images.

This is also a Salter-Harris type III fracture.
Notice that there is also a Tilleaux fracture.
We will discuss these fractures in a moment.

Type IV

Type IV is a fracture through all three elements of the bone, the growth plate, metaphysis and
epiphysis.
Notice that the epiphyseal fracture is in the sagittal plane, the fracture through the growth plate is
in the axial plane and the metaphyseal fracture is in the coronal plane.
These fractures are also named triplane fractures.
These are discussed in the next chapter.

Proper positioning is also essential with type IV growth plate fractures, and surgery may be
needed to hold the bone fragments in proper position.

Type V

Type V growth plate injuries occur with the growth plate is crushed.
Type V growth plate fractures carry the most concerning prognosis as bone alignment and length
can be affected.
These types of fractures may permanently injure the growth plate, requiring later treatment to
restore alignment of the limb.

Triplane fracture

Triplane fracture

This fracture is named triplane because it occurs in the coronal, sagittal and axial plane.
It is actually a Salter-Harris type IV.
It is seen exclusively in young adolescents in the period, when the medial tibial epiphysis is
closed, while the lateral portion is still open leaving it vulnerable to injury.
As the force cannot continue into the medial part of the growth plate since this is already closed,
the epiphysis will fracture.
As in most ankle fractures the mechanism is external rotation.

The injury results in:

1. Epiphyseal fracture in the sagittal plane

2. Injury to the growth plate in the axial plane

3. Metaphyseal fracture in the coronal plane



Study the images and then continue reading.

Triplane fracture

At first this looks like a Weber B fracture with an oblique fracture in the fibula as seen on the
lateral view (black arrows).
Notice however that this fracture line stops at the level of the epiphyseal plate.
So this is the fracture of the metaphysis in the coronal plane.
On the AP-view there is a lucency within the epiphysis, which is the epiphyseal fracture in the
sagittal plane.
Notice also that the medial epiphysis is already closed, while the lateral portion is still open(blue
arrows).
We have to assume that there is an epiphysiolysis of this lateral portion.

Here another example.

There is only a small metaphyseal fragment, which is usually the case (red arrow).
The fracture through the epiphysis is indicated by the blue arrow.

Maisonneuve fracture

In 1840 Maisonneuve described a frature of the proximal shaft of the fibula, which was caused
by exorotation force applied to the ankle.
It is a high Weber C fracture.
These fractures are easily overlooked because the patients rarely complain of pain in the region
of the proximal fibula, since the ankle is most painful.

There are three situations in which we should suspect a high Weber C or Maisonneuve fracture:

1. Isolated fracture of the medial malleolus

 2. Isolated fracture of the malleolus tertius without a fracture on the lateral side

3. 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 pronation exorotation injury, which results
in a Weber C fracture.
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 a Weber C stage 4 sometimes only a fracture of the medial malleolus will be visible.
In the illustration we see the fractures and ligamentous injury on the left and the resulting x-rays
on the right.

Isolated fracture of the malleolus tertius

Truely isolated fractures of the malleolus tertius are very uncommon.
Most fractures of the malleolus tertius are part of a complex ankle injury, either Weber B or
Weber C.
A Weber B fracture is easily detected because of the characteristic oblique fracture.
So if there is a tertiu sfracture and no sign of a Weber B fracture, then we have to start looking
for a high Weber C fracture.

In that case 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 the ankle radiographs indicates the presence of an unstable ankle
injury.

Any medial painful swelling or hematoma

Normal radiographs do not rule out a Weber C fracture.

We may 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



Example 1
On the left images of a patient with a hematoma on the medial side.

First impression
We can exclude a Weber A or B fracture, because we see no fracture.
A high Weber C is still a possibility, i.e.

o medial ligament rupture

o high fibular fracture

o posterior syndesmosis rupture.

 Re-examination
Additional radiographs of the lower leg were taken and demonstrated a high fibular
fracture, also known as Maisonneuve fracture.

Final report
Weber C stage 4, i.e. medial collateral ligamentous rupture, rupture of the anterior
syndesmosis, high fibular fracture and probably a rupture of the posterior syndesmosis.

Teaching point No fracture on the radiographs of the ankle does not exclude an unstable ankle
injury

This case demonstrates that there can be an unstable ankle injury that needs surgery even when
the radiographs of the ankle do not show a fracture.
In any patient with an ankle injury you should always ask yourself the question......can I exclude
a high Weber C fracture or do I need additional imaging.

Example 2

First impression
There is a fracture of the posterior malleolus.
Classification according to Weber is not possible.
An isolated fracture of the malleolus tertius is uncommon, but as part of a supination
exorotation (Weber B) or pronation exorotation injury (Weber C) it is quite common.
So 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 (red arrow).
Additional radiographs of the lower extremity demonstrate a high fibular fracture (blue
arrow).

Final report
Weber C stage 4.

Example 3
In this case no fracture is seen, but only soft tissue swelling on the medial side.
In such a case, you have to rule out a Maisonneuve fracture, which is a high Weber C fracture.
Additional x-rays of the lower leg were taken.

There is a high fibula fracture.

Tilleaux fracture


External rotation injury of the ankle is the most common ankle injury and can lead to a Weber B
or Weber C fracture.
One of the first stages in this injury is rupture of the anterior tibiofibular ligament (or anterior
syndesmosis).
Less frequently it leads to an avulsion of the anterolateral tibial epiphysis.
Whenever you see such a fracture, you have to look for higher stages of this exorotation injury.

The x-ray shows a subtle Tilleaux fracture, which is better appreciated on the CT-images.


Study these images carefully and remember the stages of an exorotation injury.
What is going on here?

There is a Tilleaux fracture due to avulsion of the anterolateral part of the distal tibia by the
anterior syndesmosis.
This can be a stage 2 of a Weber C fracture.
Stage 1 is rupture of the medial collateral ligaments and stage 3 is a fibula fracture above the
level of the syndesmosis.
So now we start looking for stage 4, which is rupture or avulsion of the posterior syndesmosis.

Do you now see the tertius fracture on the axial CT-image?

This patient has an unstable ankle injury and a syndesmotic screw needs to be inserted.

Stages of exorotation injuries of the ankle



Another Tilleaux in a patient with a strange combination of findings. There is an avulsion of the
lateral malleolus, a Tilleaux and a medial malleolar fracture.

juvenile Tilleaux

A Tilleaux fracture is more commonly seen in adolescents at the age of 12 -15 years.
At that age it is a fracture through the growth plate and is then called a juvenile Tilleaux.
It occurs before the distal tibial epiphysis has completely fused.
The fracture occurs when the medial epiphysis has fused and the lateral part becomes avulsed at
the attachment of the anterior tibiofibular ligament (or syndesmosis).

Study the images and then continue reading.

You can enlarge the images by clicking on them.
There is a subtle widening of the lateral part of the growth plate of the right ankle.
There is also a very subtle fracture through the epiphysis.
Continue with the CT.

The CT-images show a epiphysiolysis fracture Salter Harris type 3.

This juvenile Tilleaux is especially seen in young athletes.
Always look for higher stages of an exorotation injury.