The Lauge Hansen Classification of Malleolar Fractures

Acta Orthopaedica Scandinavica ISSN: 0001-6470 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/iort19 The Lauge Hansen Classification of Malleolar Fractures Johannes Yde To cite this article: Johannes Yde (1980) The Lauge Hansen Classification of Malleolar Fractures, Acta Orthopaedica Scandinavica, 51:1-6, 181-192, DOI: 10.3109/17453678008990784 To link to this article: https://doi.org/10.3109/17453678008990784 1980 Informa UK Ltd All rights reserved: reproduction in whole or part not permitted Published online: 08 Jul 2009. Submit your article to this journal Article views: 1480 View related articles Citing articles: 57 View citing articles Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalinformation?journalcode=iort19

Acta orthop. wand. 51,181-192.1980 THE LAUGE HANSEN CLASSIFICATION OF MALLEOLAR FRACTURES JOHANNES YDE Department of Orthopaedic Surgery, Hjerring Hospital, Hjerring, Denmark A total of 488 fractures of the ankle are described and classified into types and stages according to Lauge Hansen (1942). The classification was partly based on operative findings. The type division was: supination-eversion fractures 57.4 per cent, supination fractures 20.1 per cent, pronation and pronationsversion fractures 20.1 per cent and pronation-dorsiflexion fractures 0.4 per cent. A small percentage of the fractures (1.2) could not be fitted into this system, and two-thirds of these were found to have an isolated fracture of the posterior tibial margin. This fracture seems to be a special type of ankle fracture. It was found that the stage 2 injury in pronation and pronation-eversion fractures is not fully explained by Lauge Hansen. The classification of Lauge Hansen gives a very exact description of ankle fractures. This is very important for the operative treatment and also indispensable for the evaluation of the results of various methods of treatment. Key words: ankle fractures; ankle joint; fractures, articular Accepted 26.ix.79 The classification and stage division of malleolar fractures by Lauge Hansen (Hansen 1942) has been recommended by several authors (Burwell & Charnley 1965, Cedell 1967, Maatz & Nonnemann 1973 and others). In 1922 a classification based on fracture genesis was published by Ashhurst & Bromer (1922). This system was further developed by Lauge Hansen on the basis of dissection findings after experimentally produced fractures and by means of combined clinical and roentgenological examinations. He established the following groups of ankle fractures: supination-adduction, supinationeversion, pronation-abduction, pronationeversion and pronation-dorsiflexion. Depending on the degree of severity the main groups can be further divided into stages. OO01-6470/80/010181-12802.50/0 Over the past 20 years an increasing number of reports of operative treatment of ankle fractures have appeared. Thus the understanding of ankle fractures and the recognition of all associated injuries has become more important. The purpose of this paper is to present a rather large series of ankle fractures classified and described according to Lauge Hansen, partly because we feel that his classification has not gained the acceptance it deserves. PATIENTS AND METHODS During the period July 1st 1968 - June 30th 1976, 487 patients with 488 ankle fractures were treated at the Department of Orthopaedic Surgery, Hjerring Hospital. 0 1980 Munksgaard, Copenhagen 13

182 J. YDE The series does not include patients under 15 years of age. Also excluded were patients with epiphyseal separations, direct fractures and isolated ligamentous injuries, i.e. all supinationeversion injuries of stage 1 and some of the stage 1 supination-adduction, pronation-abduction and pronation-eversion injuries. The following nomenclature is used: S = supination or supination-adduction fractures, SE = supinationsversion or supinationoutward rotation fractures, PE = pronationeversion or pronation-outward rotation fractures, P = pronation or pronation-abduction fractures and PD = pronation-dorsiflexion fractures. The figures following the type designation indicate the stage division. Osteosynthesis and suture of ligaments were performed in 210 of the ankle fractures. During the period of the survey, the treatment principle was on the whole to cany out primary osteosynthesis on displaced fractures of all patients under the age of 50 years and on some of the elderly patients with serious fractures. The survey is retrospective, but owing to the department s special interest in these injuries very thorough case records have been kept and the information available concerning clinical and intraoperative findings is therefore sufficient. All fractures have been X-rayed in frontal, lateral and oblique projections. 270 5 male.! c60 h 0 female - NNP)P)*bV) 1;) bhb li)& hd IijObO iij m o m + + years Figure 1. The distribution of the 488 ankle fractures according to age and sex of the patients. Figures on top of the columns indicate the number of operatively treatedfractures. (1942) appears in Table 2. The classification is based on clinical, roentgenological and intraoperative findings. Only 1.2 per cent of the material cannot be fitted into this system. In the following, the stages of the individual fracture types will be described, partly on the basis of roentgenological and partly on the basis of intraoperative findings. RESULTS The causative factors are shown in Table 1. More than half of the injuries were caused by slipping or falling on level ground. The series involves 263 men and 224 women. The age distribution is shown in Figure 1. The mean age is 44 years. In all the age groups over 40 years women predominate. The distribution of the entire material into types and stages according to Lauge Hansen Supination-eversion fractures SE fractures made up 57.4 per cent (280/488) of all the ankle fractures. The stage division and the associated injuries are shown in Figure 2. Stage 1: Injuries in the anterior part of the tibiofibular syndesmosis corresponding to the anterior tibiofibular ligament (ATFL), Isolated rupture of the ATFL is not Table 1. Causative factors in 488 ankle fractures Sports injuries Traffic accidents Slipping or fall on level ground Fall from a height Other and unknown causes 57 11.5 per cent 63 28 1 13.0 per cent 57.6 per cent 53 34 10.9 per cent 7.0 per cent 488 100.0

Table 2. Distribution of 488 ankle fractures into type and stage according to the patho-genetic classification of N. Lauge Hansen SE fractures: 280 P/PEfiactures: 102 Sfiactures: 98 Other fractures 57.4 per cent 20.9 per cent 20.1 per cent 1.2 per cent per no. stage no. cent oper. per no. stage no. cent oper. per no. stage no. cent oper. type number SE 2 162 58.0 55 SE 3 11 4.0 7 SE4 87 66 37.3 SE 4 (lux) 18 16 SE 5 2 0.7 2 P/PE 1 46 45.9 15 P/PE2 18 17.6 6 P3 8 7.8 4 PE3 19 18.6 18 PE4 11 10.1 7 S 1 79 80.6 2 Isolated post. tibial margin 4 S2 19 19.4 7 Atypical PDfiactures: 2 fractures 2 0.4 per cent PD1 1-1 PD2 1-1

184 J. YDE SE ~ fractures the insertion of the ATFL. Of the 29 cases found at operation to have avulsion of a fragment, only in 10 could this be demonstrated radiologically. In three cases the ATFL was found to be intact at operation, In these the line of fracture was described as running distal to the fibular insertion of the ATFL. Figure 2. The stage division of supinationeversion (SE) fractures according to Lauge ffansen. included in this material. In connection with osteosynthesis of the lateral malleolus the anterior part of the syndesmosis was explored in 141 ankles. The injuries to the ATFL are shown in Figure 3. A further 4 per cent (6/141) had an incomplete rupture of the ATFL. Although X-rays were taken in oblique projection, it was difficult roentgenologically to diagnose the avulsion of bone fragments at Stage 2: Oblique spiral fracture of the lateral malleolus running from the anterior margin in a dorso-proximal direction and including the stage 1 injury (Figure 4.). SE 2 fractures made up 58.0 per cent (162/280) of all SE fractures. The line of this fracture can be more or less vertical and be at a variable distance from the tibiotalar joint space, as shown in Figure 5. The three high fiwtures in the area d are made up Figure 3. Stage 1 SE fractures. Operative findings of the injuries to the ATFL in 141 fractures; a further 4.2 per cent had inwmplete rupture of the ATFL. Figure 4. SE 2 fracture. Typical oblique and spiral fracture of the lateral malleolus (oblique project ion).

LAUGE HANSEN CLASSIFICATION OF ANKLE FRACTURES 185 3 12 7 % 2 60-5 \'shell: 49 % Fkure 5. Stage 2 SE fractures. The location of the distal end of the fracture of the fibular malleolus in relation to the tibio-talar joint in 280 fractures. of one stage 2, one stage 3 and one stage 4 fracture. As a rule only a slight instability of the syndesmosis is present because only the ATFL is ruptured. Still in nine cases marked instability was found. This occurred in one stage 2 fracture and in eight stage 4 fractures. Seven of these fractures were located in area UbPP Stage 3: Fracture of the posterior tibial margin including stages 1 and 2 (Figure 6). SE 3 fractures made up 4.0 per cent (1 1/280) of all SE fractures. Only in 14 per cent of the cases did the posterior fragments include more than 25 per cent of the joint surface. It is not necessary to have a fracture of the posterior margin before the injury advances to a stage 4 fracture. Among 107 stage 4 and 5 fractures 32.7 per cent (35/107) did not have any roentgenological fracture of the posterior tibial margin, Stage 4: Fracture of the medial malleolus or rupture of the deltoid ligament including stages 1, 2 and perhaps stage 3. Figure 6. Stage 3 SE fractures. Roentgenological classijication of the injuries to the posterior tibial margin in 83 stages 3, 4 and 5 fractures. SE 4 fractures made up 37.3 per cent (105/280) of all SE fractures. Seventy-five out of a total of 107 stage 4 and 5 fractures were treated surgically. If during the acute clinical examination tenderness, swelling and discoloration were present over the deltoid ligament, and the X-ray revealed no fracture of the medial malleolus, then the ligament was considered injured. The frequency of the various injuries is shown in Figure 7. Fourteen per cent (15/107) of the fractures of the medial malleolus were found to have an oblique (> 30') direction. Among women, fractures in the medial malleolus were found in 63 per cent (37/59) whereas among men only 35 per cent (17/48) sustained this fracture. Stage 5: Spiral fracture of the distal part of the tibia including stages 1, 2, 4 and perhaps stage 3. This fracture was only found in 0.7 per cent (2/280) of all SE fractures (Figure 8).

186 J. YDE - - - / F 0.5% Figure 7. Stage 4 SE fractures. Roentgenological, clinical and operative classijcation of the injuries to the medial malleolus and deltoid ligament in 107 stages 4 and 5 fractures. Supination fractures S fractures made up 20.1 per cent (38/488) of all fractures. The stage division and the associated injuries are shown in Figure 9. Stage 1: Fracture of the lateral malleolus at or distal to the level of the tibiotalar joint or rupture of the anterior talofibular and calcaneofibular ligament. Isolated ligamentous rupture is not included in this material. S 1 fractures made up 80.1 per cent (79/98) of all S fractures. The injuries of the lateral malleolus are shown in Figure 10. At operation the ATFL Figure 8. SE 5 fracture. Typical spiral fracture of the distal part of the tibia. a) Frontal view b) Lateral view.

LAUGE HANSEN CLASSIFICATION OF ANKLE FRACTURES 187 S -fractures Figure 9. The stage division of supination (S) fractures according to Lauge Hansen. 7 0.5'04 S 2 fractures made up 19.4 per cent (19/98) of all S fractures. In 63 per cent (12/19) of the fractures an oblique to vertical (> 30') fracture line was found, but transverse (< 30 ) fractures were also seen (Figure 11). The four cases of rupture of the deltoid ligament were not operatively explored. In a few cases a one-piece fracture of the posterior tibia1 margin and the medial malleolus was found (Figure 9). Pronation and pronation-eversion fractures P and PE fractures made up 20.9 per cent (102/488) of all malleolar fractures. The stage division and the associated injuries are shown in Figures 12 and 13. Stage 1: Fracture of the medial malleolus or rupture of the deltoid ligament. Figure 10. Stage 1 S fractures. Roentgenological, clinical and operative class@cation of the injuries to lateral malleolus and anterior talofibular and calcaneofbular ligament in 98 S 1 and tfractures (isolated ligamentous ruptures are not included). was found to be ruptured in one case and avulsed from the tibia in another case. Stage 2: Fracture of the medial malleolus or rupture of the deltoid ligament, including stage 1. ":;'d& F- Fipre 11. Stage 2 S fractures. Roentgenological, clinical and operative (7pts.) classilfication of the injuries to the medial malleolus and deltoid ligammt in 17 S Zfractures.

188 J. YDE Figure 12. The stage division of pronation (P) fractures according to Lauge Hansen (1942). P E - f r a ct ures Figure 14. Stage 1 P and PE fractures. Roengenological clinical and operative classtjication of the injuries to the medial malleolus and deltoid 1i;grament in 56 stages 2, 3 and Ifractures. Figure 13. The stage division of pronationeversion (PE) fractures according to Lauge Hansen. According to Lauge Hansen (1942) the fracture-causing mechanism in stage 1 of P and PE fractures is identical. P/PE 1 made up 45.9 per cent (46/102) of all P and PE fractures. The Occurrence of various stage 1 injuries in stages 2, 3 and 4 is shown in Figure 14. If the small avulsion fragments are looked on as rupture of the deltoid ligament this type made up 58.5 per cent (33/46) of the medial injuries. Stage 2: Rupture of the distal tibiofibular syndesmosis including stage 1. Clinically and roentgenologically it is impossible to distinguish between stage 2 injuries of P and PE fractures, and so they will be classified as P/PE 2 fractures. These fractures made up 17.6 per cent (18/102) of all P and PE fractures. If a bone avulsion from the posterior tibial tubercle cannot be found the diagnosis can only be made on the findings of the clinical examination showing tenderness, swelling and often discoloration in front of and behind the lateral malleolus. The stage 2 injuries of 18 P/PE 2 fractures are shown in Figure 15. As regards P 3 and PE 3 and 4, the ATFL was explored in 30 cases. Rupture of the ligament proper was found in 27 cases and avulsion fragments from the anterior tibial tubercle in three cases. P stage 3: Low transverse supramalleolar fracture of the fibular including stages 1 and 2 (Figure 12). P3 fractures made up only 7.8 per cent

LAUCE HANSEN CLASSIFICATION OF ANKLE FRACTURES 9189 ant. ant. a b C rupt. shell ant. ant. c 1/4 > 114 73% 17% 10% Figure 16. Stage 3 PE fractures. Roentgenological evaluation of the site of the distal end of the fibular fracture in relation to the tibio-talar joint and illustrations of typical fracture lines (a, b and c) of 30 stages 3 and 4fractures. Figure 15. Stage 2 P and PE fractures. Roentgenological and clinical evaluation of 18 stage ffiactures. (8/102) of all P and PE fractures. Roentgenological fracture of the posterior margin was found in only one of these fractures. PE stage 3: High supramalleolar fracture of the fibular including stages 1 and 2 (Figure 13). The level of this fracture varies greatly as shown in Figure 16. No fracture was less than 2.5 cm above the tibiotalar joint. An assessment of the course of the fibular fracture was made from the lateral X-ray. Seventy per cent (21/30) had a fracture line running from the anterior fibular margin in a dorso-distal direction (Figure 16a), 17 per cent (5/30) had a fracture line running in the opposite direction (Figure 16b) and 13 per cent (4/30) had a transverse or comminute fracture (Figure 16c). No cases had rupture of the proximal tibiofibular syndesmosis. Figure 17 shows a PE 3 fracture with luxation of the talus and total rupture of the syndesmosis but without any avulsion fragment from the posterior tibial tubercle. PE stage 4: Fracture of the posterior tibial margin including stages 1, 2 and 3. The size of this fracture varies as shown in Figure 18. The posterior tibiofibular ligament is intact and the fragment is in this way connected to the lateral malleolus. In 73 per cent (8/11) of these cases the posterior fragment included more than 25 per cent of the joint surface. Prona t ion-dmsgexion fractures These fractures made up 0.4 per cent (2/488) of all malleolar fractures. Stage 1 includes fracture of the medial malleolus and the anterior tibial margin. In this series one PD 1 fracture was found (Figure 19). In the one stage 2 fracture an additional transverse fibular fracture was found. Isolated fracture of margin the posterior tibial This group included four fractures making up 0.8 per cent (4/488) of the material. These patients were remarkably young with a age range from 23-44 years. Three stumbled and one fell down 2 meters.

190 J. YDE T \s h e I I: 18 55 18 9 % % % % Figure 18. Stage 4 PE fractures. Roentgenological evaluation of the fracture of the posterior tibial margin in 11 stage 4 fractures. DISCUSSION In the present material 98.8 per cent of all malleolar fractures could be classified in accordance with Lauge Hansen s system, which consequently must be considered suitable for the characterization of ankle fractures. This is in agreement with the investigations of Kristensen (1953) Burwell & Charnley (1965) and Maatz & Nonnemann (1973), whose results showed that between 93 and 99 per cent of these fractures could be classified according to Lauge Hansen. The roentgenological and intraoperative findings also corresponded well to the observations of Lauge Hansen (1942) and, in the case of SE fractures, to the findings of Cedell(l967). Figure 17. PE 3 fracture. Total lateral dislocation of the talus with complete rupture of the syndesmosis but without fracture of the posterior tibial tubercle. a) Frontal view, b) Lateral view.

LAUGE HANSEN CLASSIFICATION OF ANKLE FRACTURES 191 F2ure 19. Stage 1 pronation-dorsiflexion (PO) fractures according to Lauge Hansen. a) Frontal view, b) Lateral view. However, for P and PE fractures the ligamentous injuries of the syndesmosis do not seem to be fully explained by Lauge Hansen (1942). Concerning the stages 2, 3 and 4 (cf. Figure 17) it seems that the posterior tibiofibular ligament is found to be ruptured in cases without fracture of the posterior tibial margin (Weber 1966). This means that fracture of the posterior tibial margin even in cases of PE fractures precedes the fibular fracture as a stage 2 injury and not as a stage 4 injury as supposed by Lauge Hansen. As shown in Figures 7, 11 and 14 injuries to the deltoid ligament and the medial malleolus are not pathognomonic for the various types of fractures as found by Lauge Hansen (1942). In SE fractures the transverse (< 30') fracture is most frequently seen, in S fractures the oblique (> 30 ) fracture and in P/PE fractures almost equal frequency is seen. Lauge Hansen (1942) and Kristensen (1953) did not find any isolated fractures of the posterior tibial margin. This fracture is, however, described by Magnusson (1944), Frank (1941) and Bonnin (1950). In the four cases found in this material the deltoid ligament was not explored and the clinical estimate cannot be considered to be completely reliable. However, in January 1979, a case of posterior marginal fracture was examined by the author and it was not possible to establish tenderness, swelling or discoloration over the deltoid or the anterior talofibular and calcaneofibular ligaments. As shown in this paper the Lauge Hansen classification gives a very precise and detailed description of malleolar fractures. A classification of this type is an excellent and necessary

192 J. YDE means of conducting a comparable evaluation of results of various types of treatment of malleolar fractures. In clinical work this classification is also very useful, because it gives important information about ligamentous injuries which may accompany the fractures seen roentgenologically. REFERENCES Ashhurst, A. & Bromer, R. (1922) Classification and mechanism of fractures of the leg involving the ankle. Arch. Surg. 4, 51. Bonnin, J. G. (1950) Injuries of the ankle. William Heinemann, Medical Books Ltd., London. Burwell, H. N. & Charnley, A. D. (1965) The treatment of displaced fractures of the ankle by rigid internal fixation and early joint movement. J. Bone Jt Surg. 47-B, 634-659. Cedell, C.-A. (1967) Supination-outward rotation injuries of the ankle. Acta orthop. scand., Suppl. 110. Frank, S. (1941) Isolerede brud i nedre skinnebenskant (marginalbrud). Nord. Med. 9, 643. Hansen, N. Lauge (1942) Ankelbrud I. Genetisk diagnose og reposition. Diss. Munksgaard, Kbhn. Kristensen, T. B. (1953) Ankelbrud. Diss. Nyt Nordisk Forlag, Arnold Busch., Kbhn.. Maatz, R. & Nonnemann, H. C. (1973) Bericht uber 938 bimalleoliire Luxationsfrakturen. 1. Teil. Chirurg 44, 456-460. Magnusson, R. (1944) On the late results in nonoperated cases of malleolar fractures. Fractures by external rotation. Acta chir. scand., Suppl. 84. Weber, B. G. (1966/72) Die Verletsungen des oberen Sprunggelenkes. Verlag Hans Huber, Bern Stuttgart, Wien. Correspondence to: Johannes Yde, Department of Orthopaedic Surgery, Hjerring Hospital, 9800 Hjerring, Denmark.