Main Malleolar Fracture Classifications
For a systematic evaluation of radiographs, two main classifications are used:
- Danis-Weber Classification. Based on the level of the fibular fracture (fibula) relative to the talar dome (talar dome) and the tibiofibular syndesmosis:
- Type A: fracture below the syndesmosis.
- Type B: fracture at the level of the syndesmosis.
- Type C: fracture above the talar dome (often with syndesmotic injury).
Its limitation is poor evaluation of soft tissue injuries.
- Lauge-Hansen Classification. Focuses on the injury mechanism and predicts the sequential destruction of bones and ligaments. Takes into account:
- Foot position: supination or pronation.
- Direction of force: adduction, abduction, or external rotation.
There is also a simple anatomical classification dividing fractures into uni-, bi-, and trimalleolar (when the posterior malleolus is involved — posterior malleolus).
Lauge-Hansen Injury Patterns
Let's examine the main injury variants:
- Supination-Adduction (SAD): Begins with lateral ligament rupture or a low fibular fracture (stable). In the second stage, an oblique medial malleolar fracture is added (unstable).
- Supination-External Rotation (SER): Classic sign is an oblique fibular fracture, well-visualized on the lateral view. The injury progresses from the anterior tibiofibular ligament (Stage 1) to the posterior tibiofibular ligament/posterior malleolus (Stage 3) and the medial malleolus (Stage 4).
- Pronation-Abduction (PAB): Eversion injury. First, the medial complex (deltoid ligament or malleolus) is injured, followed by the tibiofibular ligaments, and in Stage 3, an oblique fibular fracture occurs.
- Pronation-External Rotation (PER): Sequence: medial complex $\rightarrow$ anterior tibiofibular ligament $\rightarrow$ high spiral fibular fracture $\rightarrow$ posterior tibiofibular ligament/malleolus. The difference from SER is the high fibular fracture (often called the Maisonneuve fracture, Maisonneuve fracture).
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Other Significant Fractures
- Pilon Fracture (Pilon fracture): Destruction of the weight-bearing articular surface of the distal tibia. Occurs with high axial loading (fall from height). Often comminuted, requiring complex osteosynthesis.
- Osteochondral Lesions of the Talar Dome: Occur during foot inversion. Lateral lesions are thin and linear, medial lesions are deeper.
- Calcaneal Fractures (calcaneus): The most vulnerable tarsal bone under axial load. Frequently bilateral (10%) and can be associated with lumbar spine fractures (10%). It is important to determine whether the subtalar joint articular surface is involved. A lateral view is required for visualization.
- Pediatric Injuries: Tillaux fracture (Tillaux fracture) — avulsion of a tibial fragment in adolescents (equivalent to Salter-Harris type III). Triplane fracture (Triplane fracture) involves sagittal, horizontal, and coronal planes (Salter-Harris type IV).
Class and exam questions
Why is it necessary to include the calcaneus and the base of the fifth metatarsal in ankle radiography?
Occult fractures that are easily missed if focusing solely on the malleoli can be localized in these areas.
What is the essence of a Maisonneuve fracture?
This is a high (proximal) spiral fibular fracture accompanied by rupture of the tibiofibular syndesmosis along its entire length. Corresponds to Stage 3 of a pronation-external rotation (PER) injury.
What should be done if a radiograph in a PER injury shows only a posterior malleolar fracture while the fibula appears intact?
The absence of a distal third fibular fracture in the presence of a posterior malleolar fracture indicates Stage 4 PER. Radiographs of the entire lower leg are necessary to search for a high fibular fracture.
What complications can arise from undetected occult injuries?
Failure to timely identify occult fractures or instability leads to the early development of osteodegenerative changes (arthrosis).
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What else to study on this topic
- Biomechanics of Operative Fixation in Pilon Fractures
- Types of Calcaneal Fractures: Tongue-Type and Vertical Oblique
- Imaging Features of Talar Dome Lesions in the Mortise View
- Detailed Analysis of Pediatric Fractures (Tillaux and Triplane)
- Choosing Between MRI and CT in Surgical Planning
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