*Derived from cadaver studies, the Lauge-Hansen system categorizes ankle fractures based on the position of the foot and the forces acting on it at the time of injury, while Danis-Weber relies on the level of fibular fracture.
*Lauge-Hansen classification: Position of the foot (eg, supination, pronation) is described first. Second, the deforming force is described as external rotation, abduction, or adduction. A definitive number of combinations exist, and the severity of the injury conforms to the amount of force applied in each direction.
This classification does not include axial compression injuries.
Supination-adduction class :
Stage I - Transverse fracture of lateral malleolus
Stage II - Steep oblique fracture of medial malleolus
Supination-external (eversion) rotation class :
Stage I - Rupture of anterior tibiofibular ligaments
Stage II - Spiral fracture of distal fibula
Stage III - Disruption of posterior tibiofibular ligaments with or without avulsion of the posterior malleolus
Stage IV - Oblique fracture of medial malleolus
Pronation-abduction class :
Stage I - Transverse fracture of medial malleolus or torn deltoid ligament
Stage II - Disruption of posterior and anterior tibiofibular ligaments with or without avulsion of posterior malleolus
Stage III - Oblique fracture of distal fibula
Pronation-external (eversion) rotation class :
Stage I - Transverse fracture of medial malleolus or torn deltoid ligament
Stage II - Disruption of anterior tibiofibular ligament complex and interosseous membrane
Stage III - High fracture of fibula (above the joint)
Stage IV - Disruption of posterior tibiofibular ligament with or without avulsion of posterior malleolus
Pronation-dorsiflexion class :
Stage I - Fracture of the medial malleolus
Stage II - Fracture of the anterior lip of the tibial
Stage III - Fracture of the supramalleolar aspect of the fibula
Stage IV - Rupture of the posterior inferior tibiofibular ligament or fracture of the posterior malleolus
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Danis-Weber classification: These fractures are classified according to location of the fracture and appearance of the fibular component. The higher the fibular fracture, the greater the likelihood for ankle mortise insufficiency.
*Type A depicts a transverse fibular avulsion fracture, occasionally with an oblique fracture of the medial malleolus. These result from internal rotation and adduction.
*Type B describes an oblique fracture of the lateral malleolus with or without rupture of the tibiofibular syndesmosis and medial injury (either medial malleolus fracture or deltoid rupture). These result from external rotation.
*Type C designates a high fibular fracture with rupture of the tibiofibular ligament and transverse avulsion fracture of the medial malleolus. Usually syndesmotic injury is more extensive than in type B. These result from adduction or abduction with external rotation.
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FRACTURE EPONYMS :
*Pilon fracture :
- A pilon fracture designates a fracture of the distal tibial metaphysis combined with disruption of the talar dome. This fracture originates from an axial loading mechanism in which the talus drives into the tibial plafond, such as when a patient involved in an auto accident compresses his foot on the floorboard to brace against injury. Skiers coming to an unexpected sudden stop and victims of free fall from heights also may sustain pilon fractures. Incidence of pilon fractures ranges from 1-10% of all tibial fractures.
- While managing these fractures; Establish vascular and integument integrity. Perform a meticulous exam of the skin, because marked swelling and breaching of the integument frequently accompany these fractures.
- Skin sloughing is not uncommon. Subsequent edema, fracture blisters, and skin necrosis from the original injury may convert closed fractures to open injuries.
- Associated injuries include spinal compression fractures, especially of L1, and ipsilateral or contralateral fractures of the os calcis, tibial plateau, pelvis, or acetabulum.
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Maisonneuve fracture :
- A Maisonneuve fracture is defined as a proximal fibular fracture coexisting with a medial malleolar fracture or disruption of the deltoid ligament. Maisonneuve fractures are associated with partial or complete disruption of the syndesmosis.
- Treatment of Maisonneuve fractures depends on stability of the ankle mortise.
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Tillaux fracture :
- A Tillaux fracture describes a Salter-Harris (SH) type III injury of the anterolateral tibial epiphysis caused by extreme eversion and lateral rotation of the ankle. Incidence is highest in adolescents, usually those aged 12-14 years, because the fracture occurs after the medial aspect of the epiphyseal plate of the tibia closes but before the lateral aspect arrests.
- Distinguish a Tillaux fracture from a triplane fracture. Triplane fracture is a combination of a SH II and III fracture and is more likely than a Tillaux fracture to require open reduction and internal fixation.
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Pott's fractures:
Bimalleolar fractures, termed Pott fractures, involve at least 2 elements of the ankle ring. These fractures should be considered unstable and require urgent orthopedic attention.
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Cotton's fractures:
A trimalleolar, or Cotton, fracture involves the medial, lateral, and posterior malleoli. These fractures are considered unstable and require urgent orthopedic attention.
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Snowboarder's fracture :
- With the popularity of snowboarding in the late adolescent and young adult population, it is likely the emergency physician will come across a fracture of the lateral process of the talus, the so-called snowboarding ankle fracture.
- A combination of dorsiflexion and inversion of the ankle produces the lateral talar fracture.
- A high index of suspicion should be used in snowboarders who complain of lateral ankle pain with a normal-appearing ankle radiograph. Computed tomography imaging is often required to diagnose a talus fracture.
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