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Short overview
Weber A
Weber B
Weber C
Exorotation injury
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
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
Stage 2 - Oblique
fracture of the medial
malleolus.
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 2 - Oblique
fracture of the fibula
(this is the true Weber B
fracture)
or - fracture of the
malleolus tertius
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.
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
Weber A stage 2
Weber B stage 3 -4
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.
Understanding the fracture mechanism and the stages according to Lauge-Hansen helps you to make the right diagnosis
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
Stage 2
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 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.
Immediately after the injury the injured parts may again align, which can make it difficult to
detect the injuries.
Weber B fracture
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.
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
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.
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.