Ankle Fractures: Lauge-Hansen Classification

Author: Michelle Lin, MD
Updated: 2/18/2010

Ankle Fractures: Lauge-Hansen Classification

Lauge-Hansen Classification

  • Describes position of foot and mechanism of injury
  • Fracture(s) progress from Stage 1--> 4 involving more areas
  • Each type of fracture type has classic radiographic appearance

4 areas of injury

  • Anterior talofibular ligament (AFTL) tear
  • Lateral malleolus (LM) fx
  • Posterior malleolus (PM) fx, or posterior talofibular ligament (PTFL) tear
  • Medial malleolus (MM) fx, or deltoid ligament tear

Graphic displaying the 4 areas of injury

* Often fibula fx pattern hints at classification

Supination-External Rotation (SER)

40-75% of all ankle fractures

  • Stage 1: ATFL tear
  • Stage 2: Spiral oblique distal fibula fx at ankle mortise level
  • Stage 3: PM fx or PTFL tear
  • Stage 4: Transverse MM fx or deltoid ligament tear

X-ray image showing Supination-External Rotation (SER)

Supination-Adduction (SAD)

10-20% of all ankle fractures

  • Stage 1: Low avulsion LM fx or lateral ligament injury
  • Stage 2: Vertical shear fx of MM

X-ray image showing Supination-Adduction (SAD)

Pronation-Abduction (PAB)

5-20% of all ankle fractures

  • Associated with syndesmosis instability
  • Stage 1: Transverse MM fx (or deltoid ligament tear)
  • Stage 2: ATFL or PTFL tear
  • Stage 3: Transverse fibula fx at or above ankle mortise
  • Typically fibula fx has butterfly segment (comminuted)

X-ray image showing Pronation-Abduction (PAB)

Pronation-External Rotation (PER)

7-19% of all ankle fractures

  • Maisonneuve fx is a type of PER injury
  • Associated with syndesmosis instability
  • Staging:
    • Stage 1: Transverse MM fx (or deltoid ligament tear)
    • Stage 2: ATFL tear
    • Stage 3: Spiral oblique fibula fx above ankle mortise
    • Stage 4: PM fx or PTFL tear
  • To diagnose deltoid ligament instability, use “gravity stress” view (lateral portion of ankle rests on xray table to increase medial mortise)
  • Operative repair depends on talar stability under tibial plafond. A 1 mm lateral talar shift causes loss of joint surface contact by 42% --> chronic arthritis complications

X-ray image showing Pronation-External Rotation (PER)


  • Clare MP. A rational approach to ankle fractures. Foot Ankle Clin. 2008 Dec;13(4):593-610. [PubMed]