Classification system
Lauge-Hansen Classification
Lauge-Hansen Classification of Ankle Fractures
The Lauge-Hansen classification is a mechanistic system that sorts rotational ankle fractures into four patterns named for the position of the foot and the direction of the deforming force — supination–adduction, supination–external rotation, pronation–abduction and pronation–external rotation — each staged by how far the predictable sequence of bone and ligament failure has progressed.
What the Lauge-Hansen category means
Lauge-Hansen categories describe different patterns, not increasing severity — a higher-lettered or higher-numbered category is not necessarily a worse problem. The groups below are descriptive.
- Stage I1–1
One structure has failed. Usually a stable injury, with the exception of the pronation patterns, in which stage I is the medial-side failure.
- Stage II2–2
Stability depends on the mechanism: SER II is a stable isolated fibular fracture, while SA II and PA II are unstable.
- Stage III3–3
Three structures have failed. SER III warrants a stress view; PA III and PER III are unstable.
- Stage IV4–4
Both sides of the ankle ring have failed. Unstable, and operative fixation is the usual treatment.
Published criteria and reliability
The published cut-offs that define this instrument, and the measured agreement between observers using it. Each is reported with the population it was derived in.
| Type | Value | Subscale | Population | Follow-up | Source |
|---|---|---|---|---|---|
| Criterion | Supination–external rotation is the most frequently observed pattern | — | Rotational ankle fractures | — | Lauge-Hansen N 1950 |
| Criterion | The ligament injuries the classification predicts are frequently absent on MRI | — | Operatively treated ankle fractures imaged with MRI | — | Gardner MJ 2006 |
| Criterion | The described failure sequence could not be reproduced in controlled cadaveric loading | — | Cadaveric ankle loading experiments | — | Haraguchi N 2009 |
Criterion is a published cut-off, definition or performance figure belonging to a classification or decision rule — it is not a change score and should not be read as one.
How the score is calculated
Stated in full so the calculation can be independently checked, and reproduced by hand if needed.
Each pattern is named by two words: the position of the foot at the moment of injury (supination or pronation) followed by the direction of the force applied to the talus (adduction, abduction or external rotation). Within each pattern the structures fail in a fixed order, and the stage is simply the highest point that sequence reached, so the stages are cumulative. Supination–adduction has two stages: lateral collateral ligament rupture or a transverse fibular avulsion below the joint, then a vertical medial malleolar fracture. Supination–external rotation has four: anterior inferior tibiofibular ligament rupture, then a spiral fibular fracture at the level of the joint, then posterior inferior tibiofibular ligament rupture or a posterior malleolar fracture, then a transverse medial malleolar fracture or deltoid rupture. Pronation–abduction has three: medial malleolar fracture or deltoid rupture, then syndesmotic rupture, then a transverse fibular fracture above the joint with lateral comminution. Pronation–external rotation has four: medial malleolar fracture or deltoid rupture, then anterior inferior tibiofibular ligament and anterior interosseous membrane rupture, then a spiral fibular fracture above the joint, then posterior inferior tibiofibular ligament rupture or a posterior malleolar avulsion.
Missing data
Both the mechanism and the stage are required; a stage alone is meaningless because the same stage number denotes a different injury in each pattern. Selecting a stage the chosen mechanism does not have — stage IV for supination–adduction, for example — returns no classification and an explanatory note rather than the nearest valid stage.
Instrument profile
- Developer
- Niels Lauge-Hansen
- Institution
- Copenhagen, Denmark
- First published
- 1950
- Items
- 2
- Response format
- Branching assessment — mechanism, then stage
- Score range
- 1 to 4
- Direction
- Categories are not ranked by severity
- Completion time
- About 2 minutes
- Age range
- Skeletally mature patients
- Regions
- Foot & Ankle
- Conditions
- Ankle fracture, Malleolar fracture, Syndesmotic injury, Deltoid ligament injury, Maisonneuve fracture
- Procedures
- Open reduction internal fixation of the ankle, Syndesmotic fixation, Deltoid ligament repair
- Validity
- Face validity is high — the system explains why fibular fracture level and obliquity differ between patterns, and it predicts where to look for injuries that plain films do not show, such as a Maisonneuve fracture in a pronation–external rotation injury. Criterion validity against MRI is weaker: the predicted ligament ruptures are often not present.
- Reliability
- Interobserver agreement is moderate at best and is poorest at distinguishing the stages within a pattern, which is why most surgeons classify the fibular level with Danis-Weber and use Lauge-Hansen for the mechanism.
Normative values
Reference values from published cohorts, for comparison against the score you calculated.
| Population | Age | Mean | SD |
|---|---|---|---|
| Rotational ankle fractures | — | Supination–external rotation is the dominant pattern; supination–adduction is the least common | — |
When to use the Lauge-Hansen
Well suited to
- Working out which structures to examine and image after a rotational ankle fracture — the mechanism tells you where the unseen injury is likely to be.
- Recognising the pronation–external rotation pattern, in which the fibular fracture may lie at the neck of the fibula and be missed on ankle films entirely.
- Planning the reduction: knowing the direction of the deforming force tells you which reduction manoeuvre reverses it.
- Research and teaching, where the mechanistic sequence is the most instructive description of ankle fracture anatomy.
Limitations and poor fits
- As a stand-alone determinant of stability — the stage is a description of structures injured, and a weight-bearing or gravity stress radiograph is what actually establishes whether the talus shifts.
- For pilon fractures, which are axial-load injuries of the plafond and are not produced by the mechanisms this system describes.
- In children, where the physis dictates the pattern and the Salter-Harris system applies.
- When a quick, reproducible descriptor is all that is needed — Danis-Weber is more reliable between observers.
Lauge-Hansen compared with other instruments
Instruments measuring a related construct, with the practical difference between them.
| Instrument | Items | Range | What it adds |
|---|---|---|---|
| Weber | 3 | 1–3 | The Danis-Weber classification sorts ankle fractures into three types by the level of the fibular fracture relative to the tibiotalar joint line — type A below the syndesmosis, type B at it, and type C above it — because the height of the fibular fracture predicts how much of the syndesmosis is torn. |
| AO/OTA | 3 | 1–3 | The AO/OTA classification gives every fracture an alphanumeric code in which the first digit is the bone, the second the segment and the letter the fracture type — extra-articular, partial articular or complete articular in an end segment, and simple, wedge or multifragmentary in a shaft — so that 32-A is a simple femoral shaft fracture and 43-C a complete articular pilon fracture. |
| Ottawa Ankle Rules | 7 | 0–1 | The Ottawa Ankle Rules determine whether an acute ankle or midfoot injury requires radiographs, based on bone tenderness at four specific sites and the ability to bear weight for four steps; they are approximately 98% sensitive for clinically significant fractures. |
Copyright and permitted use
Published openly because it is the question every clinician and researcher asks before using an instrument, and almost nobody answers it.
A published mechanistic fracture classification derived from cadaveric experiment. No licence is required to describe or apply it.
References
- Lauge-Hansen N. Fractures of the ankle. II. Combined experimental-surgical and experimental-roentgenologic investigations. Archives of Surgery. 1950.
- Michelson JD, Solocoff D, Waldman B, Kendell K, Ahn U. Ankle fractures. The Lauge-Hansen classification revisited. Clinical Orthopaedics and Related Research. 1997.
- Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG. The ability of the Lauge-Hansen classification to predict ligament injury and mechanism in ankle fractures: an MRI study. Journal of Orthopaedic Trauma. 2006.
- Haraguchi N, Armiger RS. A new interpretation of the mechanism of ankle fracture. Journal of Bone and Joint Surgery (American). 2009.
Editorial status
This page has not yet been signed off by a named clinical reviewer. The scoring logic is stated in full above so it can be independently verified, and every threshold is traceable to its source. See our editorial methodology.