R. S. PHILLIPS - Postgraduate Medical...

Postgrad. med. J. (March 1968) 44, 199-211.

A plea for simplicity in the classificationof anide fractures

R. S. PHILLIPSF.R.C.S.E.

Consultant Orthopaedic Surgeon, North Manchester Group of Hospitals,Department of Orthopaedics, Crumpsall Hospital, Manchester 8

C. J. E. MONKM.Ch.(Orth.), F.R.C.S.

Senior Registrar, Department of Orthopaedics,Royal Southern Hospital, Liverpool 8

Summary1. Ashurst and Bromer's classification of ankle

fractures is a useful one, but falls into the com-plexities of subdivision into sequential progres-sion of severity, i.e. 'degrees' of fracture.

2. A similar criticism can be made of theLauge-Hansen classification which has an addedsemantic disadvantage. Doubts are also cast uponthe validity of the direct application of experi-mental results in cadaveric specimens to a clini-cal series.

3. A third classification, essentially a modifiedform of those preceding it but with both ananatomical and a functional basis is presented, inthe belief that it can provide evidence of: (a) themechanism of production and hence the achieve-ment of reduction; and (b) the recognition ofsignificant ligamentous damage, i.e. the recogni-tion of major from minor, stable from unstableinjuries-when used in association with radio-graphs taken while straining the ankle underanaesthesia.

4. An Appendix to the paper (pp. 210-211), giv-ing a more detailed account of our revised classifi-cation, is included.

IntroductionThe classification of a group of fractures can

be scrupulous in its anatomical detail, but unlessit has practical significance it degenerates into apedantic exercise. When a group of diseases orinjuries displays certain common features, to seekout the differences that exist in aetiology, clinicalpresentation and pathology is useful in formulat-ing sensible plans of management. Rose (1962)pointed out that systematic classification is a

G. A. BALMERF.R.C.S.E.

Senior Registrar, University Department ofOrthopaedics, Manchester Royal Infirmary,

Oxford Road, Manchester 13

logical process of collecting under a commonname a number of objects which are alike inone or more respects. But the importance ofsuch associations lies less in the features com-mon to the group, but more in the persistent,but usually less obvious, differences that exist.

Requirements of classificationsAnkle fractures constitute a complex group of

injuries. Any fracture involving a joint may becomplicated by secondary osteoarthritis. Treat-ment must be aimed at the restoration of normalfunction by reconstituting congruity of articularsurfaces. Most fractures are diagnosed clinically,but the characteristics of the fracture are seenon radiographs. Recognition of broken bones canbe easy, but the associated ligamentous damagethat may exist is recognized with difficulty-ornot at all, unless one presupposes a knowledgeof the mechanism of the injury, i.e. recognitionof the force producing it. Hence, a rational classi-fication of fractures and fracture dislocations atthe ankle should be based on the predominantforce acting on the ankle at the moment ofinjury, for only in this way can the route ofdisplacement be retraced to achieve reduction.Ankle fractures are common and a busy casu-

alty department will deal with a large numberin a short period of time. The bulk of these aredealt with by junior staff who, at an early stagein their professional career, must use their judg-ment in recognizing fracture types. In so doingthey assume the responsibility of deciding whichinjury is of minor and which is of major signi-ficance (and associated with important morbidity)of differentiating the stable from the unstableinjury and of electing to follow a course of treat-

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R. S. Phillips, C. J. E. Monk and G. A. Balmer

ment which, by its planned orderliness, resultsin the functional restoration of the part. Thisimplies that they have an understanding of bio-mechanics and a wealth of clinical experienceor, alternatively, that they can pick out certainsalient features on a radiograph which will fitinto an easily recognizable and understandablepattern.A classification of ankle fractures should be

simple and immediately applicable to any indi-vidual problem. It should be based on informa-tion obtained from the patient's history andclinical and radiological examinations, i.e.founded on observed clinical data. In the limi-ted dissections of open operations some corro-borative evidence justifying the classification maybe found. Mechanical experiments in cadavericlimbs can provide a wealth of information onthe pathogenesis of such fractures. This idealclassification should be a clinical one. However,it is well known that 'the history of injury is oftendisappointing' (Rose, 1962). The confusion of theaccident and the disquieting effect of pain makeit unlikely that the patient will have a clear re-collection of the position of his foot or the direc-tion of the causative force at the time of injury.Certainly physical examination may reveal speci-fic areas of bruising or tenderness overlying frac-tured bony processes or damaged ligaments. De-formity of foot and ankle may be a helpfulclue, but in fact has little bearing on the fullextent of displacement at the time of injury.Radiographs provide considerable information ifthey are of good quality and taken in at leasttwo different planes. Oblique views and, parti-cularly, views while straining the ankle underanaesthesia are a valuable aid.The experimental production of fractures in

cadaveric limbs is essential for confirmation, butthe facts obtained must be interpreted with cau-tion and applied judiciously to a clinical classi-fication. The wearing of footwear, the protectivecontraction of muscle at the time of injury andthe influence of transmission of body weight arefeatures which cannot be fully considered inlaboratory experiments, yet are acting signific-antly at the moment of fracture in clinicalpractice.

Importantly, any classification which is basedon the recognition of forces producing a frac-ture stands or falls (other things being equal)upon the functional and anatomical results oflogically applied treatment.

Historical aspectsAstley Cooper (1822) used a simple classifi-

cation based on observation. Patterns of frac-

ture were recognized according to the displace-ment of the proximal fragment, i.e. the distaltibia. While failing to take into account the com-plexities of the fracture and associated ligamen-tous rupture, it did provide the clue to reduction.The trend in experimental production of ankle

fractures in cadaveric limbs was set by Maison-neuve (1840), Bonnet (1845), Tillaux (1872) andRochet (1890). These men described specific frac-ture types or associated ligamentous damage byapplying controlled forces in certain planes. Ofnecessity, in the absence of radiographs, suchexperiments were valuable, but interpretationswere somewhat speculative when applied to clini-cal series. Honigschmied (1877) listed his resultsof cadaveric studies, but in so doing produced asomewhat academic classification.

Destot (1911), Quenu (1912a, b) and Quenu &Mathieu (1912) returned to a more obviouslyclinical basis for their interpretation of anklefractures. Tanton (1916), combining the views ofthese latter two, recognized: (a) fractures of themalleoli-isolated or associated, and (b) frac-tures of the tibial pestle (lower end of the tibialshaft)-isolated, associated or complete. This, atleast, was a division according to observed radio-graphic and anatomical fact, but it paid no heedto the mechanism of production.Two authors whose work is essential for an

understanding of fractures of the ankle areAshurst and Lauge-Hansen. The former (Ashurst& Bromer, 1922) undertook a critical analysisof 300 fractures, so formulating a comprehen-sive classification based on the principal deform-ing force producing the fracture complex. Reli-ance was placed on the experimental evidenceof previous authors, but only in a confirmatoryway. If one excludes those fractures grouped asdue to direct violence, then ankle injuries arecaused by external rotation, abduction, adduc-tion and vertical compression. Each group wassubdivided into first, second and third degrees,depending on certain recognizable clinical andradiographic features. This numerical index ofseverity implied a sequential prolongation of thedeforming force in either time-duration or mag-nitude or both, which, on the evidence, did notseem justified.Lauge-Hansen (1948, 1950, 1952, 1953) pro-

duced, experimentally, a sequential group of frac-tures and fracture dislocations determined notonly by the deforming force applied, but alsoby the position in which the foot was placed atthe time during which the deforming force wasacting. This 'genetic' classification, he claimed,allowed 'genetic' reduction. Realizing the short-comings of such experimental results, he related

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Classification of anklefractures

them to a group of clinical injuries and foundcomplete accord.One drawback to the understanding of Lauge-

Hansen's work is his use of words which can bemisunderstood and, therefore, are ill-used. Heused the terms 'pronation' and 'supination' inreference to movements of the foot when, in fact,these are specifically defined in standard worksof anatomy (Cunningham, 1964) as rotatorymovements of the radius and ulna at the sup-erior and inferior radioulnar joints-a state ofaffairs not comparable to that existing in legand foot. This may seem pedantic, but to explainthese terms to students and surgeons in trainingin reference to the foot makes confusion moreconfused.The position of the foot and ankle at the time

of experimentally produced fracture is easily de-termined, but this cannot be directly applied toa clinical series where the factors of footwear,muscle contraction and transmission of bodyweight are playing a part.

Despite these criticisms the classifications ofLauge-Hansen and Ashurst are well founded andhave meaning in clinical orthopaedics. Both take

into account the mechanism of injury, both dif-ferentiate minor fractures from those of greaterfunctional significance and both consider the de-tection of ligamentous rupture (i.e. possible ankleinstability). However, can they be simplified forthe understanding of those who must use them?

Object of present studyThis present study was undertaken to deter-

mine the possibility of readily recognizing fromthese classifications, suitably modified, that: (a)certain patterns of fracture are produced byspecific deforming forces; (b) certain fracturesare associated with significant ligamentous in-juries, and (c) that features of the X-ray providethe clue to ankle instability.

MethodIn order to analyse critically the merits of

methods of classification of ankle fractures, alarge series of such fractures has been studiedclinically and radiologically. This series has beenclassified in three ways. The ease with which anyone method can be applied to this fracture serieswill be shown, but, more importantly, the signi-

TABLE 1Lauge-Hansen classification

Classification

A. Supination-eversionStage I: Tear of anterior inferior tibio-fibular ligamentStage 2: Oblique spiral fracture distal fibula |Stage 3: As above + posterior margin of tibiaStage 4: As above + fracture of medial malleolus at its base - or detach-

ment of deltoid ligament(variant-oblique spiral fracture of distal tibia)

B. Supination-adductionStage 1: Transverse fracture of lateral malleolus (or avulsion of lateral

ligament of ankle)Stage 2: As above + vertical fracture of medial malleolus

C. Pronation-abductionStage 1: Horizontal fracture near the base of the medial malleolus(Stage 2: Avulsion of anterior and posterior inferior tibio-fibular ligaments

often with a bony shell)Stage 3: An oblique or transverse fracture of fibula 0 5-1 cm above the

distal articular surface of tibiaD. Pronation-eversion(Stage 1: As for Stage 1 pronation-abduction)Stage 2: Disruption of interosseous ligament complexStage 3: A spiral fracture of fibula more than 8-9 cm above the tip of

the malleolusStage 4: Detachment of posterior margin of tibia

E. Pronation-dorsiflexionF. Direct violenceG. MaisonneuveTotal

No. offractures

601630

44

11

23

3

5

672

209

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TABLE 2

Ashurst and Bromer classification

Classification

A. Fractures by lateral rotationFirst degree: Lower end of fibula only (mixed oblique)Second degree: As above + rupture of medial ligament or fracture of}

the medial malleolusviz:

(a) Medial ligament uncomplicatedMedial ligament complicated by posterior marginal fragment of tibia

(b) Medial malleolus uncomplicatedMedial malleolus complicated by posterior marginal fragment oftibia

Third degree: Same plus fracture of whole lower end of tibiaB. Fractures by adduction

First degree: Transverse fracture of lateral malleolusSecond degree: Same plus fracture of medial malleolus

(a) Below level of tibial articular surface(b) Median surface of tibia upwards and medially from joint surface

C. Fractures by abductionFirst degree: Medial malleolus onlySecond degree: Same plus fracture of fibula

(a) Below inferior tibio-fibular joint(b) Above inferior tibio-fibular joint (with diastasis)

Third degree: Same plus whole lower end of tibia (supramalleolar)D. Vertical compressionE. Direct violenceF. MaisonneuveTotal

No. offractures

60

105

2011

44

56

22

131372

209

ficant exceptions to each will be stressed andillustrated.Lauge-Hansen's classification has been claimed

by many as the answer to the understanding ofankle fractures. His classification is reproducedin Table 1. Our series of 209 ankle fractures hasbeen analysed accordingly. The classification ofAshurst & Bromer (1922) is reproduced in Table2 and again our series has been analysed in ac-cordance with this.One of us (Monk, 1966) has repeated Lauge-

Hansen's work on the experimental productionof ankle fractures. It was not found possible toendorse completely all Lauge-Hansen's conclu-sions. This was particularly true of the 'supina-tion-eversion' (lateral rotation)* injury, where itwas found that the sequence of events he des-cribed could not be reproduced. Lauge-Hansenfurther stated that if the foot is held in 'pro-nation' while a lateral rotation force is applied(after preliminary fracture of the medial malle-olus) a fracture occurred in the lower third of

* The term 'eversion' as used by Lauge-Hansen is inter-preted as meaning 'lateral rotation'.

the fibula above the inferior tibio-fibular joint.Attempts to reproduce this were unsuccessful.The clinical examples of fibular fractures at thislevel were found to have associated completeseparation of the inferior tibio-fibular joint. Fur-ther experimental studies may be justified, but itmay be more convenient, and indeed more ac-curate, to regard the pronation-eversion (lateralrotation) injury simply as a variant of the pro-nation-abduction group.As a result of experimental work one of us

(Monk, 1966) has formulated a classificationwhich is in two parts; the first is a division intothe number of bones fractured and the secondan assessment of the mechanism involved, butcarrying with it the implication of ligamentousdamage not visible radiographically. This classi-fication is reproduced in Table 3 and again ourseries of 209 fractures analysed accordingly.

In all three methods of classification fracturesdue to vertical compression (the pronation-dorsi-flexion group of Lauge-Hansen) are readily re-cognized and are excluded from further discus-sion-Fig. 1. This is also true of two fracturesproduced by direct violence. The rare fracture

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203Classification of ankle fractures

TABLE 3Proposed simplified classification (Monk, 1966)

Classification

1. Lateral malleolar fracturesA. Abduction type

Distal to syndesmosisProximal to syndesmosis

B. Adduction typeC. Lateral rotation type

2. Medial malleolar fracturesA. Abduction typeB. Adduction type

3. Bimalleolar fracturesA. Abduction type


B. Adduction typeC. Lateral rotation type

4. Lateral malleolar and posterior tibial marginal fracturesA. Lateral rotation type

5. 'Trimalleolar' fracturesA. Abduction type


B. Lateral rotation type6. Vertical compression fractures7. Maisonneuve fractures8. Direct violence fracturesTotal

No. offractures

03

4472

231

1019

5

03

11712

209

FIG. 1. This vertical compression fracture is characterized by the large triangularfragment from the anterior aspect of the distal tibia. A common feature also visiblehere is comminution of the tibial articular surface.



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described by Maisonneuve (1840), although pro-duced by lateral rotation, has been segregated(Fig. 2).

FIG. 2. In this Maisonneuve fracture the fibula isfractured at its neck. The lateral rotation strain producestypically an oblique fracture line directed upwards andlaterally.

Lateral rotationIn the group of injuries produced by lateral

rotation the characteristic feature is the obliqueor spiral fracture of the fibula (Fig. 3). BothLauge-Hansen and Ashurst recognized this as thefirst stage of this fracture complex (although pre-ceded by rupture of the anterior inferior tibio-fibular ligament). In the third classification(Monk, 1966) an additional twelve fractures areincluded in the group of lateral malleolar frac-tures caused by lateral rotation. These twelveare unstable injuries because of the co-existenceof a ruptured medial ligament (Fig. 4)-a featureof importance which, in less obvious examples,can be missed by the inexperienced. The impli-cation is that unimalleolar fractures are not, ofnecessity, basically stable. Both Lauge-Hansenand Ashurst consider associated rupture of themedial ligament as a continuation of the lateralrotation force, making provision for this, includ-

ing it together with that group in which there isa fracture at the base of the medial malleolus.Rightly, this latter falls into our bi-malleolarlateral-rotation series.When there is an associated posterior marginal

fragment of the tibia (so-called 'third malleolus')there is little discrepancy between Lauge-Hansenand Ashurst, other than to state that there is areversal in sequence of production, i.e. Lauge-Hansen believes that the posterior marginal frag-ment is produced before the medial malleolusfractures or the medial ligament ruptures. Thatthis is not always so is shown in Fig. 5. But inour classification one can avoid the rather irrele-vant argument of sequential production of thisfracture-ligament complex by regarding it as aseparate entity. An associated rupture of themedial ligament, determined by taking strainedviews, causes this lesion to assume the func-tional significance of a 'tri-malleolar' fracture.Only one fracture could be grouped in theAshurst third-degree external rotation type, i.e.where fracture of the distal tibia represents themedial malleolus and posterior marginal frag-ment. Likewise, it is easily recognized in theLauge-Hansen method and falls into our bi-malleolar lateral rotation group.

AdductionBetween Ashurst's adduction group and Lauge-

Hansen's supination-adduction group there is nodifference of note. In our classification the onlydifference is that one fracture was placed amongthe medial malleolus group, implying an intactlateral malleolus, but with rupture of the lateralligament of the ankle-a point of functional im-portance to be discussed in a later communica-tion. Fig. 6 illustrates a typical adductionfracture.

AbductionFractures produced by abduction provoke the

most serious disagreement among the classifica-tions. Although Lauge-Hansen recognizes that thefirst stage of pronation-abduction and prona-tion-eversion (lateral rotation) is a horizontalfracture near the base of the medial malleolus(Fig. 7), he reckons that each force, continuingto act, produces its own specific fracture-liga-ment rupture complex. It has already been statedthat this has not been confirmed experimentally.If, in fact, Lauge-Hansen's pronation-abductionand pronation-eversion (lateral rotation) seriesare grouped together, then they differ little fromAshurst's abduction group, although the latterdoes emphasize that in abduction injuries thefracture of the fibula may be distal to the in-ferior tibio-fibular joint, or proximal to it with

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205

FIG. 3. A lateral rotation fracture in which the characteristic feature is a fracture linein the distal fibula, either oblique or spiral, directed upwards and backwards butcommencing at the level of the distal tibial articular surface. This is seen most clearlyon the lateral view.

FIG. 4. In this lateral rotation injury the typical oblique fracture of the fibula is notedand is displaced. On the antero-posterior view the talus (with the lateral malleolus) isdisplaced laterally but the proximal fibular fragment maintains a normal relationshipto the tibia, i.e. there is not complete disruption of the inferior tibio-fibular syndes-mosis. With an intact medial malleolus such displacement is occurring because ofcomplete rupture of the medial (deltoid) ligament.



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206 M

FIG. 5. In this lateral rotation injury the typical oblique fracture of the fibula isnoted. The fracture of the medial malleolus is transverse in the antero-posterior planeand is just distal to the joint level. Note that the posterior tibial margin is intact.

;s~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~...

FIG. 6. In this typical adduction fracture of the ankle the fibular malleolus isfractured distal to the joint level and almost transversely, The fracture of the medialmalleolus is almost vertical and involves the 'tibial' as opposed to the medial malleolararticular surface.



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207

FIG. 7. In this abduction fracture the fibular malleolus is intact. The medial malleolusis fractured just proximal to the joint level. The fracture line is nearly horizontal.

FIG. 8. This is a typical abduction fracture in which the fibular shaft is fractured trans-versely. The talus and the distal half of the fibula are displaced laterally so that thenormal relationship of fibula to tibia is lost. This signifies complete disruption ofthe inferior tibio-fibular syndesmosis (classical diastasis). The nearly horizontal fractureof the medial malleolus is also seen. The posterior tibial margin is intact.

B



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FIG. 9. This abduction fracture may be grouped in the Lauge-Hansen pronation-eversion (lateral rotation) group, but the obliquity of the fibular fracture is not typicalof a lateral rotation injury. Again the normal relationship of the fibula to the tibia atthe inferior tibio-fibular joint is lost because of disruption of the syndesmosis (classicaldiastasis). The horizontal fracture of the medial malleolus is noted.

consequent disruption of this joint and completeseparation of the tibia from the fibula (i.e. classi-cal diastasis). This has serious functional impli-cations. It must, however, be said that in thisfracture complex there can be included a frac-ture of the posterior tibial margin, but this maybe of little practical significance. On the otherhand, in our classification the anatomical natureof the abduction fracture is stressed by divisioninto uni-, bi- and 'tri-malleolar' types, but likeAshurst, a consideration of the possibility ofcomplete disruption of the inferior tibio-fibularjoint leads us to retain the subdivision of thisgroup according to the level of the fibular frac-ture-an anatomical feature of considerable fun-tional importance. Lauge-Hansen pays directattention to rupture of the medial ligament ratherthan fracture of the medial malleolus as theearliest stage of this mechanism of injury. Twocharacteristic abduction fractures are illustrated(Figs. 8 and 9).

DiscussionIt must be repeated that any classification of

ankle fractures should provide information re-garding the nature of the fracture and its asso-ciated ligamentous damage, so permitting alogical plan of management. A classification fall-ing short of this ideal can be supplemented byinformation obtained from radiographs of theankle, strained under anaesthesia. This will oftendemonstrate significant ligamentous rupture andconfirm the mechanism of production of thetotal ankle injury.Our classification, if only founded on an ana-

tomical basis, would over-simplify the ankleinjury, and this is particularly true of the lateralrotation, lateral malleolus group. However, thereis the second, more important, consideration ofthe direction of the force producing the injury,i.e. abduction, adduction, etc., which by the ana-tomical details noted at X-ray give the indica-tion for supplementary strain views under anaes-thesia. This classification immediately brings tothe surgeon's notice the possible ligamentousinjuries that co-exist with radiologically visiblefractures whose characteristics point to the direc-tion of the force producing them. Indeed, this

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Classification of anklefractures 209

classification would allow us to answer in theaffirmative the questions already posed, i.e.:

(a) That patterns of fracture seen on X-raycan be related directly to the force producingthem;

(b) That certain fractures are associated withimportant ligamentous injuries, whose existencecan be implied from the radiological picture(although strain views under anaesthesis may wellbe necessary); and

(c) When these ligamentous ruptures are re-cognized or when fractures co-exist both onmedial and lateral sides of the ankle, instabilitycan be said to be present.Lauge-Hansen's and Ashurst's classifications

can equally provide answers to the questionsposed. That this is so is due to the fact thatthere is very little difference between them. Ifone admits that the pronation-abduction andpronation-eversion (lateral rotation) subdivisionsare simply variations on an abduction theme andif one drops the somewhat unnecessary wordreferring to the position of the foot at the timeof injury, viz. pronation or supination, then thesetwo classifications are very similar indeed.Both classifications, but particularly that of

Ashurst & Bromer (1922), by attempting to implyan ordered progression of events consequentupon injury add to the complexity of the methodwithout necessarily adding to its comprehension.This is the danger and, perhaps, the fallacy ofequating directly experimental evidence to clini-cal problems. It would, however, be foolish tobelittle the classifications of Lauge-Hansen andAshurst & Bromer, but it would seem wise toadhere to the simpler, more readily understoodsystem outlined in Table 3. Indeed this simplified,though admittedly not original, classification isgiven in a more detailed and explicit form inthe 'Appendix' to this paper (pp. 210-211).

AcknowledgmentsOur thanks are due to Mr D. LI. Griffiths and Professor

R. Roaf for their encouragement and help in the compilation

of this paper. We record our gratitude to Mrs V. Thorntonand Mrs M. Bevens for their secretarial help. The illustra-tions have been produced for us by Dr R. Ollerenshaw,Department of Medical Illustration, Manchester RoyalInfirmary.

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MONK, C.J.E. (1966) The mechanism of ankle fractures.M.Ch.(Orth.) thesis, Liverpool.

QUENu, E. (1912a) E-tude critique sur les fractures du cou-de-pied. I. Rev. Chir. (Paris), 45, 211.

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ROCHET (1890) Du m6canisme des luxations doubles de1'Astragale. Rev. Orthop. 1, 269, 401.

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TANTON, J. (1916) Fractures du membre inferior. NouveauTraite de Chirurgie. Bailliere, Paris.

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R. S. PHILLIPS - Postgraduate Medical...

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