Ankle fractures are among the most frequently encountered injuries in orthopedic and trauma surgery, accounting for approximately 9 %–18 % of all lower limb fractures. They are particularly prevalent among younger patients engaging in sports activities and among elderly patients susceptible to low-energy trauma such as simple falls [1,2]. Their incidence has been steadily rising in recent decades, paralleling increased participation in high-risk activities and population aging [3].

The upper ankle joint is anatomically complex, formed by the distal tibia and fibula articulating with the talus. This articulation is stabilized by collateral ligaments and the distal tibiofibular syndesmosis, which plays a key role in maintaining congruity of the ankle mortise [4].

Ankle fractures are traditionally classified using the Weber system—based on the level of the fibular fracture relative to the syndesmosis—and the Lauge-Hansen classification, which considers the mechanism of injury [5]. Fracture morphology may also be described by the number of malleoli involved (uni-, bi-, or trimalleolar), with trimalleolar fractures usually representing more complex and unstable injuries [6]. The syndesmosis, comprising the anterior and posterior inferior tibiofibular ligaments, interosseous ligament, and transverse tibiofibular ligament, is critical for ankle stability during weight-bearing and rotational movements [7].

Among the less commonly recognized but clinically significant injuries are avulsion fractures of the anterior inferior tibiofibular ligament (AITFL), historically described as Wagstaffe-Le Fort fractures. First reported by Wagstaffe (1875) and Le Fort (1886), these lesions result from traction forces at the fibular insertion of the AITFL during external rotation injuries [8]. They are considered the fibular counterpart of the Tillaux-Chaput fracture at the tibial insertion [9]. The presence of an AITFL avulsion fracture is an important radiographic sign of potential syndesmotic injury, often coexisting with complex ankle fracture patterns.

Despite being biomechanically well understood, AITFL avulsion fractures remain under-reported. Available studies are usually limited to small cohorts with heterogeneous definitions [10,11]. Reported prevalence varies widely, from <1 % to >20 %, reflecting differences in diagnostic methods and patient populations [12,13]. Detection on radiographs can be difficult due to the small size of fragments, anatomical overlap, or poor image quality, especially in commuted injuries [14].

Identification of these fractures is clinically relevant. They may serve as indirect markers of syndesmotic disruption and, in selected cases, the fragment itself may require fixation if large enough to interfere with joint mechanics or prevent anatomical reduction [15]. Some authors have suggested that fragments larger than 5 mm may benefit from direct fixation using screws or mini-plates to restore ligamentous tension and stability [16,17]. However, no universally accepted guidelines exists, and the decision remains highly individualized.

The correlation between AITFL avulsion fractures and specific injury mechanisms also remains debated. Some studies describe a strong association with supination-external rotation (SER) and Weber B fractures, while others report occurrences in pronation-external rotation (PER) and Weber C patterns [18]. This lack of consensus likely reflects limited sample sizes and methodological differences.

Given these uncertainties, there is a need for robust data regarding the prevalence, classification, and clinical implications of AITFL avulsion fractures. In particular, a better understanding of fragment size and its correlation with standard fracture classifications may help guide surgical decision-making.

The present study addresses these gaps by analyzing a large retrospective cohort of patients with ankle fractures. The objectives are: (1) to determine the prevalence of AITFL avulsion fractures, (2) to classify their morphology and correlate with Weber and Lauge-Hansen systems, and (3) to assess fragment size as a potential factor indicating the need for surgical fixation. We hypothesize that AITFL avulsion fractures are under-recognized in clinical practice and that specific fracture mechanisms, particularly SER/Weber B and PER/Weber C, are more strongly associated with their occurrence.