Nonoperative treatment of infrasyndesmotic ankle injuries is usually only indicated for minimally displaced, stable fractures. However, if the facilities and the skill for safe operative treatment are not available, nonoperative treatment is safer, and if performed correctly and skillfully, it can lead to acceptable results.
In any situation, a displaced ankle fracture should be reduced as soon as possible, even if surgery is planned for the near future as this decreases pain and swelling.
If severe swelling is present, the reduced ankle fracture should be immobilized temporarily with a plaster of Paris (POP) back-slab, and elevated on several pillows.
In the absence of the facility for general anesthesia, reduction can be achieved under sedation (e.g., Pethidine plus Diazepam), and/or intraarticular local anesthesia (Lignocaine 2% 15ml).
The intraarticular injection of local anesthetic is introduced anteromedially, between the tendons of tibialis anterior and extensor hallucis longus, medial to the anterior tibial neurovascular bundle.
Infrasyndesmotic fractures are caused by adduction of the talus in the ankle mortise (Lauge-Hansen adduction injury), resulting in lateral traction and medial compressive forces. The typical displacement is medial shift and varus angulation.
If x-rays are not available, it is safer to correct the deformity clinically, rather than to leave it unreduced.
Regard the injury as a two-part fracture between the lower leg (tibia and fibula) proximally, and the foot distally. The task will be to place the foot in correct alignment with the leg.