Treatment of patients presenting early
The aim of any reduction (early or late) is to correct the displacement.
Treat the patient as soon as possible, when the deformity is typical, late swelling has not yet appeared and adequate anesthesia can be administered.
Use gravity to help to reduce the fracture.
The patient lies supine on the table, with the lower leg hanging over the end of the table.
The reduction procedure involves holding the heel with the leg internally rotated, so that gravity tends to relocate the foot in a lateral direction.
Detailed reduction will be considered later.
Treatment of patients presenting late
If the patient presents late and there is no possibility to administer general anesthesia, so that the patient is not fully relaxed, but merely sedated, or has only local intraarticular analgesia, reduction will not be achieved by gravity alone.
Manual reduction is performed on the hanging leg, with the knee flexed to reduce the pull of the Achilles tendon.
The aim is to bring the foot into correct alignment with the lower leg.
If x-rays are not available, this is the only alignment reference available.
Patterns of fracture morphology
The medial malleolus has been pushed off by the adducting talus. The traction fracture of the lateral malleolus often leaves a lateral fibular shoulder.
If the lateral traction injury is purely ligamentous, or an osseo-ligamentous failure with fracture of the tip of the lateral malleolus, the lateral buttress is substantial.
Any anteroposterior (AP) displacement is corrected.
Hold the hindfoot firmly and gently pull both distally and forwards to correct any posterior displacement.
The heel then needs to be pressed upwards and laterally, buttressing the talus against the shoulder of the lateral malleolus.