Nonoperative treatment of 44B 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 may 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.
The typical mechanism of injury in transsyndesmotic fractures is external rotation of the talus in the ankle mortise with the foot in supination (Lauge-Hansen supination external rotation injury), producing first a transsyndesmotic, oblique fibular fracture from distal anterior to proximal posterior. The talus then dislocates posteriorly, sometimes producing a posterior tibial fracture (Volkmann’s fragment). Finally, the medial side fails (either a deltoid rupture or a medial malleolar fracture).
Less commonly these fractures are cause by an abduction force (Lauge-Hansen abduction injury). The fracture of the lateral malleolus may be transverse or complex with some buckling of the lateral cortex.
The typical clinical displacement in transsyndesmotic fractures is posterior and lateral, usually with the foot lying externally rotated.
Careful review of the x-ray images is essential for a full understanding of the injury.
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 get place the foot into correct alignment with the leg.
If x-rays are not available, it is safer to correct the deformity clinically, rather than to leave it unreduced.