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.
Hold the heel of the injured foot with the forefoot pointing upwards as shown and lift the externally rotated leg. In this procedure the weight of the leg will, in many cases, reduce the posterior and the lateral displacement automatically. If the mechanism of injury was external rotation of the foot relative to the leg, internally rotating the foot relative to the leg should reduce the fracture. Further pressure against lateral malleolus is usually unnecessary.
If the mechanism of injury was abduction, adducting the foot should reduce the fracture.
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
In some transsyndesmotic fractures there will be a medial shoulder.
Either the fracture of the medial malleolus has left a shoulder (or beak) on the tibia...
..., or the medial failure is a deltoid ligament rupture.
In some patterns of transyndesmotic fractures the medial malleolar fracture is flush with, or above, the joint level, and no medial shoulder remains against which to reduce the talus.
In these injuries, there is rarely a lateral (fibular) shoulder.
Reduction of fracture with a medial shoulder present
Firstly, the posterior displacement is corrected.
A plantigrade position of the foot is important, but needs to be achieved by manipulation of the hindfoot downwards, forwards and correcting any external rotation, rather than pushing upwards on the forefoot.
Avoid pushing the forefoot into dorsiflexion, as this tends to displace the talus posteriorly in the mortise. This is especially important when the fracture complex includes a posterior tibial marginal fracture (Volkmann’s fragment).
After the AP correction, the talus can be pressed against the medial shoulder, if present, by pushing the mid - and hindfoot (heel) from lateral to medial against the counterpressure of the other hand on the lower end of the tibia as shown. At the same time any external rotation deformity is corrected.
By exploiting the resistance of the medial shoulder, over-reduction should be avoided.
Reduction of fracture without medial or lateral shoulder
There is a danger of overcorrection of the ankle medially, although the reduced distal fibula will tend to minimize this risk. In such cases, the AP displacement is corrected, and the foot orientated in alignment with the lower leg, avoiding any undue medial pressure, and correcting any malrotation.