In multifragmentary fractures, care must be taken to avoid excessive stripping of the periosteum as well as devascularization of the fragments.
Indirect reduction may be obtained by longitudinal traction, either on the foot, or of the main distal fragment using a bone hook.
In a transsyndesmotic fracture, if the distal fragment is large enough, insert one or two K-wires to hold the reduction.
Rotation and anatomical position are difficult to determine. All methods of visualization of the distal tibiofibular joint such as image intensification, and palpation with a finger can be used. It is useful to have a comparative x-ray of the other, uninjured ankle as a template.