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.
In a suprasyndesmotic fracture, once the lateral malleolus is reduced in its anatomic position, it may be helpful to insert a K-wire, 30 degrees from dorsal, 2-3 cm supramalleolar.
Reduction with the plate
Alternatively, the plate can be used for gaining length after fixing it to the distal fibular fragment (see step 4).
For this purpose, insert a screw into the fibula proximal to the plate and distract the fracture to the correct length with a laminar spreader. When tension on the plate can be felt, secure the plate to the fibula with pointed reduction forceps applied through a hole in the plate.
Check rotation and the position in the incisura fibularis before fixing the plate to the proximal fibula.