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.
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, as shown.
If x-rays are not available, this is the only alignment reference available.
Patterns of fracture morphology
In suprasyndesmotic fractures associated with fracture of the medial malleolus, a shoulder (or beak) on the tibia usually remains, which will tend to prevent medial over-reduction.
In cases with a deltoid ligament rupture, there is a substantial medial buttress against which the talus can be reduced.
Reduction of fracture with a medial shoulder present
Any anteroposterior (AP) displacement is corrected.
Hold the hindfoot firmly and pull both distally and forwards to correct any posterior displacement.
At the same time, any external rotation displacement is reduced.
Avoid pushing the forefoot into dorsiflexion, as this may displace the talus posteriorly in the mortise, if secondary posterior displacement had occurred.
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 counter pressure 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 a medial shoulder
In some suprasyndesmotic fractures, the medial malleolar fracture is flush with, or above, the joint level, and no medial shoulder remains, against which to reduce the talus.
The surgeon must therefore guard against medial over-reduction.
Without a medial shoulder, there is a risk of overcorrection of the ankle medially, although the reduced distal fibula will tend to minimize this possibility. In such cases, the AP displacement is corrected, and the foot then orientated in alignment with the lower leg, avoiding any undue medial pressure, and correcting any malrotation.