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This description of nonoperative treatment considers all malleolar injuries.


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Preliminary remarks

Nonoperative treatment of ankle fractures is usually only indicated for undisplaced, 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 can 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.


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If severe swelling is present, the provisionally reduced ankle fracture should be immobilized temporarily with a plaster of Paris (POP) back-slab, and elevated on several pillows.


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If the injury is of the rotational type, and unstable, an above-knee back-slab will be more comfortable.


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Anesthesia

In the absence of the facility for general anesthesia, reduction can be achieved under sedation (e.g., Pethidine plus Diazepam), and/or intraarticular local anaesthesia (Lignocaine 2% 15ml).

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.


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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.


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Typical displacement in ankle fractures

The stated mechanism of injury, the history and the clinical appearance of the foot and ankle offer hints to the clinical diagnosis.


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The typical displacement in most ankle fractures is posterior and lateral, usually with the foot externally rotated (transsyndesmotic and suprasyndesmotic injuries). In the infrasyndesmotic fractures, the displacement is medial.
Careful review of the x-ray images is essential for a full understanding of the mechanism of 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 place the foot in 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.