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Treatment of patients presenting early

The aim of any reduction (early or late) is to correct the displacements.

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.

For laterally displaced and externally rotated injuries (trans- and suprasyndesmotic injuries), hold the heel of the injured foot as shown and lift the externally rotated leg. In this procedure the weight of the leg will, in most cases, reduce the posterior and the lateral displacement automatically. Further pressure against medial or lateral malleoli is usually unnecessary.


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For medially displaced injuries (infrasyndesmotic), the reduction procedure involves holding the heel of the foot with the leg internally rotated, so that gravity tends to relocate the foot in a lateral direction.

Detailed reduction will be considered later.


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Treatment of patients presenting late

If the patient presents late and you have no possibility to administer general anesthesia, so that the patient is not fully relaxed, but merely sedated, or has only local intraarticular anesthesia, 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.


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Correct alignment

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.


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X-rays

For the choice of the correct reduction technique, it is useful to differentiate three patterns of fracture morphology.
This differentiation can only be made if x-rays are available.

Three radiographic views are taken:

  • Anterior-posterior (AP) view
  • AP in 20 degrees of internal rotation (mortise view) 
  • Lateral view

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Patterns of fracture morphology

Pattern 1) Lateral fibular buttress (infrasyndesmotic, adduction mechanism of injury)

The medial malleolus has been pushed off by the adducting talus. The traction fracture of the lateral malleolus, or the osseo-ligamentous injury, has left a lateral fibular buttress.


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Pattern 2) Those with a medial shoulder (some trans- and suprasyndesmotic injuries, external rotation mechanisms of injury)

The fracture of the medial malleolus has left a shoulder (or beak) on the tibia.
Many displaced ankle injuries fall into this pattern.


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Pattern 3) Combined fractures of the lateral and medial malleoli without medial or lateral shoulder (some trans- and suprasyndesmotic injuries, external rotation mechanisms of injury).

Both medial and lateral fractures are flush with, or above, the joint level, not leaving any medial or lateral bony shoulder against which to reduce the talus.


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Reduction of pattern 1: Fracture with a lateral fibular buttress

First, any AP displacement is corrected.

Hold the hindfoot firmly and gently pull both distally and forwards to correct any posterior displacement.


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The heel then needs to be pressed upwards and laterally, buttressing the talus against the shoulder of the lateral malleolus.


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Reduction of pattern 2: Fracture with medial shoulder present

First, any 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.


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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).


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A plantigrade position of the foot is important, but needs to be achieved by manipulation of the hindfoot downwards and forwards, rather than pushing upwards on the forefoot.


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The lateral displacement is then corrected 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. This presses the talus against the medial shoulder. At the same time any external rotation deformity is corrected.


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By exploiting the resistance of the medial shoulder, over-reduction is avoided.


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Reduction of pattern 3: Reduction of combined fractures of the lateral and medial malleoli without medial or lateral shoulder


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Reduction pressure needs to be applied above (lower leg) and below (heel and midfoot) the malleoli, not directly over the malleoli.


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Here, the danger is of overcorrection of the ankle medially, or laterally. In such cases, the AP displacement is corrected, and the foot orientated in alignment with the lower leg, avoiding any undue medial or lateral pressure, and correcting any malrotation. It is only the soft tissues and surgical acumen that help to prevent overcorrection.