Dislocated Ankle Joint

    Demonstrated on plain radiographs

    Clinically dislocated with neurovascular compromise

CONTRAINDICATIONS

 Open dislocations without neurovascular compromise may be better managed in the operating room for cleaning before reduction

 After one or two unsuccessful attempts at reduction, orthopedic consultation should be considered

RISK/CONSENT ISSUES

 Neurovascular damage may result from reduction attempt

 Closed reduction may be unsuccessful and operative repair may be required

 Risks of intravenous (IV) analgesia/sedation

 Risks of regional anesthesia

LANDMARKS

 The ankle joint is a modified saddle joint that comprises the distal fibula, tibia, and the talus bone of the foot

 Is a stable joint with strong ligamentous support

 Dislocations are a result of significant forces applied to the ankle and are often associated with fractures; isolated dislocations are uncommon

TECHNIQUE

 Preprocedure Examination

    Search for other injuries, especially if high-energy mechanism

    Check neurovascular status of the foot

    Get prereduction radiographs of dislocation (anteroposterior [AP], lateral, mortise views)

       If there is neurovascular compromise or tenting of the skin, perform immediate reduction before obtaining radiograph

    Try to ascertain the mechanism of injury

 Analgesia and Sedation

    Procedural sedation

    Regional analgesia

       Bier block

       Hematoma block

 Procedure

    Technique depends on type of dislocation but, in general, involves downward traction on heel while a force opposite to the direction of the dislocation is applied

    Flexion of the hip and knee to 90 degrees may aid reduction by relaxing the gastrocnemius–soleus complex

       If no assistant is available this can be accomplished by hanging the patient’s knee over the end of the bed

LATERAL DISLOCATION (FIGURE 67.1)

 Most common ankle dislocation seen in the emergency department (ED)

 Usually result of forced inversion of the foot

 Associated with malleolar or distal fibula fractures

 May be associated with rupture of the deltoid ligament

 Presents with foot laterally displaced with the skin very taut over the medial aspect of the ankle joint

 Technique

    Place one hand on the heel and the other on the dorsum of the foot

    Apply longitudinal traction to the foot

    While assistant applies countertraction to the leg, gently manipulate the foot medially. Successful reduction usually produces a palpable thud.

POSTERIOR DISLOCATION (FIGURE 67.1)

 Usually result of forced plantar flexion or a strong forward force applied to the posterior tibia

 Most are associated with a fracture of one or more malleoli

 Presents with the ankle held in plantar flexion with foot shortened in appearance and resistant to dorsiflexion

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