Ankle Dislocations

Happy New Years Eve everyone! Before people head out for some NYE festivities lets talk Ankle Dislocations!

One was seen in the ED this week and managed beautifully from what I hear, so lets make sure we all know what to do as this is an orthopedic emergency!

Mechanism:

• Mc= Post dislocation of talus can be medial, ant, lateral and superior
• HIGH force injury --> plantar flexion
  • Greatest instability as talus becomes narrower
  • Inversion? posteromedial discplacement + injury to ATF and CF Ligaments
  • Eversion? Lateral dislocation
• Fall with axial load, car accident
• mc Young males, pt with previous ankle injuries, Ehrles Danlos

 

Complications:

• High association with fractures
• High risk of Neurovascular injury so need FAST RECOGNITION AND REDUCTION!
  • Can lead to avascular necrosis of the talus, sensation loss and LE tissue necrosis--> gangrene
• Nonunion/malunion, tendon entrapment, cartilaginous injury chronic arthritis, rarely a/w compartment syndrome

Work up:

• PE: Edema, tenting os skin, tip along joint line, deformity
• ALWAYS CHECK FOR PULSES and SENSATION
• XR- A/P, Late and Mortise views

When to Reduce:

• Indications:
  • NV compromise- Just reduce! don't need X-rays 1st if high clinical suspicion
  • No compromise- confirm with X-ray first
    • Can be open, can be a/w fracture

• Contraindications:
  • Multiple failed attempts
  • Subtalar Dislocation
    • Rare, high force on forefoot
    • 20% are irreducible and need OR

Reduction

• Pre-Procedure:
  • Sedation and pain control is key
  • Have material ready to cast following reduction
• POST:
  • Hold foot in plantar flexion, apply axial traction
  • Posterior traction to to ditasl tibi and ant pressure to heel
  • https://www.youtube.com/watch?v=ANA2b-g3qaw
• ANT: Same 1st steps but apply anterior traction to distal tibia and posterior force to foot

Post Reduction:

• Immbolize with LONG LEG POST splint w/ SUGAR TONG component
• Repeat X-ray
• Can cause conversion to open injury during reduction--> give Tdap and abx
• Ortho Follow up for ORIF

Surgical Indications:

• Failure to reduce x 2-3 attempts
• Increasing tension or tenting of skin
• multiple other intra-articular fractures, subtler dislocation
• Amputation

Sources: OrthoBullets, Medscape

Wishing everyone a happy and healthy New Years, see you in 2018!

Julie