Ankle Dislocation

Aka: Ankle Dislocation, Tibiotalar Dislocation

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II. Mechanism

  1. Ankle Dislocation associated with Ankle Fracture (most cases)
    1. Severe twisting injury results in dislocation of the tibiotalar joint
    2. Associated with various Ankle Fractures of the medial malleolus or lateral malleoulus
  2. Isolated Ankle Dislocation alone (rare)
    1. Force directed anteriorly or posteriorly impacts a plantar flexed foot
    2. More likely to be open dislocations due to high force injury required for dislocation

III. Exam

  1. See Ankle Exam
  2. Follow trauma Musculoskeletal Exam approach ("joint above, joint below, nerves, vessels, skin and compartments")
  3. Observation
    1. Skin Tenting and other swelling
    2. Signs of open dislocation (overlying Laceration or puncture)
    3. Ankle Range of Motion
  4. Palpation
    1. Palpate joint margins as well as midshaft and proximal tibia and fibula for Fractures
    2. Palpate foot for associated Fractures (Fifth Metatarsal Fracture, Lisfranc Fracture, Navicular Fracture)
  5. Neurovascular Exam (before and after reduction)
    1. Dorsalis Pedis Pulse
    2. Posterior Tibial Pulse
    3. Distal Capillary Refill
    4. Distal Sensation and motor function

IV. Imaging

  1. Ankle XRay
    1. Obtain before and after closed reduction
  2. CT Ankle
    1. Indications
      1. Multiple Fractures
      2. Significant comminuted Fractures
      3. Calcaneal Fracture suspected or poorly visualized on XRay
      4. Talar Fracture suspected or poorly visualized on XRay
      5. Surgical Planning for open repair

V. Management: Dislocation Reduction

  1. Anesthesia
    1. Procedural Sedation (most common method)
    2. Intraarticular Block or Hematoma Block (adequate analgesia for reduction)
      1. White (2008) J Bone Joint Surg Am 90(4):731-4 +PMID: 18381308 [PubMed]
      2. MacCormick (2018) Foot Ankle Int 39(10):1162-8 +PMID: 29860875 [PubMed]
  2. Technique
    1. Patient supine with knee at 90 degrees flexion (reduces achilles tendon tension)
    2. Assistant stabilizes knee and upper leg
    3. Examiner grasps the foot by the Calcaneus (and the distal calf with the opposite hand)
      1. Foot typically held in plantar flexion
        1. Slight dorsiflexion may be helpful in isolated anterior Tibiotalar Dislocations
      2. Apply gentle longitudinal, inline traction
      3. Guide talus back into proper alignment with the tibia
  3. Post-reduction
    1. Reevaluate neurovascular exam
    2. Postreduction Ankle XRay
      1. Consider Ankle CT

VI. Management: Disposition

  1. Splinting
    1. Short leg posterior splint and short leg stirrup splint
  2. Orthopedic Consultation in all cases of Ankle Dislocation or Ankle Fracture-dislocation
    1. Urgent orthopedic or sports medicine referral for follow-up (3-5 days) in most cases
    2. Emergent Orthopedic Consultation indications
      1. Total Ankle Arthroplasty Dislocation
      2. Vascular Injury
      3. Ankle Dislocation not able to be reduced or poorly aligned reduction
      4. Open dislocations
      5. Concurrent Ankle Fracture type that specifically indicates emergent Consultation

VII. Complications

  1. Neurovascular Injury
    1. Associated with delayed reduction
  2. Talus Fracture (including Talar Dome Fracture)
  3. Open Fracture

VIII. Resources

  1. Ankle Dislocation (Stat Pearls)
    1. https://www.ncbi.nlm.nih.gov/books/NBK554610/

IX. References

  1. Kirwin, Conroy, McGrath (2021) Crit Dec Emerg Med 35(7): 15-24

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