Morning Report: 4/16/2013

Here’s Dr. Basile with today’s Morning Report!

Ankle Dislocations

– Can lead to long-term morbidity

– Most commonly in young people in sports, falls, or MVCs

– Isolated ankle dislocation is rare

– Usually associated with malleolar fractures or fracture of the tip of the tibia

– Open 25% of the time

– Often treated definitively in the OR, although some can be managed nonoperatively with closed reduction and casting

– Most occur from force against a plantarflexed foot and lead to posterior or posteromedial dislocation

– Almost all dislocations are associated with ligamentous ruptures, either partial or complete

– Risk of vascular injury and development of compartment syndrome

– Dorsalis pedis and posterior tibial vessels and superficial peroneal and sural nerve are at risk

Indications for reduction:

– All closed ankle dislocations should be reduced emergently- some recommend prior to imaging

– Any dislocation (open or closed) with distal neurovascular compromise should be reduced emergently

– Open dislocations require IV antibiotics, irrigation, surgical debridement, and reduction by an Orthopedic Surgeon in the OR. Reduction should occur in the ED after copious irrigation if neurovascular compromise or Surgeon or OR not available.

– ASSESS AND DOCUMENT NEUROVASCULAR STATUS BEFORE AND AFTER REDUCTION

Analgesia:

– Procedural sedation provides analgesia, muscle relaxation, and sedation

– If procedural sedation is contraindicated, intraarticular injection of local anesthetic can be used

Types of Dislocation and the Technique for Reduction:

Posterior/Posteromedial
1. Most common
2. Force applied posteriorly to distal tibia with foot plantarflexed
3. Commonly associated with malleolar, distal fibula fracture, and posterior marginal tibia fracture
4. Procedure:
  1. Flex the patient’s hip and knee by placing a pillow behind the knee
  2. Grasp calcaneus with one hand and forefoot with the other hand
  3. Simultaneously apply distal traction to the heel and plantarflex the foot while the assistant (grasping the calf) provides countertraction to the leg
  4. The next step is to dorsiflex the foot while distracting the heel and a second assistant provides posteriorly directed pressure on the distal leg
Lateral
1. Always associated with malleoli fractures
2. Force on distal fibula with foot fixed to the ground
3. Procedure:
  1. Flex the patient’s hip and knee by placing a pillow behind the knee
  2. Grasp calcaneus with one hand and forefoot with the other hand
  3. Apply distal traction to the heel while the assistant (grasping the calf) provides countertraction to the leg
  4. Rotate the foot medially while simultaneously dorsiflexing the foot
Anterior
1. Rare
2. Fall on heel with foot dorsiflexed or from anterior force on distal tibia with a fixed foot
3. Associated with anterior margin of the tibia fracture
4. Procedure:
  1. Flex the patient’s hip and knee by placing a pillow behind the knee
  2. Grasp calcaneus with one hand and forefoot with the other hand
  3. Simultaneously apply distal traction to the heel and dorsiflex the foot while the assistant (grasping the calf) provides countertraction to the leg
  4. Push the foot posteriorly while a second assistant provides anteriorly directed pressure on the distal leg
Superior
1. Uncommon
2. Force from above driven through the leg/ankle (fall from height)
3. Should be splinted and managed by orthopedic surgeon

Aftercare:

– Splint in three sided short leg splint or bivalved cast from base of the toes to just below the knee

– Limb elevated with no weight bearing

– All require admission for frequent neurovascular checks and monitoring for signs/symptoms of compartment syndrome

Complications:

– Possible neurovascular injuryà can become impinged in relocated joint or fracture fragment

– Emergently contact orthopedics if diminished or absent neurovascular function

References:

Comes J. Chapter 74. Ankle Joint Dislocation Reduction. In: Reichman EF, Simon RR, eds. Emergency Medicine Procedures. New York: McGraw-Hill; 2004. http://www.accessemergencymedicine.com/content.aspx?aID=53472. Accessed October 18, 2012.