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How To Reduce an Ankle Dislocation

By

Matthew J. Streitz

, MD, San Antonio Uniformed Services Health Education Consortium

Last full review/revision Sep 2022| Content last modified Sep 2022
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Most ankle dislocations are fracture-dislocations. Reduction uses traction-countertraction to disengage the talus from the distal tibia, followed by repositioning of the talar dome into the joint mortice and splinting to stabilize the reduction until definitive orthopedic treatment. Procedural sedation and analgesia (PSA) is usually required.

Indications for Ankle Dislocation Reduction

  • Dislocation or fracture-dislocation of the ankle

Most ankle dislocations are posterior or posteromedial and are fracture-dislocations associated with malleolar, distal fibular, and posterior marginal tibial fractures.

Reduction of a closed ankle dislocation or fracture-dislocation should be attempted soon after the diagnosis is made. An associated neurovascular deficit or a fracture-dislocation with skin tenting that threatens skin penetration warrants immediate reduction.

Open dislocations require surgery, but closed reduction techniques and splinting should be done as interim treatment if the orthopedic surgeon is unavailable and a neurovascular deficit is present.

Contraindications to Ankle Dislocation Reduction

There are no contraindications to attempting closed reduction of ankle dislocations, even those awaiting orthopedic evaluation and treatment. However, open dislocations without vascular compromise—if surgery is impending—may be better managed with thorough irrigation in the operating room (rather than irrigation in the emergency department) before the reduction.

Complications of Ankle Dislocation Reduction

Most complications are the result of the fracture-dislocation itself.

Equipment for Ankle Dislocation Reduction

  • Materials and personnel required for procedural sedation and analgesia (PSA)

  • For intra-articular analgesia: anesthetic (eg, 5 to 10 mL of 1% lidocaine, 10-mL syringe, 2-inch 20-gauge needle), antiseptic solution (eg, chlorhexidine, povidone iodine), gauze pads

  • Pillow

  • Short leg splint (stockinette, cotton padding wrap, splint material [posterior, 3-sided splint], elastic bandage)

Additional Considerations for Ankle Dislocation Reduction

  • X-rays should be done before reduction of ankle dislocations unless neurovascular deficits are present, but typically x-rays can be done in the time that it takes to get the supplies together for PSA and reduction.

  • Intravenous analgesia is preferably given prior to x-rays.

  • Intra-articular or regional anesthesia may be sufficient in some cases.

  • Lateral dislocations should not be reduced without orthopedic involvement unless vascularity is compromised or the patient must be transported to the orthopedic surgeon.

Relevant Anatomy for Ankle Dislocation Reduction

  • Ankle ligaments are strong and ankle dislocations are high-energy injuries that usually involve fractures and ligament ruptures. Associated fractures include those of the malleoli, fibula, or tibial margins.

  • Anterior dislocations may disrupt the dorsalis pedis artery.

  • Malleolar or distal fibular fractures generally accompany lateral dislocations.

Positioning for Ankle Dislocation Reduction

  • Place the patient supine, with the affected foot at the end of the stretcher and the knee in slight flexion.

Step-by-Step Description of Ankle Dislocation Reduction

Neurovascular examination

  • Do a pre-procedure neurovascular examination of the foot and ankle, including posterior tibial and dorsalis pedis pulses, capillary refill time (normally < 2 seconds), and sensation of the foot's plantar surface (tibial nerve), dorsal surface (peroneal nerves), lateral surface (sural nerve), and medial surface (saphenous nerve).

Analgesia

Reduce the ankle dislocation

  • Place a pillow behind the knee of the affected leg, to flex the hip and the knee.

  • Have one assistant grasp the calf with both hands, ready to pull cephalad (countertraction).

  • Have a second assistant grasp the ankle with one hand (to stabilize lower leg).

  • Grasp the foot, with one hand at the heel and the other hand at the forefoot.

For a posterior dislocation:

  • First free the talus from the distal tibia: Slightly plantarflex the foot and distract the heel axially (ie, pull it away) from the tibia, with the first assistant providing axial countertraction to the calf.

  • Next, while maintaining axial distraction of the heel, and with the second assistant applying a counterforce to the anterior ankle, dorsiflex the foot, to reposition the talar dome anteriorly into the joint mortice.

For an anterior dislocation:

  • First dorsiflex the foot to distract the talus from the tibia.

  • Apply axial traction and then push the foot directly backward while an assistant applies countertraction to the posterior part of the leg.

For a lateral dislocation:

  • Distract the heel axially from the tibia, then move the foot medially and dorsiflex it.

For all dislocations:

  • Successful reduction may be accompanied by a perceptible "clunk."

Aftercare for Ankle Dislocation Reduction

Warnings and Common Errors for Ankle Dislocation Reduction

  • Ankle joint fracture-dislocations with 2 or more areas of fracture are inherently unstable; exercise caution when transporting a patient with an ankle that is still dislocated because neurovascular compromise may develop en route.

Drugs Mentioned In This Article

Drug Name Select Trade
XYLOCAINE
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