eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Dislocation, Ankle: Treatment & Medication
Updated: Apr 22, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
- Prehospital personnel should immobilize the joint following standard procedure for any extremity injury.
- If neurovascular compromise is identified in the field by examination, revealing a cold, discolored, and pulseless or insensate foot, the joint should be realigned unless transport time is brief. This is accomplished by in-line traction with countertraction. Traction or splinting should be maintained en route to the hospital (see Splinting, Ankle).
- Intravenous opioids should be administered to make the patient comfortable and especially if traction is applied to reduce the dislocation en route. If intravenous opioids are unavailable, intravenous benzodiazepine medications can be used as an alternative.
Emergency Department Care
- Early reduction is essential since delay may increase risk of neurovascular compromise or damage to articular cartilage. In patients with vascular compromise, perform reduction prior to radiologic examination.
- Postreduction radiographs should confirm proper joint alignment. Appropriate pain management is the greatest contribution an emergency physician can make to the patient's care. Postreduction splinting is discussed below.
Consultations
Dislocations of the ankle are, by definition, unstable due to accompanying disruption of the lateral or medial ligaments or the tibiofibular syndesmosis. These require an immediate orthopedic consultation for internal fixation of any associated fractures and repair of capsular or ligamentous tears.
Medication
Drugs used to treat the pain associated with dislocations include analgesics and anxiolytics.
Analgesics
Pain control is essential for quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained injuries.
Fentanyl citrate (Duragesic, Sublimaze)
Narcotic analgesic with greater potency and much shorter half-life than morphine sulfate. DOC for conscious sedation analgesia. With short duration (30-60 min) and ease of titration, an excellent choice for pain management and sedation. Easily and quickly reversed by naloxone. After initial dose, subsequent doses should not be titrated more frequently than q3h or q6h.
Adult
0.5-1 mcg/kg/dose IV/IM q30-60min
Pediatric
<2 years: 2-3 mcg/kg/dose IV/IM q30-60min
2-12 years: 1-2 mcg/kg/dose IV/IM q60min
>12 years: Administer as in adults
Phenothiazines may antagonize analgesic effects; tricyclic antidepressants may potentiate adverse effects
Documented hypersensitivity; hypotension; potentially compromised airway in which establishing rapid airway control would be difficult
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention; idiosyncratic reaction, known as chest wall rigidity syndrome, may require neuromuscular blockade to increase ventilation
Oxycodone and acetaminophen (Percocet)
Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients. Different strengths available.
Adult
1-2 tab or cap PO q4-6h prn
Pediatric
0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose oxycodone
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants may increase toxicity
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly patients; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4,000 mg/24 h of acetaminophen; higher doses may cause liver toxicity
Oxycodone and aspirin (Percodan)
Drug combination indicated for relief of moderately severe to severe pain.
Adult
1-2 tab or cap PO q4-6h prn
Pediatric
0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose oxycodone
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants may increase toxicity; may potentiate anticoagulant effects of warfarin
Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma; because of association of aspirin with Reye syndrome, do not use in children (<16 y) who have the flu
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly patients; caution in renal or liver impairment, peptic ulcer disease, and erosive gastritis
Acetaminophen and codeine (Tylenol-3)
Drug combination indicated for treatment of mild to moderately severe pain.
Adult
30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab q4h; not to exceed 12 tab/d
Pediatric
0.5-1 mg/kg/dose based on codeine content PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen
CNS depressants or tricyclic antidepressants may increase toxicity
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Morphine sulfate (MS Contin, MSIR)
DOC for analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Various IV doses are used; commonly titrated until desired effect obtained.
Adult
Starting dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h
Relatively hypovolemic patients: Start with 2 mg IV/IM/SC; reassess hemodynamic effects of dose
Pediatric
Infants and children: 0.1-0.2 mg/kg dose IV/IM/SC q2-4h prn; not to exceed 15 mg/dose; may initiate at 0.05 mg/kg/dose
Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAO inhibitors, and other CNS depressants may potentiate adverse effects of morphine
Documented hypersensitivity; hypotension; potentially compromised airway where establishing rapid airway control would be difficult
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hypotension, respiratory depression, nausea, emesis, constipation, urinary retention, atrial flutter, and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate
Anxiolytics
Patients with painful injuries usually experience significant anxiety. Anxiolytics allow the clinician to administer a smaller analgesic dose to achieve the same effect.
Diazepam (Valium)
Depresses all levels of CNS, including limbic and reticular formation, possibly by increasing activity of GABA, a major inhibitory neurotransmitter. Individualize dosage and increase cautiously to avoid adverse effects.
Adult
5-10 mg PO/IV/IM q3-4h; repeat q2-4h prn; not to exceed 30 mg in 8-h period
Pediatric
0.05-0.3 mg/kg/dose IV/IM over 2-3 min; repeat in 2-4 h prn; 0.12-0.8 mg/kg/d PO divided q6-8h; not to exceed 10 mg/dose
Phenothiazines, barbiturates, alcohols, or MAOIs may increase CNS toxicity
Documented hypersensitivity; narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity)
Lorazepam (Ativan)
Sedative hypnotic in benzodiazepine class that has short onset of effect and relatively long half-life. By increasing GABA, a major inhibitory neurotransmitter, may depress all levels of CNS, including limbic and reticular formation. When patient needs to be sedated for >1 d this medication is excellent. Monitor patient's blood pressure after administering dose and adjust as necessary.
Adult
1-10 mg/d IV divided bid/tid; not to exceed 4 mg/dose
Pediatric
0.05-0.1 mg/kg IV slowly over 2-5 min; may repeat a dose of 0.05 mg/kg IV slowly
Alcohol, phenothiazines, barbiturates, or MAOIs may increase CNS toxicity
Documented hypersensitivity; preexisting CNS depression; hypotension; narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease
More on Dislocation, Ankle |
| Overview: Dislocation, Ankle |
| Differential Diagnoses & Workup: Dislocation, Ankle |
 Treatment & Medication: Dislocation, Ankle |
| Follow-up: Dislocation, Ankle |
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References
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Further Reading
Keywords
ankle dislocation, ankle joint, dislocated ankle, ankle injuries, ankle fracture, ankle sprain, sprained ankle, broken ankle, tibia, fibula, talus, ankle bones, posterior ankle dislocation, anterior ankle dislocation, superior ankle dislocation, lateral ankle dislocation, dislocation of the ankle, dislocation of the ankle joint
