Reduction of Ankle Dislocation Periprocedural Care

Consent for both the procedure and sedation should be obtained from the patient or the patient's representative (eg, a family member). ^[20] Explanations of the following should be provided:

• Reason for performing the procedure (suspected diagnosis)
• Risks and benefits of the procedure, as well as any alternatives to the procedure
• Risks and benefits of alternatives to the procedure
• Risks and benefits of not undergoing the procedure

Allow the patient the opportunity to ask any questions and address any concerns they may have. Make sure that they have an understanding about the procedure so they can make an informed decision. Ask the patient or the patient’s representative if he or she would like others to be present for the procedure.

In particular, the patient should be counseled about the risks of vascular or neurologic complications, soft-tissue injury, or creation of additional fractures. The patient should also be counseled that the reduction may not be successful and that additional procedures, surgery, or both may be necessary.

Discuss how the relevant risks can be avoided or prevented (eg, through proper positioning, by ensuring that the patient remains as still as possible during the procedure, or by providing adequate analgesia).

History and physical examination

Obtain and document a thorough preprocedural history, including the following:

• History of prior injuries and surgical procedures
• Mechanism of trauma
• Amount of time elapsed since the traumatic event
• Description of the presenting symptoms
• Prior medical allergies and reactions
• Any subjective loss of strength or sensation
• Patient’s age in reference to skeletal maturity

Perform and document a thorough physical examination, with particular attention to the following:

• Ecchymoses
• Swelling
• Pallor
• Abrasions and lacerations
• Paresthesias
• Weakness
• Notable deformities of the ankle or foot
• Presence and character of the dorsalis pedis and posterior tibial pulses
• Exact position in which the ankle and distal foot are held
• Comparison examination of the contralateral ankle

Emphasis should be placed on assessing the neurovascular status of the distal foot. Carefully explore all areas of skin overlying the ankle joint for dermal compromise that may make the injury an open dislocation.

If the ankle injury is associated with lacerations of the skin in the area of the ankle joint, the injury is likely an open injury; tetanus prophylaxis and antibiotic coverage of skin flora should be given.

Assess the patient for additional injuries, particularly life-threatening injuries that may have resulted from the high-force trauma that caused the ankle dislocation. Follow Advanced Trauma Life Support (ATLS) protocols, when these are deemed appropriate. Continue management of the ankle dislocation as soon as proper evaluation and resuscitation of the patient have insured hemodynamic stability.

Diagnostic imaging

Obtain radiographs of the patient's ankle, choosing the type of radiograph that may be obtained and evaluated in the shortest amount of time. Prereduction films are often a valuable source of information; however, if significant neurovascular compromise is present and radiography would delay the time until reduction can be attempted, prereduction films need not be obtained.

Anteroposterior (AP) and lateral views of the ankle are the most common and efficient means of radiographic assessment. These two views usually provide an excellent depiction of the direction of the dislocated talus and show the presence of most associated fractures. Additional views add little to the initial evaluation of the dislocated ankle and are usually more appropriate in the postreduction setting.

Computed tomography (CT) of the ankle, though superior to flat-plate radiography in revealing small fracture fragments, is usually not the test of choice, because it cannot be performed portably and may delay the time to reduction. This test should be considered only if neurovascular compromise is not present and the scan can be quickly performed and evaluated.

Equipment that may be used in reduction of a dislocated ankle includes the following:

• Oxygen supply
• Bag-valve mask
• Oxygen saturation monitor
• Wall suction, suction tubing, and Yankauer suction catheter
• Intravenous catheter (≥20 gauge)
• Medications as needed for procedural sedation
• Normal saline (0.9% NaCl)
• Rolls of 4-in. (10-cm) Webril (3 or 4)
• Stockinette, 5 in. (12.5 cm)
• Rolls of 6-in. (15-cm) plaster (2 or 3)
• Rolls of 4-in. (10-cm) elastic bandage (eg, Ace wrap)

Anesthesia

Anesthesia for reduction of an ankle fracture or dislocation is usually performed by means of procedural sedation, if the reduction is not taking place in the operating room under general anesthesia. Regional ankle blocks should not be attempted because of the difficulty in application in the context of distorted ankle anatomy and the subsequent loss of a reliable neurologic examination.

If possible, one clinician should be responsible only for the procedural sedation and should not take part in the reduction attempt but, rather, ensure that sedation and hemodynamics remain optimal. For more information, see Procedural Sedation.

Intra-articular hematoma block has been studied as an alternative to procedural sedation for closed reduction of displaced ankle fractures. ^[21]

Positioning

Because of the application of procedural sedation, ankle reduction is usually performed with the patient in the supine position to provide immediate access to the patient's airway for bag-mask ventilation, if needed. The reduction is performed with the ipsilateral knee in a position of flexion, thus relieving tension on the Achilles tendon and making reduction easier.

Proper positioning can be accomplished through the following steps:

• Bring the patient toward the foot of the bed until the knee hangs off in a flexed position; the reduction must then be performed with the clinician sitting at the foot of the bed at the patient's feet
• Have an assistant grasp the ipsilateral leg at the proximal tibia and fibula and bring the knee and hip into a position of flexion (this requires the assistant to hold the leg in this position for the duration of the reduction); the patient may be turned slightly on his or her side so that the ipsilateral leg is not held straight into the air but, rather, is braced against the bed in a position of flexion

Long-term orthopedic follow-up should be arranged in conjunction with the orthopedic specialist who will continue to manage this patient’s case. Many patients require surgical intervention for associated fractures of the ankle, and admission to the hospital may be needed for open fractures. If outpatient management is deemed appropriate, the patient should follow up in the next 2-3 days.

Outpatient instructions should include the following:

• The patient should not bear weight on the affected ankle until instructed otherwise upon follow-up with orthopedics; the ankle should remain in the splint at all times, and instructions as to the care of the splint must be given
• The patient should return for emergency care immediately if pain increases, if the skin color of the distal foot changes, or if the injured leg exhibits any numbness, weakness, or change in temperature
• The patient should understand instructions for pain medicine as deemed appropriate; narcotics, nonsteroidal anti-inflammatory drugs (NSAIDs), or both are usually warranted