Reduction of Ankle Dislocation Technique

Anterior dislocations of the talus are associated with loss of a palpable dorsalis pedis pulse due to impingement from the displaced talus. This represents a vascular emergency, in that the true status of the artery cannot be accurately assessed while the ankle remains dislocated.

Doppler ultrasonography (US) may aid in establishing that some blood flow is present; however, without the presence of a palpable pulse, emergency reduction is required to restore blood flow.

If adequate reduction cannot be achieved, or if reduction has not restored the presence of a palpable pedal pulse, emergency operative management is indicated.

Prepare for and perform procedural sedation. Position the patient as previously described. (See Periprocedural Care.)

Posterior talus dislocations are reduced by performing the following steps (see the video below):

• Hold the foot in a position of plantarflexion, thus recreating the position of the initial injury
• Apply axial traction to the ankle by having an assistant grasp the distal foot and provide constant force to fatigue the musculature of the extremity
• Grasp the distal tibia with one hand, and create posterior traction proximal to the dislocation; at the same time, place the other hand on the posterior heel of the foot, distal to the injury, and create persistent anterior pressure; this maneuver effects reduction after a few moments

Anterior talus dislocations are reduced by performing the following steps (see the video below):

• Hold the foot in a position of plantarflexion, thus recreating the position of the initial injury
• Apply axial traction to the ankle by having an assistant grasp the distal foot and provide constant force to fatigue the musculature of the extremity
• While anterior traction is being applied to the distal tibia, grasp the foot at a point distal to the injury and create both axial traction and a posterior force; this posterior pressure effects reduction after a few moments

Lateral talus dislocations are reduced by performing the following steps:

• Hold the foot in a position of plantarflexion, thus recreating the position of the initial injury
• Apply axial traction to the ankle by having an assistant grasp the distal foot and provide constant force to fatigue the musculature of the extremity
• Grasp the distal tibia with one hand and create lateral traction proximal to the dislocation; at the same time, place the other hand on the posterior heel of the foot, distal to the injury, and create persistent medial pressure; this maneuver effects reduction after a few moments

Medial talus dislocations are reduced by performing the following steps:

• Hold the foot in a position of plantarflexion, thus recreating the position of the initial injury
• Apply axial traction to the ankle by having an assistant grasp the distal foot and provide constant force to fatigue the musculature of the extremity
• Grasp the distal tibia with one hand and create medial traction proximal to the dislocation; at the same time, place the other hand on the posterior heel of the foot, distal to the injury, and create persistent lateral pressure; this maneuver effects reduction after a few moments

After each reduction attempt, repeat the neurovascular examination to ensure that blood flow has been maintained and no new sensory or motor compromise has occurred.

If reduction has been achieved but neurovascular compromise is apparent after reduction, emergency operative management is indicated.

If neurovascular compromise is present but reduction has not been achieved, operative management may be needed to reduce the injury, and limited future attempts should be made. If reduction cannot be accomplished after two or three attempts under optimal conditions, operative management should not be delayed further.

Once reduction is achieved and the neurovascular status of the limb is stable, apply a long leg posterior splint with a sugar-tong component, which immobilizes the joint in a position of 90° of flexion. All efforts should be made to avoid applying any material that may become constricting to the ankle; remarkable swelling may take place in the postreduction period. The distal foot and toes should be left open to allow serial neurovascular checks.

Repeat radiography may now be performed to assess the adequacy of the reduction and document any associated fractures. Flat-plate radiography may consist of repeat anteroposterior (AP) and lateral views at a minimum; a mortise or additional view may be added to further describe the condition of the joint. Computed tomography (CT) of the ankle may provide additional information as to the presence of smaller fractures and the position of fracture fragments.

Irreducible dislocation

Osseous fragments, capsular ligaments, and ruptured tendons, as well as foreign bodies, may all become interposed in the anatomic joint space and make closed reduction impossible. Repeat forceful attempts at reduction can cause additional soft-tissue injury and iatrogenic fractures and can convert a closed injury into an open injury if the skin around the ankle is ruptured. Concurrent fracture of the anterior calcaneal process may make closed reduction of a subtalar dislocation impossible. ^[20]

Need for surgical intervention

Surgical intervention should be considered in the following scenarios:

• Failure to reduce the injury despite two or three attempts under optimal conditions
• Increasing tension or tenting of the skin in a closed injury during reduction attempt
• The presence of multiple other intra-articular fractures or subtalar dislocation demonstrated by radiography, in a neurovascularly intact injury
• Amputation of the foot distal to the injury

Conversion of closed injury to open injury

During closed reduction, if the skin over the ankle joint is ruptured (particularly over the malleoli), the injury has been converted into an open injury. Tetanus prophylaxis and antibiotic coverage of skin flora should be administered. If necessary, the wound should be surgically debrided.