Ankle Dislocation Management in the ED Workup

Updated: Jan 26, 2022
  • Author: James E Keany, MD, FACEP; Chief Editor: Trevor John Mills, MD, MPH  more...
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Imaging Studies

Routine radiographic examination of the ankle includes the following views:

  • Anteroposterior

  • Lateral

  • Mortise or oblique views: These are taken with an internal rotation of 10-20 degrees. This places the medial and lateral malleoli in the same horizontal plane, which provides optimal viewing of the tibial plafond and the talar dome.

Obtain prereduction and postreduction films.

Computed tomography (CT) may be indicated for evaluation of osseous structures, occult fractures, and alignment.

Ultrasound may be used for guiding injection of pain medicine into the ankle. [17]




Reduction of the ankle joint

For patients with obvious or complete neurovascular compromise, perform reduction prior to radiographic studies. Prompt reduction is important in reducing the risk of complications related to neurovascular compromise.

Reduction is accomplished with the knee in flexion to reduce tension on the Achilles tendon. With one hand on the heel and the other on the dorsum of the foot, apply traction while maintaining countertraction at the knee. Entrapment of the tibialis posterior tendon (or of a fracture fragment within the joint space) may result in an irreducible dislocation.

Anesthesia includes Bier block, spinal block, conscious sedation with narcotics and/or benzodiazepines, or general anesthesia. Bier block is the preferred method because of its efficacy and risk profile, although time may not permit in cases of vascular compromise. Another technique is the hematoma block (injection of intra-articular local anesthetic into the ankle joint and associated fracture hematoma). Ross et al suggest this as an alternative to conscious sedation, avoiding the risks of seizure and/or respiratory arrest. [18]