Approach Considerations
Reduction of some foot dislocations, especially isolated dislocations of the talus or some of the more complex dislocations of the Lisfranc joint complex, can be very difficult and is inadvisable in the ED. In these cases, consulting an orthopedic specialist is always wise. Closed reduction is frequently insufficient, and open reduction internal fixation (ORIF) is required.
Urgent reduction of a dislocation in the ED is often necessary to prevent further vascular or neurologic compromise. Whenever possible, adequate analgesia should be ensured; conscious sedation may be required. The joint should be reduced via gentle traction, and the limb should then be immobilized. Further therapy or operative intervention may be required after this initial reduction.
If the dislocation is open, antibiotics are essential.
Emergency Department Care
When the dislocated foot is seen as one of numerous injuries in a patient with major trauma, management of other potentially life-threatening injuries takes priority. When the dislocation is an isolated injury, immobilize the limb to make the patient as comfortable as possible. Control bleeding with direct pressure, and cover any open dislocation with a sterile dressing.
Immediate management may be dictated by concomitant injuries. Assess the neurovascular status of the foot as part of the secondary survey. Consider urgent reduction of any dislocation that causes significant neurovascular compromise.
In cases of isolated injury, assess and record neurovascular status. Radiographs should be urgently obtained. Make arrangements for referral to an orthopedic specialist for reduction of the dislocation and further management as appropriate.
Remember the possibility of compartment syndrome after severe injuries to the foot. Often, signs of compartment syndrome may be initially masked by severe pain related to the injury. Failure to diagnose this problem can result in serious long-term sequelae for the patient, including contractures, deformities, and chronic pain. A high index of suspicion for this complication is required, and measurement of compartment pressures in the foot should be instituted if any findings suggest that this complication is present.
Any open dislocation with or without an associated fracture typically should not be reduced in the ED. Appropriate prophylactic antibiotics should be administered, and the tetanus status of the patient should be updated. Sterile dressings should be applied.
Treatment of subtalar and total talar dislocations consists of the following.
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Total talar dislocations are often open and, as such, should not be reduced in the ED. If a closed injury is present, or if urgent reduction is necessary secondary to neurovascular compromise, reduction may be attempted, ideally with appropriate consultation available.
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With the knee flexed, apply longitudinal traction at the foot. Initial accentuation of the injury followed by reversal of the deformity with pressure over the talus may result in reduction. For example, after distraction, apply an abduction force for a medial dislocation.
Injury to the tarsometatarsal joint complex, also referred to as a Lisfranc injury, is a relatively uncommon presentation in the ED; however, accurate diagnosis is vital to prevent the risk of long-term disability. Clinicians must use a broad range of clinical skills to manage patients' injuries effectively. A high level of suspicion, recognition of the clinical manifestations of Lisfranc injury, and attainment of appropriate radiographic images are required to formulate a correct diagnosis. [23]
Lisfranc dislocations frequently require operative reduction. An orthopedic surgeon should be involved in the care of patients with these injuries. ED care typically involves appropriate analgesia, ice, and elevation. [24]
In a study of 31 patients with dislocations and fracture dislocations of the Lisfranc joint over a 10-year period, outcomes were evaluated based on the Baltimore Painful Foot Scale (PFS) score and the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scoring scale. Among surgical treatments, internal fixation with screws received the highest scores. Eight patients (25.8%) developed posttraumatic arthritis of the tarsometatarsal joints. [25] However, a case series at a Level I trauma center found that functional outcomes after Lisfranc fracture are most dependent on the quality of anatomic reduction, rather than on the choice of fixation implant used. [26]
Dislocations of the toes often can be reduced in the ED with simple longitudinal traction and the patient under local anesthesia (digital block). Dislocation of the first toe may be difficult to reduce.
Urgent ED orthopedic consultation is indicated for subtalar, total talar, and Lisfranc dislocations. Additionally, first metatarsophalangeal (MTP) and interphalangeal (IP) joint dislocations that are open or are not reducible require orthopedic consultation. Most other MTP and IP dislocations are easily managed by the ED physician.
Complications
One of the major complications of dislocation of the foot involves failure to make the diagnosis. Some of these dislocations can be subtle, especially those around the Lisfranc joint complex. These dislocations often are missed, resulting in significant morbidity.
Other complications include the following.
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Infection as a result of compound dislocations or, occasionally, as a postoperative complication
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Long-term stiffness of the foot
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Foot pain not specifically localized to one area
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Secondary osteoarthritis
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Avascular necrosis, especially of the talus, after a total talar dislocation
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Damage to the medial plantar nerve with associated wasting of the intrinsic muscles of the foot (rare)
Compartment syndrome injuries are associated with long-term morbidity in a significant proportion of patients.
In one study, by Perron et al, 48% of patients with midfoot dislocations (Chopart and Lisfranc joints) had a fair or poor result at follow-up 20-56 months after the injury. Fair or poor in this classification indicated substantial limitation of activities. [27] The quality of the initial reduction was the major determinant for obtaining an excellent long-term result. When treating midfoot trauma, it is important for the clinician to fully understand the injury pattern, as this dictates the principles and techniques of fixation. Identification and knowledge of injury patterns will aid surgeons in future management of these injuries and may improve treatment outcomes. [3]
