Foot Dislocation Treatment & Management

Updated: May 10, 2016
  • Author: Christopher M McStay, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Treatment

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 inadvisable in the ED. In these cases, consulting an orthopedic specialist is always wise. Closed reduction is frequently insufficient and open reduction and internal fixation are required.

Urgent reduction of a dislocation in the ED is often necessary to prevent further vascular or neurological compromise. Whenever possible, ensure adequate analgesia; conscious sedation may be required. The joint should be reduced using 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.

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Prehospital Care

When the dislocated foot is seen as one of numerous injuries in a patient with major trauma, management of the 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 and promptly transport the patient.

Control bleeding with direct pressure and cover any open dislocation with a sterile dressing.

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Emergency Department Care

Immediate management may be dictated by concomitant injuries. Assess the neurovascular status of the foot as part of the secondary survey. Consider an urgent reduction of any dislocation that causes significant neurovascular compromise.

In cases of isolated injury, assess and record neurovascular status. Urgent radiographs should be 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 developing after severe injuries to the foot. Often the signs of compartment syndrome may be initially masked by the 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 associated with or without a fracture should typically 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 include the following:

  • Most subtalar dislocations can be treated with closed reduction under appropriate analgesia and sedation. [14] The interposition of soft tissues may prevent reduction, necessitating open reduction. Consider an urgent reduction if significant neurovascular compromise is evident. [15]
  • 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.
  • 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 medical dislocation.

Lisfranc dislocations frequently require operative reduction. An orthopedic surgeon should be involved in the care of these injuries. ED care typically involves appropriate analgesia, ice, and elevation. [16]

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 score (PFS) and American Orthopaedic Foot and Ankle Society (AOFAS) mid-foot scoring scale. Of the surgical treatments, internal fixation with screws had the highest scores. Eight patients (25.8%) developed posttraumatic arthritis of the tarsometatarsal joints. [17]

Dislocations of the toes often can be reduced under local anesthesia (digital block) in the ED with simple longitudinal traction. Dislocations of the first toe may be difficult to reduce.

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Consultations

Urgent ED orthopaedic consultation is indicated for subtalar, total talar, and Lisfranc dislocations.

Additionally, first metatarsophalangeal (MTP) and interphalangeal (IP) dislocations that are open or not reducible require orthopedic consultation. Most other MTP and IP dislocations are easily managed by the ED physician.

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Complications

One of the major complications of dislocations of the foot involves a 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:

  • Infection as a result of compound dislocations or, occasionally, as a postoperative complication
  • Long-term stiffness of the foot
  • Foot pain not specifically localized to one area
  • Secondary osteoarthritis
  • Avascular necrosis, especially of the talus, after a total talar dislocation
  • 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, 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. [18] The authors found that the quality of the initial reduction was the major determinant for obtaining an excellent long-term result.

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