Swing and a Miss: Ankle Fracture Dislocations in the ED
Written by: Kevin Hon, DO; Edited by, Timothy Khowong, MD
Case:
A 19 year old male presents to the ED with acute pain to the right foot starting about an hour ago. He was playing soccer and went to kick before an opposing player got to the ball. While his opened foot did not hit the ball, it did hit the other player’s foot with a resounding snap. He was unable to ambulate immediately after the injury. While he has no numbness or weakness to his foot or other trauma or complaint, he has an obvious deformity to the right foot.
Physical exam shows a laterally rotated right ankle. With the tibia perpendicular to the bed, the foot is rotated about 70 degrees to the right. Sensation intact to light touch at the superficial peroneal, deep peroneal, saphenous, sural, and plantar nerves. Capillary refill is less than 2 seconds. Patient is able to wiggle his toes.
X-rays were obtained showing a trimalleolar fracture with posterolateral dislocation.
After appropriate pain control using fentanyl and morphine, a hematoma block was performed injecting 10cc of 1% lidocaine in the ankle joint medial to Tibialis anterior tendon by the medial malleolus. See image below for visual reference.
Modified Quigley maneuver was used for gravity assisted reduction of the posterolateral ankle reduction and the ankle was popped back into alignment in one satisfying attempt.
Ankle Reduction Learning Points:
Ankle fractures are very common and typically occur due to twisting mechanisms or inversion injury. The incidence of these injuries is bimodal, with a focus on young active males engaging in sports to the elderly who slip and fall. The severity of these injuries depends on stability of the ankle and likelihood of healing without surgical involvement. Isolated malleolus fractures account for 70% of injuries and may be stable depending on Weber classification for lateral malleolus fractures. Higher grade Weber fractures, bimalleolar, and trimalleolar fractures are more unstable and are more likely to be candidates for operative management.
The ankle consists of a 3 ligament complex that stabilizes the ankle. These are injured depending on the mechanism of injury. Inversion ankle sprains injure the lateral triad of ligaments: Anterior talofibular ligament (ATFL always tears first ligament), calcaneofibular, and posterior talofibular ligament (PTFL). Eversion ankle sprains injure the medial deltoid ligament which has superficial and deep components. Lastly, high grade injuries, load bearing axial load, or extremes of inversion or eversion can injure the syndesmosis stabilizing the ankle mortise: Anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament, interosseous ligament (IOL), interosseous membrane, and lastly the inferior transverse ligament (ITL).
The most common fracture pattern of ankle dislocations involves lateral subluxation of the talus. When reducing, you should hold the hindfoot with one hand and use the lateral hand to apply a medial varus force, translating and internally rotating the foot until reduction is successful. Afterwards, a 3 way splint (posterior slab and stirrup) can be applied. While forming the splint, it is imperative to maintain appropriate medial pressure at the ankle while cupping the heel to ensure stability when the joint is set. The last thing you want to do is to let this dislocate again.
