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Dislocation Reduction of the Ankle Joint

  • Editor(s): Todd W Thomsen, MD, Gary S Setnik, MD, FACEP
  • Section Editor(s): Phillip M Harter, MD
  • Contributor(s): Carmie Chan, MD
PRE-PROCEDURE
INDICATIONS
  • All ankle dislocations must be reduced.
  • Lateral dislocations are always associated with fractures of the malleoli or distal fibula.
CONTRAINDICATIONS

There are no absolute contraindications to reduction of a dislocated ankle.
ANATOMY
  • Ligaments and tendons
    • The peroneus longus and peroneus brevis tendons traverse the posterior aspect of the lateral malleolus to insert on the lateral foot.
    • The tibialis posterior, flexor digitorum longus, and flexor hallucis longus tendons traverse the medial aspect of the ankle, posterior to the medial malleolus.
    • On the superior-anterior aspect of the ankle are the extensor hallucis longus, extensor digitorum longus, peroneus tertius, and tibialis anterior tendons.
    • The deltoid ligament stabilizes the distal tibia.
    • The lateral collateral ligament stabilizes the distal fibula.
  • Vascular anatomy
    • The posterior tibial artery enters the foot posterior to the medial malleolus.
    • The anterior tibial artery continues dorsally into the foot as the dorsalis pedis artery.
  • Nerve supply
    • The deep peroneal nerve continues into the foot beside the dorsalis pedis artery.
    • The tibial nerve enters the foot with the posterior tibial artery, posterior to the medial malleolus.
Fracture-dislocation of the ankle joint.
Figure 1 :  Fracture-dislocation of the ankle joint.

Bony anatomy of the ankle.
Figure 3 :  Bony anatomy of the ankle.


PROCEDURE
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1: Plantar flexion and axial traction. 2: Downward pressure on tibia. 3: Anterior translation.
Figure 5 :  1: Plantar flexion and axial traction. 2: Downward pressure on tibia. 3: Anterior translation.

1: Dorsiflexion. 2: Upward pressure on tibia. 3: Posterior translation.
Figure 6 :  1: Dorsiflexion. 2: Upward pressure on tibia. 3: Posterior translation.

1: Plantar flexion and axial traction. 2: Tibial stabilization. 3: Medial translation.
Figure 7 :  1: Plantar flexion and axial traction. 2: Tibial stabilization. 3: Medial translation.


POST-PROCEDURE
CARE
  • Splint the ankle at 90 degrees with a posterior splint and a sugar tong splint.
  • Check the vascular status by palpating the pulse at both the posterior tibial artery and dorsalis pedis artery and checking the capillary refill time of the toes.
  • Check neurologic status.
    • Numbness in the dorsal foot suggests peroneal nerve damage.
    • Numbness in the webspace between the great and second toe suggests deep peroneal nerve damage.
  • Loosen the dressing and immediately consult orthopedic and vascular surgery if there is any sign of vascular compromise.
  • Repeat radiographs of the ankle to confirm reduction.
  • Prescribe analgesic medications.
  • Arrange for orthopedic evaluation and possible surgical intervention.
COMPLICATIONS
  • Rarely, vascular injury to the anterior tibialis artery and dorsalis pedis artery may occur.3
  • Injury to the tibial nerve, superficial peroneal nerve, and sural nerve are uncommon.
  • Loss of range of motion may occur but is usually clinically insignificant.3
  • Joint instability
Apply a posterior and a stirrup (“sugar-tong”) splint.
Figure 8 :  Apply a posterior and a stirrup (“sugar-tong”) splint.

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