text:
Ankle Dislocation in Emergency Medicine Clinical Presentation
- Author: James E Keany, MD, FACEP; Chief Editor: Trevor John Mills, MD, MPH more...
A detailed history regarding the mechanism of injury often helps predict the type of injuries to expect. Furthermore, an understanding of the injury mechanism aids treatment, since an opposite force is required in reduction of the joint. Because of the inherent stability of the ankle joint mortise and surrounding tendons and ligaments, dislocation is most usually caused by high-energy trauma that causes plantar flexion of the ankle combined with either inversion or eversion stress upon the foot.[1] Four types of dislocations are seen around the ankle joint: posterior, anterior, lateral, and superior:
A posterior dislocation in the most common type of ankle dislocation. The talus moves in a posterior direction in relation to the distal tibia as force drives the foot backward.[8] The wider anterior talus wedges back, resulting in forced widening of the joint. This must be accompanied by either a disruption if the tibiofibular syndesmosis or a fracture if the lateral malleolus, occurring most commonly when the ankle is plantar flexed.
Anterior dislocations result from the foot being forced anteriorly at the ankle joint.
Typically, anterior dislocation occurs with the foot fixed and a posterior force applied to the tibia or with forced dorsiflexion.
Lateral dislocations result from forced inversion, eversion, or external or internal rotation of the ankle.They are associated uniformly with fractures of either (or both) the malleoli or the distal fibula.
Diastasis occurs when a force drives the talus upward into the mortise. These dislocations usually are the result of a fall from a height. In such cases, the patient should be evaluated carefully for concomitant spine injury and fracture of the calcaneus.
Inspection of the ankle reveals significant edema with deformity ranging from trace to obvious. Tenting of the skin by the malleoli may be noted.
Palpation of the joint reveals tenderness along the joint line, corresponding to areas of capsular or ligamentous disruption.
In associated fractures, tenderness, deformity, or tenting proximal to the joint may be seen.
Possible risk factors that may predispose a patient to dislocation include the following: joint hyperlaxity, internal malleolar hypoplasia, peroneal muscle weakness, and a history of prior ankle sprains.[1]
Complications of ankle dislocation may include the following:
Nonunion or malunion
Entrapment of the tibialis posterior tendon or of a fracture fragment
Cartilaginous injury
Osteochondral fractures of the talar dome
Joint stiffness and decreased range of motion (eg, osteoarthritis [9] )
Arterial injury (anterior and posterior tibial, peroneal)
Compartment syndrome (rare)
Thangarajah T, Giotakis N, Matovu E. Bilateral ankle dislocation without malleolar fracture. J Foot Ankle Surg. 2008 Sep-Oct. 47(5):441-6. [Medline].
Wilson M, Michele A, Jacobsen E. Ankle dislocations without fracture. JBJS. January 1939. 21:198-204.
Moehring HD, Tan RT, Marder RA, Lian G. Ankle dislocation. J Orthop Trauma. 1994. 8(2):167-72. [Medline].
Tarantino U, Cannata G, Gasbarra E, Bondi L, Celi M, Iundusi R. Open medial dislocation of the ankle without fracture. J Bone Joint Surg Br. 2008 Oct. 90(10):1382-4. [Medline].
Karampinas PK, Kavroudakis E, Polyzois V, Vlamis J, Pneumaticos S. Open talar dislocations without associated fractures. Foot Ankle Surg. 2014 Jun. 20(2):100-4. [Medline].
Graeme KA, Jackimczyk KC. The extremities and spine. Emerg Med Clin North Am. 1997 May. 15(2):365-79. [Medline].
Kim DI, Kim YS, Han SH. Topography of human ankle joint: focused on posterior tibial artery and tibial nerve. Anat Cell Biol. 2015 Jun. 48 (2):130-7. [Medline].
Weston JT, Liu X, Wandtke ME, Liu J, Ebraheim NE. A systematic review of total dislocation of the talus. Orthop Surg. 2015 May. 7 (2):97-101. [Medline].
Lübbeke A, Salvo D, Stern R, Hoffmeyer P, Holzer N, Assal M. Risk factors for post-traumatic osteoarthritis of the ankle: an eighteen year follow-up study. Int Orthop. 2012 Jan 17. [Medline].
Soneji N, Peng PW. Ultrasound-Guided Interventional Procedures in Pain Medicine: A Review of Anatomy, Sonoanatomy, and Procedures: Part VI: Ankle Joint. Reg Anesth Pain Med. 2016 Jan-Feb. 41 (1):99-116. [Medline].
Ross A, Catanzariti AR, Mendicino RW. The hematoma block: a simple, effective technique for closed reduction of ankle fracture dislocations. J Foot Ankle Surg. 2011 Jul-Aug. 50(4):507-9. [Medline].
Grotz MR, Alpantaki K, Kagda FH, Papacostidis C, Barron D, Giannoudis PV. Open tibiotalar dislocation without associated fracture in a 7-year-old girl. Am J Orthop (Belle Mead NJ). 2008 Jun. 37(6):E116-8. [Medline].
Heyworth J. Ottawa ankle rules for the injured ankle. Br J Sports Med. 2003 Jun. 37 (3):194. [Medline]. [Full Text].
Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. 1993 Mar 3. 269 (9):1127-32. [Medline].
[Guideline] Mosher TJ, Kransdorf MJ, Adler R, Appel M, Beaman FD, Bernard SA, et al. ACR Appropriateness Criteria acute trauma to the ankle. J Am Coll Radiol. 2015 Mar. 12 (3):221-7. [Medline].
Agrawal AC, Raza H, Haq R. Closed posterior dislocation of the ankle without fracture. Indian J Orthop. 2008 Jul. 42(3):360-2. [Medline]. [Full Text].
Camarda L, Martorana U, D'Arienzo M. Posterior subtalar dislocation. Orthopedics. 2009 Jul. 32(7):530. [Medline].
Daffner RH. Ankle trauma. Semin Roentgenol. 1994 Apr. 29(2):134-51. [Medline].
Daffner RH. Ankle trauma. Radiol Clin North Am. 1990 Mar. 28(2):395-421. [Medline].
Dean DB. Field management of displaced ankle fractures: techniques for successful reduction. Wilderness Environ Med. 2009 Spring. 20(1):57-60. [Medline].
Distefano S, Divita G. A case of pure dislocation of the ankle joint. Ital J Orthop Traumatol. 1988 Mar. 14(1):133-7. [Medline].
Finkemeier C, Engebretsen L, Gannon J. Tibial-talar dislocation without fracture: treatment principles and outcome. Knee Surg Sports Traumatol Arthrosc. 1995. 3(1):47-9. [Medline].
Greenbaum MA, Pupp GR. Ankle dislocation without fracture: an unusual case report. J Foot Surg. 1992 May-Jun. 31(3):238-40. [Medline].
Griffiths HJ. Trauma to the ankle and foot. Crit Rev Diagn Imaging. 1986. 26(1):45-105. [Medline].
Krishnamurthy S, Schultz RJ. Pure posteromedial dislocation of the ankle joint. A case report. Clin Orthop Relat Res. 1985 Dec. (201):68-70. [Medline].
Merianos P, Papagiannakos K, Hatzis A, Tsafantakis E. Peritalar dislocation: a follow-up report of 21 cases. Injury. 1988 Nov. 19(6):439-42. [Medline].
Mooney JF, Naylor PT, Poehling GG. Anterolateral ankle dislocation without fracture. South Med J. 1991 Feb. 84(2):244-7. [Medline].
Schuberth JM. Diagnosis of ankle injuries: the essentials. J Foot Ankle Surg. 1994 Mar-Apr. 33(2):214. [Medline].
Wehner J, Lorenz M. Lateral ankle dislocation without fracture. J Orthop Trauma. 1990. 4(3):362-5. [Medline].
Wilson AB, Toriello EA. Lateral rotatory dislocation of the ankle without fracture. J Orthop Trauma. 1991. 5(1):93-5. [Medline].
Wroble RR, Nepola JV, Malvitz TA. Ankle dislocation without fracture. Foot Ankle. 1988 Oct. 9(2):64-74. [Medline].