Ortho Dx: How would you treat this ankle fracture dislocation? - Clinical Advisor

Ortho Dx: How would you treat this ankle fracture dislocation?

Slideshow

  • Radiographs of a 51-year-old man who hurt his ankle while hiking show a left ankle fracture dislocation.

    Slide

    Radiographs of a 51-year-old man who hurt his ankle while hiking show a left ankle fracture dislocation.

  • Radiographs of a 51-year-old man who hurt his ankle while hiking show a left ankle fracture dislocation.

    Slide

    Radiographs of a 51-year-old man who hurt his ankle while hiking show a left ankle fracture dislocation.

  • After the ankle was closed reduced, these postreduction radiographs confirm reduction of the talus under the tibia.

    Slide

    After the ankle was closed reduced, these postreduction radiographs confirm reduction of the talus under the tibia.

  • After the ankle was closed reduced, these postreduction radiographs confirm reduction of the talus under the tibia.

    Slide

    After the ankle was closed reduced, these postreduction radiographs confirm reduction of the talus under the tibia.

 

A 51-year-old man presents to the emergency department with left ankle pain and deformity after tripping while hiking. He stepped awkwardly on a rock while climbing down a mountain and felt a “crack” as his ankle gave way. He was transported to the emergency department, where radiographs show a left ankle fracture dislocation. The ankle is closed reduced with the patient under conscious sedation. Postreduction radiographs confirm reduction of the talus under the tibia. Motor and distal pulses remain intact after the reduction.

This case has been brought to you in partnership with the Journal of Orthopedics for Physician Assistants.



Casting involves placing plaster or fiberglass circumferentially around an injured extremity. Circumferential casting should not be done in the emergency department setting as swelling will occur after an acute fracture and a cast may restrict tissue expansion caused by inflammation....

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Casting involves placing plaster or fiberglass circumferentially around an injured extremity. Circumferential casting should not be done in the emergency department setting as swelling will occur after an acute fracture and a cast may restrict tissue expansion caused by inflammation. Swelling after placement of a rigid circumferential cast may result in complications such as compartment syndrome, skin breakdown, and vascular compromise.

Casts are more often applied in a clinical setting 7 to 10 days after the initial injury, when swelling has subsided and complications are far less likely to occur. Bivalved casts accommodate swelling and are used occasionally in the emergency department setting for rigid support. However, splints are much easier and faster to apply and therefore are the preferred method of immobilization in the emergency department setting. Splints are also much easier to remove for skin checks or if the splint gets wet or dirty.1,2

Ankle fracture dislocations can be quite unstable after reduction. If the talus cannot be reduced under the tibia, urgent surgical intervention is required. If the ankle is left dislocated, pressure necrosis of the skin may develop, neurovascular injury may occur, and the articular cartilage can be further damaged.

Applying a posterior and stirrup splint provides the most support for the ankle to maintain alignment. The posterior splint keeps the ankle in dorsiflexion, and the stirrup splint maintains supination of the foot to hold the reduction. It is helpful to have a second pair of hands holding the big toe up with the ankle in dorsiflexion to maintain the reduction while the splint is placed. The Quigley maneuver is used for posterior and lateral dislocations. This maneuver involves flexing the knee, rotating the leg externally, and supinating and adducting the foot to hold the reduction. While the fiberglass splint hardens, posterior-lateral force is applied to the distal tibia and anterior medial force is applied to the heel to help mold the splint properly.1,2

Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).

Reference

  1. Boyd AS, Benjamin HJ, Asplund C. Principles of casting and splinting. Am Fam Physician. 2009;79:16-22.
  2. Egol K, Koval KJ, Zuckerman JD. Handbook of Fractures. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.

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