Professional Documents
Culture Documents
105
Katrina John, Jeffrey Kile, and Amish Aghera
105.2 Contraindications 1. Check the neurovascular status of the affected foot and
ankle.
Relative 2. If there is no evidence of critical neurovascular compromise,
Open dislocations where there is no evidence of acute obtain a lateral and an anteroposterior radiograph of the
neurovascular compromise are better managed defini- affected ankle.
tively in the operating room to avoid further 3. Ensure adequate parenteral sedation and analgesia to
contamination. maximize success and limit pain and suffering.
4. Position the patient on a stretcher with the knee flexed at
90 over a folded pillow or rolled-up sheet or with the
105.3 Materials and Medications lower leg and knee hanging over the edge of the stretcher.
105.4.1 Posterior Dislocations 4. Dorsiflex the foot while another assistant applies down-
ward pressure to the distal anterior leg (Fig. 105.2).
1. Hold the heel in one hand and pull with longitudinal 5. Examine foot for restoration of normal anatomy and for
traction. any new lacerations or defects to the skin.
2. With the other hand, hold the top of the foot and gently 6. Recheck neurovascular integrity.
plantarflex it downward, while an assistant provides 7. Place the leg in a sugar-tong splint with the foot at 90.
countertraction at the back of the midcalf (Fig. 105.1). 8. Recheck neurovascular integrity.
3. Continue longitudinal traction at the heel and countertraction
at the calf.
105.4.2 Anterior Dislocations 4. Keeping the foot at 90 to the leg, hold the foot firmly and
push the foot downward toward the floor while another
1. Hold the heel in one hand and pull with longitudinal assistant applies upward pressure to the distal posterior
traction. leg (Fig. 105.4).
2. With the other hand, hold the top of the foot and dorsiflex, 5. Examine the foot for restoration of normal anatomy and
while an assistant provides countertraction at the back of for any new lacerations or defects to the skin.
the midcalf (Fig. 105.3). 6. Recheck neurovascular integrity.
3. Continue longitudinal traction at the heel and countertrac- 7. Place the leg in a sugar-tong splint with the foot at 90.
tion at the calf. 8. Recheck neurovascular integrity.
105.5 Complications severe stretching and tenting of the skin with resultant
skin blisters, skin necrosis, and possible conversion to
Compound fractures a compound fracture.
Neurovascular injury Be sure to check the radiograph carefully for com-
Skin and soft tissue damage monly associated fractures notably of the malleoli.
Compartment syndrome
Selected Reading
105.6 Pearls and Pitfalls
Collins DN, Temple SD. Open joint injuries: classification and treat-
ment. Clin Orthop. 1989;243:48.
Pearls
Hamilton WC. Injuries of the ankle and foot. Emerg Med Clin North
The ankle rarely dislocates without associated Am. 1984;2:361.
fractures. Kelly PJ, Peterson FP. Compound dislocations of the ankle without
Pitfalls fractures. Am J Surg. 1986;103:170.
Simon RR, Sherman SC, Koenigsknecht SJ, editors. Emergency ortho-
Ankle dislocation is an orthopedic emergency, and
pedicsthe extremities. 5th ed. New York: McGraw-Hill; 2007.
reduction should not be delayed by imaging if there is p. 264.
evidence of neurovascular impairment. Complications Wedmore IS, Charette J. Emergency department evaluation and treat-
that are exacerbated by delay in management include ment of ankle and foot injuries. Emerg Med Clin North Am.
2000;18:85.
concomitant fractures, gross deformity of the ankle,