Back to Basics: Ankle Injury

By: Charlie Ingram

CC: Ankle Injury

HPI: 53 y/o male Patient was skydiving and when he hit the ground he had a running stop as usual and his right leg and ankle twisted laterally underneath him. He then heard a pop and had obvious deformity.

Physical Exam:

• Normal ABCs.
• Pulmonary: BS present and equal.
• Abdomen: No distension or tenderness.
• Musculoskeletal: No spinal tenderness, stable pelvis. RLE with deformity (see image below). Sensation intact in R foot. Strong right DP pulse.
• Skin: R foot discoloration. R foot is cool to the touch. Skin tenting at medial aspect. No laceration or abrasions.

Imaging:

Questions:

1. What is the diagnosis?

2. How emergently should this be reduced?

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

Answers

1. Trimalleolar fracture dislocation

2. Immediate reduction after analgesia &/or sedation for foot discoloration and skin tenting

Pearls

• More than just pulse and sensation exam needed to ensure there is no neurovascular compromise- Skin appearance, temperature, pulses, sensation are better indication than finding single strong pulse
• Indications for immediate reduction of the ankle include Dusky foot, absent pulses, skin tenting
• Sedation and pain control are important aspects, this case was given 2mg Versed and hematoma block with Lidocaine/bupivacaine mixture and tolerated reduction well.

References:

Omer T, Santiago-Martinez M (2020). Ankle Injuries. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill. https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=2353&s....

Chavez S, Denq W. SplintER Series: Ankle Dislocation. Academic Life in Emergency Medicine. July 10, 2019. Accessed on on June 3, 2020. https://www.aliem.com/splinter-series-ankle-dislocation/