Critical Cases - Ankle dislocation!!


  • 29 yo male with no medical problems presents after everting his right ankle on an icy sidewalk
  • Felt immediate "pop" and pain
  • Unable to weight bear
  • No other injuries sustained

Physical exam


T 98 F HR 92 BP 173/80 Pox 96%

  • Circumferential swelling R ankle
  • Unable to range ankle d/t pain
  • Sensation intact to light touch over R foot
  • DP pulse 2+, cap refill <2s
  • +proximal fibular tenderness

Plain films


  • Plain films show: Distal fibular spiral fracture, tibio-talar subluxation, widening of the mortise joint suspicious for deltoid ligament disruption and syndesmotic injury




  • Knee plain films: no proximal fibular fracture noted



  • Decision made to perform closed reduction via procedural sedation
  • An intra-articular block would have also been a good option to obviate need for sedation
  • Goal of reduction is to restore tibio-talar alignment
  • Failure to properly reduce will lead to necrosis of joint cartilage and post-traumatic arthritis, chronic pain



  • Flex ipsilateral knee to 90 degrees for reduction, this will relax gastrocnemius muscle so you aren't pulling against it
  • Grasp affected ankle at the heel with one hand and on the dorsal foot with the other hand
  • Apply longitudinal traction
  • Apply padding, being sure to add extra padding around malleoli and the heel (bony prominences)
  • Apply sugartong and posterior splints, secure with elastic bandage
  • Molding the splint is the key challenge: with one hand apply lateral force on the medial tibia proximal to the ankle
  • With the other hand apply medial force on the distal fibula
  • The idea is that the ankle is dislocated laterally, so your overall force vector on the foot needs to be directed medially (see picture below)
  • Lean into the foot with upper chest to force into slight dorsiflexion at about 90 degrees, this will prevent the calf muscles from developing contractures while in the splint



Note: Operator's right hand is more distal, left hand more proximal: this will force the foot medially and close the medial joint space gap. Also note use of the chest to force the ankle to 90 degrees


Post-reduction plain films




  • Near perfect anatmoic alignment of tibio-talar joint and fibular fragments
  • Ankle is at 90 degrees, this will stretch the calf muscles and prevent contractures from prolonged splint immobilization

Case Outcome

  • Pt discharged on crutches, non weight bearing
  • Followed with orthopedics in the office two days later and scheduled for ORIF repair given disruption to ankle mortise
  • For a quick review of a similar but more severe injury, check out this vintage EM daily post on the dreaded Maissoneuve injury


Learning points

  • Fracture reduction and splinting are key skills for emergency physicians
  • Failure to properly reduce a fracture can lead to necrosis of joint cartilage, chronic pain and disability
  • Understanding the 3 point mold and where/how to apply force is key to a satisfactory ankle reduction