History

• 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

VS

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

Management

• 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

Technique

• 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