Reduction - Ankle dislocation

This procedure is performed using procedural sedation which is covered separately

Indications

Ankle dislocation

Contraindications (absolute in bold)

Life or limb-threatening conditions

Fractures of pelvis or femur (risk of displacement during reduction)

Delayed presentations greater than seven days (increased risk of fracture and vascular injury)

Alternatives

Reduction in operating theatre

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

or

Written consent

More complex non-emergency procedure with higher risk of complications

Potential complications

Failure (of reduction, recurrence or immobilisation)

Conversion to an open injury

Neurovascular damage

Fracture

Procedural hygiene

Standard precautions

Aseptic non-touch technique

PPE: non-sterile gloves

Area

Resuscitation bay

Staff

Procedural clinician and two assistants

Additional clinicians required for procedural sedation

Equipment

Materials for long leg backslab immobilisation

Sterile saline, gauze and non-adherent dressings (for irrigating and dressing open wounds)

Positioning

Supine with hip and knee flexed approximately 45 degrees (to relax Achilles tendon)

First assistant applies countertraction to the thigh or lower leg just below the knee

Second assistant holds lower leg, maintaining position above the bed

Medication (for procedural sedation)

No single sedative agent recommended for every patient, typically:

IV pain relief prior to procedure, followed by

Bolus ketamine or propofol 1mg/kg (dose reduced to 0.3-0.5mg/kg if frail or elderly)

Further titrated 20mg boluses to minimum level required for patient comfort

Sequence

Examination for other injuries and fractures

Neurovascular assessment of foot (pulses, power and sensation)

Bedside pre-reduction X-rays (see discussion)

Analgesia and procedural sedation

Remove debris, irrigate open wounds with 500ml sterile saline or water and dress with moist gauze

Proceduralist grips the heel and forefoot and leans backwards applying traction

Slight plantar or dorsiflexion may be applied to exaggerate the deformity (depending on direction of dislocation)

Proceduralist restores the ankle to the anatomical neutral position (90 degrees ankle flexion)

Apply lateral and medial pressure to align the talar joint if required

Post-procedure care

Check X-ray, circulation and limb function:

Assess joint stability with gentle passive movement of joint

Reassess neurovascular status

Immobilise the ankle in 90 degrees flexion with a long leg posterior backslab

Obtain post-reduction X-ray (patient should not leave the department until confirmed satisfactory)

Ongoing care:

Tetanus (ADT) and antibiotic cover (cefazolin 2g IV) for open wounds

Provide oral pain relief

Discuss ongoing management with orthopaedic team

Document procedure, neurovascular assessments, X-ray findings and management plan

Tips

Search for other fractures and serious injuries when treating a dislocated joint

Always perform a neurovascular exam before and after a relocation attempt

Reassurance, verbal distraction, effective pain relief and sedation all aid successful joint relocation

Slight traction distal to the dislocation is often enough to relocate the joint

Early orthopaedics involvement is indicated for fractures, neurovascular compromise or two failed reductions

Open wounds may be associated with exposed bony elements, be careful to avoid sharps injury

Discussion

Bedside pre-reduction X-rays are recommended to confirm dislocation and identify fracture dislocations prior to reduction attempts. Vascular compromise or threatened skin penetration indicate the need for prompt relocation, however there is usually time for an X-ray during preparation for the procedure while pain relief is provided.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Koehler SM, Eiff P. Overview of ankle fractures in adults. In: UpToDate. Waltham (MA): UpToDate. 2019 October 31. Available from: https://www.uptodate.com/contents/overview-of-ankle-fractures-in-adults

Skinner H. Current diagnosis & treatment in orthopaedics. 5th ed. New York: McGraw-Hill Medical; 2013.

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