A 38 year old truck driver is brought to the ED at 0900 with a dislocated left ankle after inadvertently stepping into a hole and twisting on it when alighting from his truck. He is well with no past medical history, and it’s an isolated injury with no complaints of pain other than that joint.
Examination of his foot is reassuring with good volume DP pulse, normal CRT and no sensory deficit. The skin overlying his distal tibia medially is however stretched and a little pale. In the good old bad old days when I was an intern, I remember vividly seeing this exact injury summarily reduced in Casualty (well it was called that then) without analgesia by orthopaedics on grounds of needing to deal immediately with a compromised joint. Have we evolved from those days? How would you proceed now to relocate this joint in your ED? Do you Xray first?
I think our EDs are now a little more sophisticated, and see no role for “old school” analgesia-less reduction of this injury unless perhaps in multi-trauma with altered conscious state. So here’s how I proceeded…
- First a quick general medical/secondary survey and review of vitals to ensure an isolated injury. No Xray pre-reduction routinely, but I do photograph them to show the surgeon (and use for teaching later)
- Secure IV access, then titrated IV analgesia with morphine (other route and agent such as IN, inhalational obviously OK too)
- Explanation and consent for procedural sedation, with move to resuscitation area, and enlisting of required team members
- I then like to work through a “checklist” type approach for procedural sedation, whether emergent or elective. This has recently been more prominently discussed in EM settings (an example from LIFL) and though I’m not always a fan, I do always use it for intubation and sedation procedures. This approach is aided by using standardised documentation sheets such as this double-sided one from my last hospital. Draft SCGH ProcSed
So this patient had a full risk assessment, equipment assembled and checked, then a colleague deftly reduced the joint whilst I sedated with IV Propofol. There were no complications, and a plaster slab was applied and the limb elevated.
Two quick tips for young players here. Firstly, I always like to have two checked IVs in place for procedural sedation, with exceptions perhaps for children and quick procedures in well very low risk patients. Failure and loss of IV access may end up being just a minor glitch, but at worst can be life threatening for the patient.
Secondly, I like to tell patients beforehand there is a small possibility that I will be unable to reduce the joint, as occasionally these prove to be irreducible closed and an open approach in theatre is required.
Here’s his post-reduction ankle Xrays and report
There is a cortical breach within the distal fibula at the level of the ankle joint consistent with a distal fibular fracture, likely Weber B. No definite medial malleolar fracture is identified, and the ankle mortise does appear widened, with widening of the space between the medial malleolus and talus
So now on to the classification of this injury, is it a Weber A, B or C? I’ve always found this classification hard to remember, but its well explained here on the Radiopedia and Bone school sites. This injury may be a Weber B or a Weber C as the ankle mortise is widened medially, but one very significant component not visualised on this Xray is the disruption of the tibio-fibular syndesmosis which occurs with the Pronation/External rotation (PER) mechanism. This was the major concern of the orthopaedic surgeon who reviewed this patient, as it is crucial for joint stability and influences the decision/requirement for ORIF. Even if tibio-fibular widening isn’t seen on Xray, it may still be demonstrated when examined under anaesthesia. He asked me to additionally obtain an xray of the full length of the fibula, which I thought odd at the time as there was no clinical tenderness more proximally.
So another lesson (re-learned) for me, I wouldn’t have picked up this proximal fracture.
This man was treated with ORIF, and is now up and about.