The tale of a twisted ankle: Closed reduction of medial subtalar dislocation in the Emergency Department.

Pratyusha Akkaraju

Consultant Emergency Physician, Kauvery Hospital, Marathahalli, Bangalore

Introduction

Subtalar dislocation is caused by the dislocation of the talocalcaneal and talonavicular articulations, commonly caused by high energy mechanisms such as road traffic accidents, twisting injuries to ankle and fall from height. I am reporting a case of medial subtalar dislocation where the patient was successfully treated with closed reduction under procedural sedation in emergency department and asked to follow up in the outpatient orthopedic department.

Case Presentation

A 23-years aged male presented to emergency department with history of pain and deformity of right ankle joint after a traumatic injury half an hour ago.  He sustained an injury when he jumped off a divider with an inverted landing of the foot after which patient was unable to walk with his injured foot. His past medical history was unremarkable.

Clinical examination of the right ankle revealed a deformity- the right foot was medially displaced, with ankle edema and restricted joint movement. There were no external wounds or discoloration. The dorsalis pedis and posterior tibial pulses were palpable and sensation was intact.

Fig (1): Clinical presentation of the right ankle with deformity and swelling on presentation

Radiograph of the right Ankle – Anteroposterior and Lateral, of the foot showed evidence of dislocation at the talonavicular joint in keeping with sSubtalar dislocation. No fracture was visualized.

Fig (2): Radiographs showing X-ray Ankle – Lateral (Left image) and AP view (Right image)

Treatment

Informed consent was obtained for procedural sedation and closed reduction of the dislocation.

The patient was made to lie supine with knee flexed, reduction was successfully performed with traction to the heel, with pressure applied to the palpable part of talus and eversion of the foot.

Post reduction ankle was checked for stability and neurovascular deficits.

Repeat radiograph done showed good joint congruence.

Patient was put on below knee slab and asked to follow up with CT scan of right ankle the following day in orthopedic outpatient department.

Fig (3): Clinical image of right ankle after reduction of the subtalar dislocation.

Fig (4): Radiograph of ankle shows a satisfactory reduction of the medial subtalar dislocation.

Discussion

Subtalar dislocations are rare injuries affecting the ankle, DeLee and Curtis reported that they represent a little less than 2% of dislocations of all major joints [1]. Medial subtalar dislocation occurs when a forceful inversion injury to the forefoot causes the talus to pivot on the sustentaculum tali, stressing the subtalar and talonavicular joints [2]. Optimal management of subtalar dislocations is immediate closed reduction with procedural sedation. Medial dislocations have a better prognosis compared to lateral, anterior or posterior injuries, which are often associated with fractures, require open reduction and fixation, and frequently result in instability and arthritis [3]. Following reduction, the foot should be immobilized for 4–6 weeks with the patient remaining non-weight-bearing [4]. Associated intra-articular fractures are difficult to identify at plain radiography and their presence can hinder anatomic reduction and worsen the overall prognosis. Therefore, routine post-reduction CT has been recommended to detect these fractures more accurately [5].

Reference

  • DeLee JC, Curtis R. Subtalar dislocation of the foot. J Bone Joint Surg Am. 1982;64:433–437.
  • De Palma L., Santucci A., Marinelli M. Clinical outcome of closed isolated subtalar dislocations. Arch Orthop Trauma Surg. 2008; 128:593–598. doi: 10.1007/s00402-007-0459-8.
  • Wagner R, Blattert TR, Weckbach A. Talar dislocations. Injury. 2004;35:SB36–SB45
  • Biswas S, Murphy M.Subtalar dislocations Internet J Orthoped Surg 200631–5.
  • Melenevsky Y, Mackey RA, Abrahams RB, Thomson NB 3rd. Talar Fractures and Dislocations: A Radiologist’s Guide to Timely Diagnosis and Classification. Radiographics. 2015;35:765–779.

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