I am often asked if we should get imaging before trying to reduce a dislocation. My answer is yes (with exceptions in unusual circumstances). Sometimes, a dislocation is not so simple, mostly due to fractures (a dislocation with a fracture may be very difficult to reduce). Occasionally, what looks like an ankle dislocation is actually a foot dislocation, and you may be pulling in the wrong direction if you don’t get an xray. And rarely, you see something that makes you go “oh oh, this is going to be impossible.”
The vast majority of ankle dislocations can be reduced with minimal effort, esp when there are bimal fractures. Some patients don’t even require anesthesia (though a little morphine helps). I usually reduce ankles under conscious sedation if the patient has not eaten recently.
EM residents should learn to reduce ankle dislocations. They’re simple and it’s useful to know once you’re alone in the community. When you see this xray, you should realize that this is not a simple boo-boo. The talus is knocked off its hinges. Carpal and tarsal dislocations are impossible to fix via closed reduction at times. You should call orthopedics because there is a good chance it will need to be fixed in the OR.
When a fracture / dislocation is tenting the skin, EM docs shouldn’t wait for ortho to get there. It should be fixed asap, and if ortho is going to take more than a few minutes, the EM docs should try to fix it (for neurovascular reasons – even if there’s a pulse, it’s not good for the skin to have a bone tenting it).
Despite the efforts of 5-6 good orthopedics residents and effective propofol, the ankle was never fully reduced. The patient had to go to the OR
Below is what an ankle dislocation usually looks like. The talus is where it’s supposed to be.
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