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1382 THE JOURNAL OF BONE AND JOINT SURGERY
CASE REPORT
Open medial dislocation of the ankle withoutfracture
U. Tarantino,G. Cannata,E. Gasbarra,L. Bondi,M. Celi,R. Iundusi
From the University
of Rome, Rome, Italy
U. Tarantino, MD, Professor
G. Cannata, MD, Assistant
Professor
E. Gasbarra, MD, Assistant
Professor
L. Bondi, PhD, Orthopaedic
Surgeon
M. Celi, MD
R. Iundusi, MD, Orthopaedic
Surgeon
Department of Orthopaedic
Surgery
University of Rome “Tor
Vergata”, Oxford Street 81,00133 Rome, Italy.
Correspondence should be sent
to Professor U. Tarantino;
e-mail:
©2008 British Editorial Society
of Bone and Joint Surgery
doi:10.1302/0301-620X.90B10.
21015 $2.00
J Bone Joint Surg [Br]
2008;90-B:1382-4.
Received 10 March 2008;
Accepted 11 June 2008
A 20-year-old man sustained an open medial dislocation of the ankle without an associated
fracture after a low-energy inversion injury. Prompt debridement and reduction with primary
wound closure of the skin were performed without suture of the capsule. Immobilisation in
a non-weight-bearing cast for 30 days followed by ankle bracing for two weeks and
subsequent physiotherapy, produced full functional recovery by three months. At follow-up
at one year there was a full range of pain-free movement, although the radiographs and MR
scan showed early post-traumatic degenerative change at the medial aspect of the tibiotalar
and the calcaneocuboid joints.
Dislocation of the ankle without fracture is
uncommon.1 Previous ankle sprains, medial
malleolar hypoplasia, weakness of the per-
oneal muscles and ligamentous laxity are pre-
disposing factors for dislocation. Although
there are few reports in the literature, Toohey
and Worsing2 and Elisé et al3 have described
the largest series, comprising 19 and 16
patients, respectively. Because of the intrinsic
stability of the ankle mortise and its ligaments
and tendons, dislocation is usually caused by
high-energy trauma which causes combined
plantar flexion and inversion or eversion of thefoot, accompanied by fractures of the malleoli.
We describe a case of an open dislocation of
the ankle without malleolar fracture which
followed a low-energy trauma.
Case report
A 20-year-old man presented after sustaining
an inversion injury to his right ankle while
running after his cat. On examination there
was a large lacerated wound over the dorso-
lateral aspect of the right ankle approxi-
mately 10 cm in length (Fig. 1). The foot was
displaced medially. The distal articular sur-faces of the fibula and the tibia were exposed.
The posterior tibial pulse was absent and
there were paraesthesiae involving the dorsal
aspect of the foot. Anteroposterior (AP)
radiographs indicated a medial dislocation of
the talus without concomitant fracture or
disruption of the ankle mortise (Fig. 2). There
was medial malleolar hypoplasia according to
the criteria described by Elise et al3 with a
medial-to-lateral ratio of 0.31.
After administration of antibiotics and local
irrigation, under general anaesthesia, the dislo-
cation was reduced, and the wound was closed
without repair of the capsule (Fig. 3). Spiral
CT angiography of the right leg, performed
immediately after reduction, showed no arte-
rial injury. The paraesthesiae over the dorsal
aspect of the foot resolved after three days. A
below-knee non-weight-bearing cast was
applied with the ankle in the neutral position
Fig. 1
Photograph showing the open dislocation of the ankle at presentation.
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OPEN MEDIAL DISLOCATION OF THE ANKLE WITHOUT FRACTURE 1383
VOL. 90-B, No. 10, OCTOBER 2008
and retained for 30 days. An ankle brace was used for
another two weeks with progressive weight-bearing. Non-
steroidal anti-inflammatory treatment was given as
prophylaxis against heterotopic bone formation for four
weeks.4
The patient started physiotherapy after removal of the
cast. Examination three months after injury revealed a
pain-free stable joint with a full range of movement. Plain
radiographs and MRI at follow-up showed a normal joint
without evidence of heterotopic bone formation. At one
year, clinical examination confirmed a full pain-free rangeof movement and he reported no limitation in sport and
activities of daily living. Radiological and MR examination
showed minor post-traumatic medial tibiotalar and
calcaneocuboid degenerative changes (Figs 4 and 5).
Discussion
Pure talotibial dislocations are rare.5,6 Generally because of
the intrinsic stability of the ankle they are associated with
malleolar fractures, mostly resulting from high-energy
trauma such as motor-vehicle accidents, sports injuries and
Fig. 2
Anteroposterior radiograph showing the medial dislocation of the rightankle at presentation.
Fig. 3
Anteroposterior radiograph immedi-ately after reduction.
Fig. 4
Anteroposterior and lateral radiographs at follow-up at one year.
Fig. 5
MR scan at follow-up at one year.
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1384 U. TARANTINO, G. CANNATA, E. GASBARRA, L. BONDI, M. CELI, R. IUNDUSI
THE JOURNAL OF BONE AND JOINT SURGERY
falls from a height. Only a few cases caused by low-energy
trauma have been reported.5,7-9
The talus, according to the studies of Fernandes,10 may
dislocate medially or laterally, without associated fractures
after application of an inversion or eversion force on a
maximally plantar flexed foot. Fahey and Murphy11
described five types of ankle displacement according to the
direction of the dislocation: anterior, posterior, medial,
lateral or superior combined. The posteromedial direction
is the most common. In our patient the dislocation was
medial. There was no history of recurrent sprains and on
examination there were no signs of ligamentous laxity.
However, there was hypoplasia of the medial malleolus
with a medial to lateral ratio of 0.31;8 the reported normal
ratio ranges from 0.58 to 0.62.3
On the lateral radiograph the cover of the talus by the
tibia measured 0.64, while the normal range is 0.58 to 0.60.
This ratio is determined by two angles (b/a) of which angle
is measured between two lines projected from the centre of
the talus through its anterior and posterior articular ridge,and angle a is measured between two lines projected from
the centre of the talus through the anterior and posterior
articular ridge of the tibia.3,5
Other authors agree that immediate reduction decreases
the risk of vascular or neurological complications and that
reduction, debridement and capsular suture should be fol-
lowed by immobilisation in a short-leg cast for six weeks.12,13
The repair of disrupted ligaments is controversial. Sev-
eral authors have recommended repair of the lateral liga-
ments at the time of debridement.3,14 Others state that
repair does not improve ankle function.11,15 It is interesting
that despite massive ligamentous disruption, instability is
rare2,5 and such types of dislocation, have a good outcome.Our patient did not undergo repair of the ligaments.
No benefits in any form have been received or will be received from a commer-
cial party related directly or indirectly to the subject of this article.
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