Dislocated Ankle

Dislocated Ankle

An ankle dislocation occurs when the joint shifts out of its normal alignment. The talus bone in the foot separates from the tibia in the leg, which can put enough strain on nearby ligaments to cause tearing. Doctors strongly suggest that a person who experiences intense ankle pain and swelling visit an emergency room as soon as possible so that specialists can properly diagnose and treat a dislocated ankle. A doctor can attempt to manually set the joint back into alignment, place a wrap or cast on the ankle, and explain home-care procedures.

Most dislocations are the result of acute ankle injuries from sudden falls or twists. A dislocation is usually easy to recognize, as the joint swells immediately and the foot appears to be misaligned from the rest of the leg. Professional medical care is necessary to properly treat a dislocated ankle. Before medical help is available, an individual should immobilize the joint as best as possible and avoid putting any pressure on the foot.

Ankle dislocations without fracture occur when significant force applied to the joint results in loss of opposition of the articular surfaces. Because of the large amount of force required and the inherent stability of the tibiotalar joint, dislocation of the ankle joint is rarely seen without an associated fracture. A dislocated ankle requires so much force that a dislocation is hardly ever found without being accompanied by some sort of fracture. Even without a fracture the dislocation can do a lot of damage to the area, especially to the ligaments and the joint.

Pure dislocation of the ankle joint is caused by a force directed posteriorly over the ankle joint with the foot flexed downwards. It is caused by high energy injuries such as road traffic accidents. In majority of cases the skin and other tissues covering the bones of the ankle break down, resulting in a contaminated wound. Generally resulting from trauma to the ankle joint, a dislocation is really a painful injury that calls for immediate medical attention.

Dislocations of the ankle are seen more frequently in young males than in any other group. This presumably is related to their increased risk overall for traumatic injury. Children and adolescents have the most ankle dislocations. An ankle dislocation represents a high force traumatic injury that often occurs in vehicular collisions or sports that involve jumping.

The ankle joint is composed of 3 primary bones: the tibia as well as fibula, the two situated within the leg, as well as the talus, located within the foot. When a dislocation happens, 1 or more of these bones might be out of joint. A pure ankle dislocation is really an unusual event. Usually, ankle dislocations happen in conjunction with either a fracture or sprain.

Signs & Symptoms:

Inability to carry weight
Tenderness upon touching
Intense pain at time of injury
Visible deformity of the ankle
Swelling and possible bruising
Possible immobility of the foot
Soreness and pain at site of the ankle dislocation
Inability to walk or stand with both feet equally on the ground

These signs do not necessarily mean you have a dislocated ankle. Until X-rays can be done of the anteroposterior, lateral and oblique views, it is hard to concretely determine whether the ankle has been dislocated.

Indications:
A traumatic ankle dislocation without associated neurovascular compromise and that has been elucidated by radiographic views of the ankle
Such dislocations may or may not have an associated fracture and may or may not be open injuries.
A traumatic ankle dislocation with associated neurovascular compromise 
These injuries may be evident by an open or closed ankle deformity with obvious malpositioning of the distal foot.

Classifying the injury:
Four types of dislocations are seen around the ankle joint: posterior, anterior, lateral, and superior:

Posterior
A posterior dislocation in the most common type of ankle dislocation. The talus moves in a posterior direction in relation to the distal tibia as force drives the foot backward. The wider anterior talus wedges back, resulting in forced widening of the joint.
This is usually accompanied by either a disruption or a fracture in the case of lateral malleolus. This occurs most commonly when the ankle is plantar flexed.

Anterior
Anterior dislocations result from the foot being forced anteriorly at the ankle joint.
Typically, this occurs with the foot fixed and a posterior force applied to the tibia or with forced dorsiflexion.

Lateral
These dislocations result from forced inversion, eversion, or external or internal rotation of the ankle.
They are associated uniformly with fractures of either or both the malleoli or the distal fibula.

Superior
Diastasis occurs when a force drives the talus upward into the mortise. These dislocations usually are the result of a fall from a height.
In such cases, the patient should be evaluated carefully for concomitant spine injury and fracture of the calcaneus.

Diagnosis:
Diagnosis is done by providing clinical history and examination. X rays show the position of dislocated bones and rule out the presence of fractures.

Inspection of the ankle might reveal significant edema with deformity ranging from trace to obvious. Tenting of the skin by the malleoli may be noted.
Palpation of the joint would reveal tenderness along the joint line, corresponding to areas of capsular or ligamentous disruption.
In associated fractures, tenderness, deformity, or tenting proximal to the joint may be seen.

As this is an emergency hence treatment includes urgent reduction (realignment) of the dislocated bones. This is followed by immobilization in a plaster cast for 6 to 8 weeks.

Treatment:
Treatment is the first part of the healing process. Without immediate treatment, blood vessels and nerve endings that are caught in the dislocation can be permanently cut off from blood supply. This could cause severe ischemic and avascular necrosis in the area. First the doctor must relocate the bone to the proper position, in essence setting the bone back in place. Once the bone is set back in place, the doctor will wrap the area in a fiberglass cast or splint to ensure that the bone remains in place until it has had a chance to heal. Treatment usually entails surgical treatment as well as a recuperation period of up to 6 months.

Healing Procedure:
The healing of a dislocation largely has to do with cells called fibroblasts and osteoblasts. These fibroblasts are collagen fibers that your body produces, which in turn make and repair the connective tissues (such as ligaments) of your body. Once the ligaments are injured, the brain sends a signal to the fibroblasts to head to the affected area and multiply. As they multiply they heal the affected ligament area in the dislocation. Since most dislocations are also accompanied by bone fractures, osteoblasts are also needed for the healing process.

Osteoblasts are similar to fibroblasts, except instead of creating new connective tissue they create bone. When a bone is broken or fractured, the brain sends a signal to the osteoblasts to head to the affected area, multiply and repair the bone. As long as the bone has been set back in place, the osteoblasts and fibroblasts should be able to heal the bone back to its original state. However, if the bone is not reset in time, the two cells may end up healing the bone into the wrong place, causing further problems in the future.

During the healing phase, a patient is usually instructed to attend regular checkups with his or her doctor to monitor progress. The physician asks about symptoms and takes x-rays to see if bones are mending properly. If a person is careful to treat a dislocated ankle according to his or her doctor’s recommendations, there is a good chance that he or she will be able to enjoy physical activity again in as little as four months.

Physical Therapy:
Once the new bone and ligaments have been produced by the osteoblasts and the fibroblasts, the new tissue must be strengthened. This is done through physical therapy. Physical therapy slowly introduces work and stress on the new tissues to help them strengthen and regain their flexibility. Without this process, the injury could be easily prone to dislocation at a later time.

Complications:

infection
late arthritis
calcification of ligaments
osteochondral fractures due to cartilage injury

Risk Factors:

Possible risk factors that may predispose a patient to dislocation include the following:

Joint hyper laxity
Running or jumping sports
Peroneal muscle weakness
Internal malleolar hypoplasia
Very forceful muscle contractions
Contact sports such as hockey or football etc
Lack of muscle conditioning in lower leg muscles
Previous injury in the area of the ankle such as previous ligament sprain

Prevention:

Warm up properly before any physical activity
Properly strengthen and condition the muscles of the lower leg
Protect the ankle in contact sports with the proper protective equipment
Seek proper medical advice if have had ankle sprain or dislocations in the past, as these previous ankle injuries put you at greater risk for dislocating your ankle

Just take your time and heal first before you do anything. Becoming upset and depressed is very normal. Listen to everything the doctor and your PT tells you. It is going to be a long process but try and stay positive.