Index:
• Background
• Relevant anatomy
• Classification
• Types of dislocations
• Clinical manifestations
• Management
• References
Background
• There are over a quarter of a million ankle fractures each year in
the United States (1), and they are among the most commonly
treated fractures (2). These injuries occur when supraphysiologic
loads force the talus against its mortise confines.
• The malleoli and soft tissue supports often fail in predictable
patterns, depending on foot position and movement of the leg, as
classified by Lauge-Hansen and others.
• The velocity of the injury can impact whether soft tissues or bones
fail (1). Continued movement of the talus, beyond the point of
bone failure, can result in displacement of fracture fragments,
open fracture injuries, and/or dislocation of the ankle joint. The
purpose of this update is to review ankle joint dislocations.
Pertinent Ankle Joint Anatomy
• The ankle is a modified hinge joint in which six
articular surfaces of three bones articulate to allow
the foot to move on the leg.
• The distal tibia and fibula are held tightly together by
the syndesmotic ligaments, and together, form the
ankle mortise. The medial, lateral, and posterior
malleoli buttress the talus inside the mortise. The
deltoid and lateral ankle ligaments provide collateral
stability. The weaker capsular ligaments provide
anterior and posterior joint support.
• The inherent stability of the ankle joint is dependent
on foot position. The talus and tibial plafond are
wider anteriorly than posteriorly.
• Therefore, as the talus plantarflexes, the ankle
mortise is relatively less confining to the narrower
posterior talar surface and the ankle joint is less
stable.
• With ankle dorsiflexion, the talus is locked into the
mortise; the wider anterior talus forces the fibula to
externally rotate through the syndesmosis (3).
• Ankle Fracture Dislocations
• High-energy forces transmitted through the ankle, can fracture the malleoli.
These injuries can result in failure of the mortise and supportive soft tissues,
destabilizing the talus confines. With the ankle in plantarflexion, the joint is not
stable, and translational forces can dislocate the talus from its mortise.
• Ankle fracture dislocations most frequently occur in young males, and are
caused during motor vehicle accidents, sports trauma, or falls (4-6). These
injuries typically result from high-energy trauma (5,7,8). Low-energy, rotational
ankle fracture dislocations have been less frequently reported (9).
• The direction of the joint dislocation is determined by the position of the foot
and the direction of the force being applied (6). Inversion injuries result in
medial joint dislocation after the anterior talofibular and calcaneofibular
ligaments are compromised (10, 11).
• Eversion injuries can disrupt the deltoid ligament and medial ankle joint
capsule, progressing to lateral ankle dislocation (10). Risk factors for these
injuries include excessive ankle joint laxity, medial malleolar hypoplasia,
weakness of the peroneals, and a history of chronic ankle sprains (8,9,12).
• In 1965, Fahey and Murphy classified ankle fracture dislocations based on the direction of
dislocation .
• This classification system defined dislocations to be Anterior, Posterior, Medial, Lateral,
Superior, or a combination of these directions .The direction of dislocation is described by
the location of the more distal bone segment (the talus).
• The AO Classification Supervisory Committee and the Orthopaedic Trauma Association’s
2007 revision of the “Compendium on Fracture Classification” defined ankle dislocations
under section 80-A . Like most AO joint dislocation classifications, there are five types which
are defined by direction of dislocation: Anterior (80-A1), Posterior (80-A2), Medial (80-A3),
Lateral (80-A4), and Other (80-A5).
• Anterior ankle dislocations occur with forced ankle dorsiflexion, when the foot is stabilized,
and the lower leg is forced posteriorly. The dorsalis pedis arterial supply is at risk due to the
anteriorly displaced talus. This mechanism is rarely reported.
• Posterior ankle dislocations are most common. These injuries occur when a high-energy axial
force drives the inverted foot backwards, trapping the wider anterior talus behind the tibial
plafond.
• These injuries are commonly accompanied by syndesmotic failure or fracture of the lateral
malleolus . This dislocation can potentially compromise the posterior tibial neurovascular
structures.
• Medial and lateral ankle dislocations are caused by forced eversion, inversion or rotational
mechanisms. These are usually associated with malleolar fractures, Superior ankle
dislocations occur when the talus is driven up into the mortise, and results in joint diastasis
Upward tibiotalar dislocations can occur with or without associated fracture .
•Anterior ankle dislocations occur with forced
ankle dorsiflexion, when the foot is stabilized, and
the lower leg is forced posteriorly. The dorsalis
pedis arterial supply is at risk due to the anteriorly
displaced talus. This mechanism is rarely reported.
•Posterior ankle dislocations are most common.
These injuries occur when a high-energy axial
force drives the inverted foot backwards, trapping
the wider anterior talus behind the tibial plafond.
These injuries are commonly accompanied by
syndesmotic failure or fracture of the lateral
malleolus . This dislocation can potentially
compromise the posterior tibial neurovascular
structures.
• Medial and lateral ankle dislocations are caused
by forced eversion, inversion or rotational
mechanisms. These are usually associated with
malleolar fractures, Superior ankle dislocations
occur when the talus is driven up into the mortise,
and results in joint diastasis Upward tibiotalar
dislocations can occur with or without associated
fracture .
• “Pure” Ankle Dislocations
• “Pure” ankle dislocations, without associated fractures are rare; however, multiple
case studies have been presented in the literature (5-7,9,16,21-24). Low-energy
rotation injuries have been presented and described by Fernands. In a cadaver study,
medial and lateral ankle dislocation, without associated malleolar failure, was
possible following sequential failure of the anterolateral joint capsule, anterior
talofibular ligament, and calcaneofibular ligament (11).
• “Pure” ankle dislocations can also occur with syndesmotic failure, with widening of
the ankle joint mortise. The mechanism for these injuries is maximal ankle
plantarflexion, usually with foot inversion (25). These injuries have been successfully
managed with either open repair or closed reduction and immobilization (5-7,9,21).
• In 2003, Ramasamy and Ward classified ankle joint (distal tibiofibular syndesmosis)
dislocations as Type 1 injuries (dislocations without a medial malleolar fracture)
• and Type 2 injuries (dislocations with medial malleolar fracture) (26). The 2007
“Compendium on Fracture Classification” defined distal tibiofibular dislocations.
• There are other dislocations. Hawkins classified talar neck fractures and the
progressive joint dislocations that occur with excessive force. Ankle dislocation is
noted in Hawkins type III and IV injuries. High-energy trauma can
• also result in talar extrusion.
• The signs of a sprain and the
signs of a fracture are very
similar. This is why a trained
medical professional should
evaluate the injured ankle as
soon as possible.
• The signs include:
– Pain, often sudden and severe
– Swelling
– Bruising
– Inability to walk or bear weight
on the injured joint
– Hearing a “crack” or “pop”
– Deformity or “drop-off” of bone
References
Maheshwari:Essential orthopaedics;fifth edition 2015,163,164
S.Brent Brotzman:Clinical orthopaedic rehabiliatation;3rd
edition 2011,358-362
http://www.webmd.com/hw-popup/types-of-ankle-sprains
http://www.webmd.com/a-to-z-guides/ankle-sprain-cause
http://www.usafoot.com/ANKSPRAIN.jpg
http://footcarexpress.com/foot-orthotics/wp-content/uploads/2
008/12/ankle.jpg
http://www.webmd.com/a-to-z-guides/ankle-sprains
http://www.sports-injury-info.com/images/ankle-fracture-torn-li
gament-or-other-type-of-injury-21312628.jpg
http://images.conquestchronicles.com/images/admin/ankle_fra
cture_bimalleolar_fx_orif.jpg
http://firstaid.webmd.com/ankle-fracture-treatment
