A 37-year old man injured his right ankle after stepping in a pothole while jogging. His ankle appears deformed with the foot displaced laterally and posteriorly. The skin over the lower tibia also appears stretched and pale. This clinical presentation is most consistent with a fracture dislocation at the ankle joint. The priorities are to provide analgesia, reduce the injury in the emergency department to preserve skin integrity, and obtain an x-ray for orthopedic guidance before definitive repair. Initial analgesia could include nitrous oxide and narcotics, with additional sedation like propofol or ketamine if needed despite his fasting status.

1. A 37 year old man out jogging stepped into a deep pothole left from
footpath repairs and injured his right ankle. The injury was half an
hour ago, he ate and drank just before he went out for the run and he
is obviously distressed by the pain. The ankle is his only injury.
•Describe and interpret the clinical photograph
•How will you manage him ?

3. The ankle is obviously deformed with the foot apparently displaced laterally and posteriorly.
The skin overlying the lower end of the tibia is stretched and pale and presumably ischaemic.
The foot itself seems to be perfused. Such an appearance could be either due to an ankle joint
fracture/dislocation or a subtalar dislocation (with or without fracture). Clinically they can be
hard to differentiate. The appearance is more consistent with a fracture dislocation at the level
of the ankle mortice, made more likely by the area of “at risk” skin which is probably being
stretched over the distal tibia fracture end. Subtalar dislocation less often compromises skin
but can be associated with foot ischaemia.
The priorities in this man are analgesia and early reduction in ED to preserve skin integrity.
Traditionally, it was taught that preserving the integrity of the skin was an emergent priority,
and that reduction should occur before anything else, including Xrays. Fortunately, while this
is still true, getting an x ray (which our Ortho colleagues find enormously helpful) doesn’t
normally lead to long delays and should occur if possible. The other thing useful in this day
and age is a photo pre reduction. Post reduction, many have a CT performed to guide
definitive repair.
Initial analgesia could be with inhaled nitrous oxide and titrated narcotic. This may be enough
to allow reduction and splinting with substantial control of his pain. Should more sedation be
required his fasting status is a minor consideration and should not delay things. Propofol has
the advantage of rapid onset/offset but doesn’t provide analgesia. Ketamine “dissociates” but
has profound analgesic actions.