HISTORY: A 22-year-old men’s club Division I Rugby-7s winger, injured his right ankle post a simultaneous opposing two-player tackle. Tackler-one locked the ball carriers foot in place wrapping the lower leg, and tackler-two changed the direction of the upper body of the player which overcame ankle mortise stability and strength, inducing an ankle inversion. Post-tackle, injured player complained of pain and inability to bear weight. History noted, no ankle supports/brace or tape used, and no previous ankle injury/ surgeries.
PHYSICAL EXAMINATION: Sideline emergency services removed injured foot cleat, found ankle deformity, which was secured for transport. ED exam revealed patient with a medially deformed right foot. Exam noted localized pain and tenderness, post palpation on right ankle deformity and lower leg, plantar flexed and supinated. Mild swelling, no lacerations or open wounds noted. Patient’s limited exam secondary to pain, however, reflected no decreased right sided lower extremity sensation, reflexes or strength. Patient was able to flex and extend toes despite extreme pain of deformed limb. Injured limb had a noted palpable dorsalis pedis and posterior tibialis pulse.
1. Subtalar joint subluxation/dislocation
2. Open sub-talar dislocation
3. Tibial-talar dislocation
4. Fractures of the ankle/foot
TEST AND RESULTS: Ankle anterior/posterior radiographs: -right posteromedial peri-talar dislocation. Ankle lateral radiographs: -navicular dislocation laterally from talus -rotary subluxation of calcaneus medially from the talus -no associated fractures of the tibia/fibula including malleoli.
FINAL WORKING DIAGNOSIS: Closed right posteromedial peri-talar dislocation without associated fracture.
TREATMENT AND OUTCOMES:
1. Emergency. Clearly seen on radiograph.
2. Immediate ED conscious sedation closed- reduction, entailing injured knee flexion to relax gastrocnemius, with traction to heel/forefoot of injured ankle to reduce joint.
3. Short-leg cast post-reduction, PWB for 4 weeks. Rehabilitation post-cast removal, with ROM and heel/calf stretches, progressing to strengthening. FWB at 7 weeks post-injury and cleared for sport.
4. 3-month follow- up, FWB, 7° dorsi-flexion, 32° plantar-flexion, 14° inversion, and 10° eversion with no restrictions.