Ankle Fracture-Dislocation Reduction

When to reduce before X-ray

• Reduce immediately, before imaging, if the skin is tented, blanched or under visible tension over the deformity, or if there is any distal neurovascular compromise (absent/reduced pulse, pallor, altered sensation).
• A grossly deformed ankle with skin at risk can progress to skin necrosis or an open fracture within minutes — do not wait for a porter, trolley round-trip, or radiographer availability.
• If the skin and neurovascular status are not threatened, and the diagnosis/injury pattern is uncertain, obtain X-rays first — reduction changes the anatomy you are trying to characterise.
• Reassess neurovascular status immediately after any reduction, and again after splintage.

Analgesia & sedation

• Titrated IV opioid analgesia as a minimum, given the urgency often precludes waiting for a full sedation work-up.
• Entonox is a useful rapid adjunct for the moment of reduction.
• Procedural sedation (e.g. ketamine or a titrated opioid/benzodiazepine combination) if time and monitoring allow — do not let sedation delay a genuinely time-critical reduction for a threatened limb.
• Haematoma block is less reliable here than for an isolated distal radius fracture given the complex, often multi-fragment injury — systemic analgesia ± sedation is the mainstay.

Equipment

Reduction technique

1. Position and relax the calf

   Flex the knee to about 90° (patient supine or with the leg over the trolley edge) — this relaxes gastrocnemius, which otherwise resists reduction across the ankle.

2. Grip and apply traction

   Grip the heel in one hand (heel-cup grip) and the forefoot/dorsum in the other ("holding the foot like the shaft of a dart, throwing it straight"), and apply firm, steady longitudinal traction.

3. Correct the deformity

   While maintaining traction, reverse the direction of displacement seen clinically (commonly correcting external rotation and posterior/lateral talar shift) with a smooth, continuous motion — avoid sudden jerking movements.

4. Hold in the corrected position

   Maintain the ankle at roughly 90° (neutral dorsiflexion) once reduced, resisting the tendency of the foot to fall back into equinus/deformity.

5. Splint while holding

   Apply a well-moulded below-knee backslab with the ankle held at 90°, maintaining the reduction until the plaster sets.

Traction direction

Post-reduction checks

• Re-examine distal pulses, capillary refill, sensation and motor function immediately after reduction and again after splintage.
• Post-reduction X-ray to assess reduction quality and fracture pattern.
• Below-knee backslab with the ankle held at 90°; elevate the limb to control swelling.
• Analgesia review and safety-netting advice (tight cast symptoms, when to return).
• Orthopaedic referral — most ankle fracture-dislocations need surgical fixation once swelling allows.

Open fracture-dislocation

• An open ankle fracture-dislocation is managed per major-trauma / open-fracture pathway (BOAST / NICE NG37 principles): early recognition, urgent reduction to reduce ongoing soft-tissue and neurovascular injury, and antibiotics given as soon as possible — ideally within 1 hour of injury.
• Photograph the wound once, then cover with a saline-soaked sterile dressing; avoid repeated wound exposure and inspection in the ED, which increases infection risk without changing immediate management.
• Splint in the reduced position, give tetanus prophylaxis per status, and involve orthopaedics (and plastics for significant soft-tissue loss) urgently — definitive debridement is a theatre procedure, not an ED one.
• Document the time of injury, time of antibiotics, neurovascular status before and after reduction, and wound description/photograph reference.

References