CASE REPORT

Open medial dislocation of the ankle without

fracture
U. Tarantino,
G. Cannata,
E. Gasbarra,
L. Bondi,
M. Celi,
R. Iundusi
From the University
of Rome, Rome, Italy

U. Tarantino, MD, Professor

G. Cannata, MD, Assistant
Professor
E. Gasbarra, MD, Assistant
Professor
L. Bondi, PhD, Orthopaedic
Surgeon
M. Celi, MD
R. Iundusi, MD, Orthopaedic
Surgeon
Department of Orthopaedic
Surgery
University of Rome Tor
Vergata, Oxford Street 81,
00133 Rome, Italy.
Correspondence should be sent
to Professor U. Tarantino;
e-mail:
umberto.tarantino@uniroma2.it
2008 British Editorial Society
of Bone and Joint Surgery
doi:10.1302/0301-620X.90B10.
21015 $2.00
J Bone Joint Surg [Br]
2008;90-B:1382-4.
Received 10 March 2008;
Accepted 11 June 2008

1382

A 20-year-old man sustained an open medial dislocation of the ankle without an associated
fracture after a low-energy inversion injury. Prompt debridement and reduction with primary
wound closure of the skin were performed without suture of the capsule. Immobilisation in
a non-weight-bearing cast for 30 days followed by ankle bracing for two weeks and
subsequent physiotherapy, produced full functional recovery by three months. At follow-up
at one year there was a full range of pain-free movement, although the radiographs and MR
scan showed early post-traumatic degenerative change at the medial aspect of the tibiotalar
and the calcaneocuboid joints.

Dislocation of the ankle without fracture is

uncommon.1 Previous ankle sprains, medial
malleolar hypoplasia, weakness of the peroneal muscles and ligamentous laxity are predisposing factors for dislocation. Although
there are few reports in the literature, Toohey
and Worsing2 and Elis et al3 have described
the largest series, comprising 19 and 16
patients, respectively. Because of the intrinsic
stability of the ankle mortise and its ligaments
and tendons, dislocation is usually caused by
high-energy trauma which causes combined
plantar flexion and inversion or eversion of the
foot, accompanied by fractures of the malleoli.
We describe a case of an open dislocation of
the ankle without malleolar fracture which
followed a low-energy trauma.

Case report
A 20-year-old man presented after sustaining
an inversion injury to his right ankle while
running after his cat. On examination there
was a large lacerated wound over the dorsolateral aspect of the right ankle approximately 10 cm in length (Fig. 1). The foot was
displaced medially. The distal articular surfaces of the fibula and the tibia were exposed.
The posterior tibial pulse was absent and
there were paraesthesiae involving the dorsal
aspect of the foot. Anteroposterior (AP)
radiographs indicated a medial dislocation of
the talus without concomitant fracture or
disruption of the ankle mortise (Fig. 2). There
was medial malleolar hypoplasia according to
the criteria described by Elise et al3 with a
medial-to-lateral ratio of 0.31.

After administration of antibiotics and local

irrigation, under general anaesthesia, the dislocation was reduced, and the wound was closed
without repair of the capsule (Fig. 3). Spiral
CT angiography of the right leg, performed
immediately after reduction, showed no arterial injury. The paraesthesiae over the dorsal
aspect of the foot resolved after three days. A
below-knee non-weight-bearing cast was
applied with the ankle in the neutral position

Fig. 1
Photograph showing the open dislocation of
the ankle at presentation.
THE JOURNAL OF BONE AND JOINT SURGERY

OPEN MEDIAL DISLOCATION OF THE ANKLE WITHOUT FRACTURE

1383

Fig. 4
Anteroposterior and lateral radiographs at follow-up at one year.

Fig. 2
Anteroposterior radiograph showing the medial dislocation of the right
ankle at presentation.

Fig. 5
MR scan at follow-up at one year.

Fig. 3
Anteroposterior radiograph immediately after reduction.

and retained for 30 days. An ankle brace was used for

another two weeks with progressive weight-bearing. Nonsteroidal anti-inflammatory treatment was given as
prophylaxis against heterotopic bone formation for four
weeks.4
VOL. 90-B, No. 10, OCTOBER 2008

The patient started physiotherapy after removal of the

cast. Examination three months after injury revealed a
pain-free stable joint with a full range of movement. Plain
radiographs and MRI at follow-up showed a normal joint
without evidence of heterotopic bone formation. At one
year, clinical examination confirmed a full pain-free range
of movement and he reported no limitation in sport and
activities of daily living. Radiological and MR examination
showed minor post-traumatic medial tibiotalar and
calcaneocuboid degenerative changes (Figs 4 and 5).

Discussion
Pure talotibial dislocations are rare.5,6 Generally because of
the intrinsic stability of the ankle they are associated with
malleolar fractures, mostly resulting from high-energy
trauma such as motor-vehicle accidents, sports injuries and

1384

U. TARANTINO, G. CANNATA, E. GASBARRA, L. BONDI, M. CELI, R. IUNDUSI

falls from a height. Only a few cases caused by low-energy

trauma have been reported.5,7-9
The talus, according to the studies of Fernandes,10 may
dislocate medially or laterally, without associated fractures
after application of an inversion or eversion force on a
maximally plantar flexed foot. Fahey and Murphy11
described five types of ankle displacement according to the
direction of the dislocation: anterior, posterior, medial,
lateral or superior combined. The posteromedial direction
is the most common. In our patient the dislocation was
medial. There was no history of recurrent sprains and on
examination there were no signs of ligamentous laxity.
However, there was hypoplasia of the medial malleolus
with a medial to lateral ratio of 0.31;8 the reported normal
ratio ranges from 0.58 to 0.62.3
On the lateral radiograph the cover of the talus by the
tibia measured 0.64, while the normal range is 0.58 to 0.60.
This ratio is determined by two angles (b/a) of which angle
is measured between two lines projected from the centre of
the talus through its anterior and posterior articular ridge,
and angle a is measured between two lines projected from
the centre of the talus through the anterior and posterior
articular ridge of the tibia.3,5
Other authors agree that immediate reduction decreases
the risk of vascular or neurological complications and that
reduction, debridement and capsular suture should be followed by immobilisation in a short-leg cast for six weeks.12,13
The repair of disrupted ligaments is controversial. Several authors have recommended repair of the lateral ligaments at the time of debridement.3,14 Others state that
repair does not improve ankle function.11,15 It is interesting
that despite massive ligamentous disruption, instability is
rare2,5 and such types of dislocation, have a good outcome.
Our patient did not undergo repair of the ligaments.

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

References
1. Kiefer EA, Wikstrom EA, Douglas McDonald J. Ankle dislocation without fracture: an on-field perspective. Clin J Sport Med 2006;16:269-70.
2. Toohey JS, Worsing RA Jr. A long-tem follow-up study of tibiotalar dislocations
without associated fractures. Clin Orthop 1989;239:207-10.
3. Elis S, Maynou C, Mestdagh H, Forgeois P, Labourdette P. Simple tibiotalar
luxation: apropos of 16 cases. Acta Orthop Belg 1998;64:25-34 (in French).
4. Radi ZA, Khan NK. Effects of cyclooxygenase inhibition on bone, tendon, and ligament healing. Inflamm Res 2005;54:358-66.
5. Rivera F, Bertone C, De Martino M, Pietrobono D, Ghisellini F. Pure dislocation
of the ankle: three case reports and literature review. Clin Orthop 2001;382:179-84.
6. Hatori M, Kotajima S, Smith RA, Kokubun S. Ankle dislocation without accompanying malleolar fracture: a case report. Ups J Med Sci 2006;111:263-8.
7. Uyar M, Tan A, Isler M, Cetinus E. Closed posteromedial dislocation of the tibiotalar joint without fracture in a basketball player. Br J Sports Med 2004;38:342-3.
8. DAnca AF. Lateral rotary dislocation of the ankle without fracture: a case report. J
Bone Joint Surg [Am] 1970;52-A:1643-6.
9. Shaik MM, Tandon T, Agrawal Y, Jadhav A, Taylor LJ. Medial and lateral rotatory dislocations of the ankle after trivial trauma-pathomechanics and management
of two cases. J Foot Ankle Surg 2006;45:346-50.
10. Fernandes TJ. The mechanism of talo-tibial dislocation without fracture. J Bone
Joint Surg [Br] 1976;58-B:364-5.
11. Fahey JJ, Murphy JL. Dislocations and fractures of the talus. Surg Clin North Am
1965;45:79-102.
12. Soyer AD, Nestor BJ, Friedman SJ. Closed posteromedial dislocation of the tibiotalar joint without fracture or diastasis: a case report. Foot Ankle Int 1994;15:622-4.
13. Kaneko K, Mogami A, Maruyama Y, Shimamura Y, Yamaguchi T. Posterolateral
dislocation of the ankle without fracture. Injury 2000;31:740-3.
14. Colville MR, Colville JM, Manoli A 2nd. Posteromedial dislocation of the ankle
without fracture. J Bone Joint Surg [Am] 1987;69-A:706-11.
15. Kelly PJ, Peterson LF. Compound dislocation of the ankle without fracture. Am J
Surg 1962:103:170-2.

THE JOURNAL OF BONE AND JOINT SURGERY