Working Diagnosis:
The final diagnosis was a tibio-talar dislocation along with a distal fibular diaphysis fracture.

Treatment:
On-field, the patient was calmed and immobilized. An air splint was placed over the patient’s right leg to stabilize the dislocation. He was backboarded and transported by EMS to the emergency room. Upon arrival at the emergency room patient received an injection of morphine. Right ankle xrays were obtained which revealed a tibio-talar dislocation, distal fibular diaphysis fracture, posterior malleolus avulsion fracture, and presumed torn distal tibiofibular syndesmosis. Patient was medicated and the frature/ disclocation was reduced. Post-reduction his right leg was splinted. Case Photo #5 Case Photo #6 Orthopedic follow up with surgical fixation was recommended.
 

Outcome:
Patient was discharged from the emergency room and actually returned to the sidelines before the conclusion of the game. The patient was clearly out for the remainder of the game as well as the remainder of the season. The patient was instructed to follow-up with orthopedics for further surgical management. The patient underwent open reduction and internal fixation at an outside institution. His fracture was stabilized with a plate and screws. The patient also underwent screw fixation of the syndemosis. He later had a separate procedure to remove one of the screws. The patient did well with rehab and has no ankle pain with activity. He considered running track in the spring and was physically able to do so, but he declined to focus on his studies.

Author's Comments:
Ankle injuries are amongst the most common of sports injuries, accounting for 15-25% of such injuries. Fracture dislocation ankle injuries represent a unique type of ankle injury due to the emergent nature of such injuries. Urgent reduction of such injuries is crucial to prevent neuro-vasacular compromise, as well as to ensure a healthy area of soft tissue remains. Definitive surgical treatment for ankle fractures often involves open reduction and internal fixation of the fracture. Additionally, in this particular case there was likely an ankle syndemosis injury, which can occur in 12-32% of sports ankle injuries (particularly sprains). This type of injury is serious and if untreated can lead to chronic instability of the ankle joint with a possible early onset of osteoarthritis. Screw fixation or tightrope mechanism are surgical options available to stabilize such injuries. Following treatment of ankle injuries and specifically ankle fractures can take a rather varied time course, perhaps more than initially thought, however, the average return to sports occurs in 3 months. Factors with a more expedited return to play include younger age, male gender, no mild systemic disease, and less severe ankle fractures. Early weight bearing has also been associated with quicker recovery times. With the exception of the very last criterion, the patient in this case meets all of the criteria for a speedier than normal return to play.

Editor's Comments:
The talus itself has three articulations; the tibial plafond superiorly, the calcaneus inferiorly, and the navicular anteriorly. Because of these numerous articulations, over 60% of the talus is covered by hyaline cartilage and ligamentous attachments, leaving a limited surface area for blood supply. Pure tibiotalar joint dislocations without associated fracture is an exceedingly rare injury. More than 50% of tibiotalar dislocations are posteriormedial, and 25% are pure posterior dislocations. In any of the above mentioned scenarios rapid identification and immediate closed reduction or open treatment is necessary to preserve the health of the surrounding soft tissue and prevention of AVN or severe osteoarthritis of the talus and it's numerous articulations.

References:
Del Buono A, Smith R, Coco, M, et al. Return to sports after ankle fractures: a systemic review. British Medical Bulletin 2013; 106: 179-191

Weston JT, Liu X, Wandtke ME, Liu J, Ebraheim NE. A systematic review of total dislocation of the talus. Orthop Surg. 2015 May;7(2):97-101.


Bhullar PS, Grant DR, Foreman M, Krueger CA. Treatment of an open medial tibiotalar dislocation with no associated fracture. J Foot Ankle Surg. 2014 Nov-Dec;53(6):768-73.

 
Payne R, Kinmont JC, Moalypour SM. Initial management of closed fracture-dislocations of the ankle. Ann R Coll Surg Engl 2004; 86
 
Porter DA, Jaggers RR, Barnes AF, Rund AM. Optimal management of ankle syndemosis injuries. Open Access Journal of Sports Medicine 2014;5: 173-182

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