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Drugs & Diseases > Emergency Medicine

FOOT DISLOCATION MANAGEMENT IN THE ED

Updated: Feb 09, 2022
* Author: Christopher M McStay, MD, FAWM, FACEP; Chief Editor: Trevor John
Mills, MD, MPH more...

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Sections
Foot Dislocation Management in the ED

* Sections Foot Dislocation Management in the ED
* Overview

* Practice Essentials
* Pathophysiology
* Epidemiology
* Show All
* Presentation

* History
* Physical
* Causes
* Show All
* DDx
* Workup
* Treatment

* Approach Considerations
* Emergency Department Care
* Complications
* Show All
* Medication

* Medication Summary
* Analgesics
* Anxiolytics
* Sedative-hypnotics
* Antibiotics
* Show All
* References

Overview

PRACTICE ESSENTIALS

Dislocation of the foot is an uncommon but potentially incapacitating injury.
The mechanism of injury may vary from a simple fall to a major motor vehicle
collision (MVC). The foot is a complex structure, and injuries often occur in
patients who sustain multiple trauma. The clinician must understand common
patterns of injury and maintain a high index of suspicion in examining the
appropriate radiographs to avoid missing foot dislocations.

Dislocations of the foot are commonly associated with other significant injuries
sustained during falls or MVCs. Delay in recognition of dislocations is common
because of the distracting effect of associated injuries, or because of the
subtle nature of these injuries. Early reduction and immobilization may reduce
morbidity. Injury may occur at any age, although the more severe forms of
dislocation associated with MVCs are more common in young adult males.

Risk factors for dislocation of the foot are the same as those for any major
trauma (ie, youth, alcohol intake, drug intake). However, dislocation of the
foot can result from an apparently simple fall (eg, twisting one's foot in a
hole in the ground when jogging).

DIAGNOSIS

Both a detailed medical history and a history of events surrounding the injury
or appearance of symptoms are essential in identifying the type of injury and
predisposition to complicating factors. Examination of the foot usually reveals
an obvious deformity; however, some dislocations are accompanied by substantial
soft tissue edema. The exact nature of the injury may be unclear until
radiography is performed.

Neurovascular examination is critical both before and after any reduction.

Laboratory studies generally are not indicated for diagnosing foot
dislocation. Routine radiography of the foot should include 3 views:
anteroposterior (AP), lateral, and 45º internal oblique.

Radiologists must have a thorough understanding of anatomy, mechanisms, and
patterns of these injuries to diagnose and help clinicians assess treatment
options and prognosis. [1]

TREATMENT

Reduction of some foot dislocations, especially isolated dislocations of the
talus or some of the more complex dislocations of the Lisfranc joint complex,
can be very difficult and is inadvisable in the ED. In these cases, consulting
an orthopedic specialist is always wise.

Urgent reduction of a dislocation in the ED is often necessary to prevent
further vascular or neurologic compromise. Whenever possible, adequate analgesia
should be ensured; conscious sedation may be required. The joint should be
reduced via gentle traction, and the limb should then be immobilized. Further
therapy or operative intervention may be required after this initial reduction.

If the dislocation is open, antibiotics are essential.

Urgent ED orthopedic consultation is indicated for subtalar, total talar, and
Lisfranc dislocations.

Additionally, first metatarsophalangeal (MTP) and interphalangeal (IP) joint
dislocations that are open or are not reducible require orthopedic consultation.
Most other MTP and IP dislocations are easily managed by the ED physician.

Many complications, including avascular necrosis, compartment syndrome,
and degenerative arthritis, have been reported. Residual pain and loss of
function are common consequences due to the complex biomechanics of the foot.

The effect of the direction of dislocation on long-term prognosis remains
controversial. [2] When treating midfoot trauma, it is important for the
clinician to fully understand the injury pattern, as this dictates the
principles and techniques of fixation. Identification and knowledge of injury
patterns will aid surgeons in future management of these injuries and may
improve treatment outcomes. [3]

Next: Pathophysiology

PATHOPHYSIOLOGY

The foot consists of 26 bones and 57 articulations. The foot is composed of 3
functional and anatomic regions. The hindfoot consists of the talus and the
calcaneus. The midfoot consists of the navicular, the cuboid, and the 3
cuneiforms. The forefoot contains 5 metatarsals and 14 phalanges.

The foot also contains numerous accessory centers of ossification that are
occasionally mistaken for avulsion injuries. The presence of a smooth cortical
surface and lack of associated soft tissue edema help to differentiate these
normal variants from fractures.

The articulations between the hindfoot and the midfoot are the midtarsal or
Chopart joints. These joints are the talonavicular and calcaneocuboid joints.
The articulations between the midfoot and the forefoot are termed the Lisfranc
joints and consist of 5 tarsometatarsal joints.

The subtalar joint, between the talus and the calcaneus, accounts for most
inversion and eversion injuries to the hindfoot. Adduction and abduction of the
forefoot primarily occur through the midtarsal joints. Flexion and extension
primarily occur at the MTP and IP joints.

Previous
Next: Pathophysiology

EPIDEMIOLOGY

All dislocations in the foot (with the exception of simple dislocations of the
toes) are uncommon injuries. The most common of these injuries is a dislocation
that involves the Lisfranc joint complex. The rarity of these injuries makes
diagnosis difficult. A significant proportion of the more subtle dislocations
are not diagnosed upon initial presentation. Dislocations through the Lisfranc
joint complex are thought to have an incidence of about 1 in 50,000 persons with
orthopedic trauma per year, representing less than 1% of all dislocations.

Dislocations of the foot are commonly associated with other significant injuries
sustained during falls or MVCs. Delay in recognition of dislocations is common
because of the distracting effect of associated injuries or because of the
subtle nature of these injuries. Early reduction and immobilization may reduce
morbidity.

Many complications, including avascular necrosis, compartment syndrome, and
degenerative arthritis, have been reported. Additionally, residual pain and loss
of function are common consequences resulting from the complex biomechanics of
the foot.

The male-to-female ratio is 6:1. This differential is largely due to the higher
number of young males who sustain significant trauma.

Injury may occur at any age, although the more severe forms of dislocation
associated with MVCs are more common in young adult males.

Clinical Presentation

REFERENCES

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CONTRIBUTOR INFORMATION AND DISCLOSURES

Author

Christopher M McStay, MD, FAWM, FACEP Associate Professor of Emergency Medicine,
Chief of Emergency Department Clinical Operations, University of Colorado School
of Medicine

Christopher M McStay, MD, FAWM, FACEP is a member of the following medical
societies: American College of Emergency Physicians, Wilderness Medical Society