Subtalar Dislocation: Understanding, Medical Reduction, and Recovery

How to Reduce Subtalar Dislocation?

Reducing a subtalar dislocation is a complex medical procedure that must be performed by a qualified healthcare professional, such as an orthopedic surgeon or emergency physician, due to the high risk of complications if attempted without proper training and equipment.

Understanding Subtalar Dislocation

A subtalar dislocation, also known as a peritalar dislocation, is a severe and uncommon injury where the talonavicular and talocalcaneal joints are simultaneously disrupted, while the tibiotalar (ankle) joint remains intact. This means the foot dislocates from the talus bone, which remains correctly positioned within the ankle mortise.

Key Anatomical Structures Involved:

• Talus: The keystone bone of the ankle, connecting the leg to the foot.
• Calcaneus: The heel bone, articulating with the talus.
• Navicular: A tarsal bone articulating with the talus anteriorly.
• Ligaments: Numerous strong ligaments stabilize the subtalar joint, including the interosseous talocalcaneal ligament and the various deltoid and lateral collateral ligaments.

Mechanism of Injury: Subtalar dislocations typically result from high-energy trauma, such as:

• Falls from a significant height.
• Motor vehicle accidents.
• High-impact sports injuries (e.g., football, basketball, gymnastics), often involving a forceful inversion or eversion of the foot while the ankle is in plantarflexion.

Types of Dislocation: Dislocations are classified based on the direction of the foot relative to the talus:

• Medial (Inward): Most common type, where the foot is dislocated medially and often plantarflexed.
• Lateral (Outward): Less common, with the foot dislocated laterally.
• Anterior and Posterior: Rare variants.

Signs and Symptoms:

• Severe Pain: Intense and immediate pain in the ankle and foot.
• Gross Deformity: Obvious visual deformity of the ankle, often with the foot appearing displaced, rotated, or angled abnormally.
• Swelling and Bruising: Rapid onset of significant swelling and ecchymosis.
• Inability to Bear Weight: Complete inability to put weight on the injured foot.
• Neurovascular Compromise: Potential for numbness, tingling, or pallor if nerves or blood vessels are compressed, indicating a medical emergency.

Why Medical Intervention is Crucial

Attempting to reduce a subtalar dislocation without proper medical training and tools carries significant risks and can lead to severe, irreversible complications.

Risks of Improper Reduction:

• Further Injury: Damage to surrounding soft tissues, ligaments, tendons, or articular cartilage.
• Neurovascular Damage: Compression or laceration of crucial nerves (e.g., tibial nerve, peroneal nerve) or blood vessels (e.g., posterior tibial artery), leading to permanent numbness, weakness, or even tissue death.
• Incomplete Reduction: Failure to fully reduce the joint can lead to chronic pain, instability, and premature osteoarthritis.
• Infection: Open dislocations (where the skin is broken) carry a high risk of infection if not managed sterilely.

The Role of a Qualified Medical Professional: Only a trained medical professional possesses the anatomical knowledge, clinical experience, and necessary equipment to safely and effectively reduce a subtalar dislocation. Their immediate priorities include:

• Accurate Diagnosis: Confirming the dislocation type and ruling out associated fractures through physical examination and imaging (X-rays, sometimes CT scans).
• Neurovascular Assessment: Meticulously checking for any compromise to nerves or blood supply, as this dictates the urgency of reduction.
• Pain Management and Sedation: Administering appropriate analgesia and sedation to relax the patient and muscles, facilitating the reduction.
• Sterile Technique: Especially for open dislocations, ensuring a sterile environment to prevent infection.

The Medical Reduction Process (General Principles)

The following describes the general approach medical professionals use for subtalar dislocation reduction. This information is for educational purposes only and is not intended as instruction for self-treatment or treatment by non-medical personnel.

1. Initial Assessment and Preparation:

• Imaging: X-rays are taken in multiple planes to confirm the diagnosis, identify the direction of dislocation, and check for associated fractures.
• Neurovascular Check: Thorough assessment of sensation, motor function, and pulses distal to the injury is performed and documented.
• Anesthesia: The patient is typically given intravenous sedation and analgesia. A regional nerve block (e.g., ankle block) may also be used to ensure muscle relaxation and pain control.

2. Reduction Maneuvers: The specific maneuver depends on the type of dislocation, but general principles apply:

• Traction: Sustained, strong traction is applied to the foot to disengage the bones and overcome muscle spasm. Counter-traction is applied to the leg.
• Manipulation: Once adequate traction is achieved, specific maneuvers are performed to guide the foot back into its correct anatomical position relative to the talus.
  • For Medial Dislocations: The foot is typically everted and abducted (moved outward) while traction is maintained, often with direct pressure applied to the displaced bones.
  • For Lateral Dislocations: The foot is typically inverted and adducted (moved inward) with traction.
• Audible Clunk/Palpable Reduction: A successful reduction is often accompanied by an audible "clunk" and a palpable return of the bones to their normal alignment.

3. Post-Reduction Confirmation:

• Repeat X-rays: Immediately after reduction, repeat X-rays are taken to confirm proper alignment and ensure no new fractures occurred during the maneuver.
• Neurovascular Re-assessment: A thorough neurovascular check is performed again to ensure no compromise occurred during the reduction.

4. Immobilization:

• Once reduced, the ankle and foot are typically immobilized in a splint or cast (usually a short leg cast) in a neutral or slightly dorsiflexed position to maintain stability and allow initial healing.

Post-Reduction Care and Rehabilitation

Successful reduction is only the first step. Comprehensive post-reduction care and a structured rehabilitation program are critical for optimal recovery and preventing long-term complications.

1. Immobilization Period:

• The limb is typically immobilized for 4-6 weeks, depending on the severity of the injury and associated soft tissue damage.
• Weight-bearing status will be determined by the surgeon; it may be non-weight-bearing initially, progressing to partial or full weight-bearing.

2. Pain Management:

• Pain medication will be prescribed to manage discomfort. Ice and elevation can also help reduce swelling and pain.

3. Physical Therapy (Rehabilitation):

• After the immobilization period, a supervised physical therapy program is essential. This typically progresses through several phases:
  • Early Phase (Range of Motion): Gentle exercises to restore ankle and subtalar joint mobility, focusing on dorsiflexion, plantarflexion, inversion, and eversion.
  • Mid Phase (Strengthening): Progressive strengthening exercises for the muscles surrounding the ankle and foot (e.g., calf muscles, peroneal muscles, tibialis anterior).
  • Late Phase (Proprioception and Balance): Neuromuscular re-education to improve balance, coordination, and proprioception (the body's awareness of its position in space), which is crucial for preventing re-injury. Exercises may include single-leg stands, wobble board exercises, and agility drills.
  • Return to Activity: Gradual return to activities and sports, guided by the physical therapist and surgeon, ensuring full strength, stability, and confidence are restored.

4. Potential Complications: Even with successful reduction and rehabilitation, potential long-term complications can include:

• Post-traumatic Arthritis: Due to cartilage damage during the injury.
• Chronic Pain: Persistent discomfort.
• Residual Instability: Feeling of "giving way" in the ankle.
• Stiffness: Limited range of motion.
• Avascular Necrosis of the Talus: A rare but serious complication where blood supply to the talus is compromised, leading to bone death.

Preventing Recurrence and Future Ankle Injuries

While preventing the initial high-energy trauma leading to subtalar dislocation is challenging, focusing on general ankle health and stability can help reduce the risk of other ankle injuries and potentially recurrence.

• Proprioceptive Training: Regularly perform balance exercises (e.g., standing on one leg, using a balance board) to enhance joint stability.
• Strength Training: Strengthen the muscles around the ankle and lower leg, particularly the peroneal muscles (which evert the foot) and calf muscles.
• Appropriate Footwear: Wear supportive shoes that fit well and are appropriate for your activity.
• Listen to Your Body: Avoid pushing through pain or fatigue, especially during sports or high-impact activities.
• Sport-Specific Training: If engaging in sports, incorporate drills that mimic the movements and stresses of your sport to build resilience.
• Bracing/Taping: For individuals with a history of ankle instability, using an ankle brace or tape during high-risk activities may provide additional support.

Subtalar dislocation is a severe injury requiring immediate, expert medical attention. While the initial reduction is critical, long-term recovery hinges on diligent rehabilitation to restore function, strength, and stability, minimizing the risk of future complications.