Discussion and Conclusion:
Pure ankle dislocation is an extremely rare ankle injury with a reported incidence of 0.065% of total ankle injuries. 3 In this case there was pure open ankle dislocation without any associated fracture which is specifically rare. Prevalence and incidence of open ankle dislocation without associated fracture are not well established due to rarity. Anterior dislocation of the hip is rarer in comparison to posterior contributing 10 % of total hip dislocation. It is even exceptional to have Epstein’s superior type of anterior hip dislocation. This case is a combination of these two rare orthopedic emergencies.4,5
The most common cause and mechanism involving open ankle dislocation are sports injuries followed by road traffic accidents.6There was a newly reported mechanism that is crushing and twisting at the left ankle possibly by valgus and extension stress force by a farmer’s garden tractor followed by hyperextension of the left lower limb at the hip joint in this case.
Diagnosis is straightforward and can be confirmed by plain radiography. Associated vascular injury can be ruled out by arteriovenous doppler. In case of anterior dislocation of the hip plain CT scan can rule out acetabular fracture and femoral head impaction.4
Both open dislocation of the ankle and anterior dislocation of the hip are orthopedic emergencies. Open dislocation of the ankle needs to be managed as early as possible to prevent limb loss and life-threatening infections.7 Due to the rarity of open dislocation of the ankle its management protocol is not well established. Early extensive debridement is required based on the principle of management of open fracture to prevent infection. Based on that we managed this case by extensive debridement and washing of wounds to prevent infection. 8 There was a large open wound with grossly exposed bones happened at farmer’s field with a high risk of infection, accompanied by extensive soft tissue swelling so we decided to do reduction by delta frame external fixator in comparison to the other reported treatment option like reduction followed by casting.6,7,9 Subsequently patients improved without infection postoperatively. Due to insufficient study, the outcome of ligament repair is controversial and the reported reports also support the outcome not affected by ligament repair for which reason we did not perform ligament repair. It has been reported that people with ligament repair return early to sports activities but it needs to be established based on further study.3,9 Subsequently in our case patient improved without infection of the wound. A superior type of anterior dislocation of the hip is rare though there are controversies regarding treatment and complications. We managed with closed reduction followed by immobilization by skin traction. Despite the delay of more than 12 hours reduction of hip avascular necrosis did not occur in our case. 10,11
We chose the period of immobilization as 6 weeks by external fixator, same as cases because of swelling but we started crutch mobilization after the 12th post-operative day.12Physiotherapy is an important modality for the treatment and good functional outcomes.
Open dislocation of the ankle is a rare limb and life-threatening orthopedic emergency. Early extensive debridement of wound, broad-spectrum antibiotics, reduction with delta frame external fixator, and post-operative rehabilitation helps in saving limb along with its function but the management of this condition needs to be established with well-designed study despite rarity.