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.