Field management of displaced ankle fractures: techniques for successful reduction

Ankle fracture/dislocations are generally low-energy injuries most commonly seen in older adults. Prompt reduction is indicated when evacuation to definitive care would be prolonged or neurovascular compromise to the foot is suspected. Reduction restores neurovascular integrity, realigns joint contact surfaces, reduces pain, and decreases soft-tissue edema. The hematoma block is a safe, easy, and effective method of obtaining adequate anesthesia to allow manipulation of displaced fractures. Although most commonly used for distal radius fractures, the hematoma block has been demonstrated to be as effective as conscious sedation for ankle reduction analgesia. Use of hematoma block is ideal for the wilderness setting because it requires few supplies, is easy to perform, and is effective. Quigley's traction consists of suspending the injured leg in a tubular fabric sling to allow gradual relaxation of deforming muscle forces and eventual reduction of a displaced ankle. For those displaced ankle fractures that are not amenable to reduction by direct manipulation, Quigley's traction applied after hematoma block may allow successful reduction. Improvised Quigley's traction can be built in a wilderness setting using available clothing. After successful reduction, fractured ankles should be adequately stabilized and the affected extremity should be kept nonweight bearing. The hematoma block and improvised Quigley's traction are valuable skills for the wilderness medical provider and may facilitate a successful and relatively pain-free reduction of dislocated ankle fractures in a wilderness setting.