Talocrural Dislocation and Fibular
Fracture in a Collegiate Football
Player: A Case Report
Josh Clayton, ATS
Weber State University, Ogden, UT
joshclayton@mail.weber.edu
Talocrural Dislocation and Fibular Fracture in a Collegiate
Football Player: A Case Report
Joshua A. Clayton, ATS
Weber State University, Ogden, UT
Abstract: To present the case of a talocrural dislocation with a fibular fracture in a National Collegiate
Athletic Association Division I football athlete. Background: The athlete was attempting to block a tackle
and an opponent hit him from behind, rolling up into his right ankle. On-field evaluation revealed a lateral
ankle dislocation. The medical doctor made the decision to reduce the injury while on the field. The
athlete was then transported off the field and taken to the nearest emergency room. Post-reduction
radiographs revealed a fibular fracture. An air splint was applied to stabilize the ankle and lower leg.
Diagnosis: Talocrural dislocation, lateral malleolar fracture, syndesmosis disruption. Treatment: After the
injury was reduced, the athlete was splinted and transported to the nearest emergency room. The athlete
underwent surgery to repair the fracture fibula. He received a plate and screws to stabilize the bone. After
surgery, a below knee cast was applied to the athlete’s right lower extremity. A scooter was also given to
the athlete to enable non-weight bearing movement. He remained in the cast for approximately 6 weeks.
Once the cast was removed, he was given a boot and crutches as he is now permitted to partially bear
weight. The athlete has begun light physical therapy and will transition from using the scooter to using the
crutches. Uniqueness: Most talocrural dislocations and fibular fractures occur due to falls or vehicle
accidents. This incident is one of the few in a collegiate athlete. Conclusions: Athletic trainers must be
made aware that the combination of talocrural dislocation and fibular fracture can happen within high
school and collegiate athletics. Quick recognition for these injuries will result in faster rehabilitation and
more successful outcomes.
Objective: To present the case of a collegiate men’s football athlete with a talocrural dislocation and
fibular fracture as the result of a traumatic blow.
Background: The athlete was struck on the posterior aspect of his right ankle during a football game.
On-field evaluation revealed dislocation of the talocrural joint. Immediate reduction was performed on the
field by the medical doctor to maintain skin integrity. A below-knee, fiberglass splint was applied to
stabilize the ankle joint complex. Post-reduction radiographs revealed a Weber type B fibular fracture.
Differential Diagnosis: Subtalar dislocation, Maisonneuve fracture, malleolar fracture, deltoid ligament
rupture, calcaneofibular ligament/ anterior talofibular ligament/ posterior talofibular ligament sprain,
syndesmosis disruption.
Treatment: The athletic training staff immediately splinted and transported the athlete to the athletic
training room to reduce the dislocation. The athlete subsequently underwent an open reduction and
internal fixation procedure to stabilize the injury: syndesmosis screws and a fibular plate were placed to
keep the ankle joint in an anatomically reduced position. With the guidance of the athletic training staff,
the athlete went through a physical rehabilitation protocol in an effort to return to sport as quickly and
safely as possible.
Uniqueness: While fibular fractures are the most common fractures to accompany an ankle dislocation,
such fractures are uncommon in the athletic realm.
Conclusions: Athletic trainers and medical professionals need to recognize that this type of injury can
occur in athletics. Proper treatment should be put in place to help the patient return to play as quickly as
possible.
Key Words: ankle dislocations, maisonneuve fracture, athletic injuries
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INTRODUCTION / ANATOMY
Talocrural dislocations are not infrequent, especially with an accompanying
fibular fracture.1 Ankle dislocations are usually supplemented by malleolar fractures
because of the mechanical strength of the ankle mortise and surrounding ligaments.2
Currently there is a lack of detailed information and case studies discussing injury to the
ankle joint in the anatomical literature.3 The published literature dealing with collegiate
football athletes is very limited.1 Many ankle fracture and dislocation injuries have poor
patient outcomes.1 These poor patient outcomes are usually from a combination of
factors ranging from age, activity level, and time and financial restraints.
The ankle is a synovial hinge joint made up of the distal fibular forming the lateral
malleolus, the distal tibia forming the medial malleolus, and the talus.4 The tibia carries
most of the body’s weight and the fibula carries only a portion of the body weight.5 The
midfoot is made up of the navicular, cuboid, and cuneiforms (lateral, intermediate and
medial). The metatarsals and the phalanges comprise the forefoot. The medial
ligaments are made of four ligaments known collectively as the deltoid ligament, which
inserts at the malleolus and runs down to connect to the talus and navicular bones of
the foot.4 The deltoid ligament protects against excessive eversion of the foot. The
lateral ankle ligaments include the anterior talofibular ligament, calcaneofibular
ligament, and the posterior talofibular ligament. The anterior talofibular ligament insterts
in the talar body just anterior to the fibular articular surface.6 The calcaneofibular
ligament attaches to the lateral malleolus and the calcaneus. The posterior talofibular
ligament is separated into intermediary fibers and long fibers; the intermediary fibers
insert along the lateral surface of the talus in a groove in the postero-inferior border of
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the laterally malleolar articular surface. 6 The long fibers insert on the posterior surface
of the talus.6 Combined ankle and posterior subtalar MR arthrography are helpful in
evaluating ligamentous injury accompanying ankle dislocation by enhancing
visualization of the ligaments attaching to the posterior and lateral talar processes.6
CASE REPORT
A 23-year-old collegiate male football offensive lineman with no previous history
of severe ankle injuries was struck in the back of his right leg by an opponent’s failed
attempt to tackle another player during a play. The athlete had been taped prior to the
game but the blow was sufficient to render the tape procedure useless. When the
athletic training staff arrived on the field, the athlete was grasping his right leg and was
in intense pain. Upon first observation, the right ankle was turned outward at an angle
that was not within normal limits. One of the athletic trainers upon seeing the ankle
pointed in a compromising position signaled for a splint. The team physician evaluated
the injury while on the field and confirmed the diagnosis of a talocrural dislocation. The
team physician then decided to reduce the dislocation on the field in an effort to
decrease the risk of skin necrosis. After the reduction, the athletic trainers applied a
vacuum splint to immobilize the ankle and the athlete was transported off the field in a
cart. The athlete was transported to the nearest emergency room. The team physician
accompanied the athlete to the emergency room. Upon further evaluation at the
emergency room, the physicians suspected a distal fibular fracture in addition to the
dislocation. The athlete was then referred to the hospital for radiographs to confirm the
fracture.
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The doctors confirmed that his dislocation was reduced and used the anteriorposterior and medial-lateral x-rays to confirm a Maisonneuve (Weber type C) fracture of
the distal fibula. The surgery was scheduled two days after the injury. During this time,
the athlete was immobilized with a soft cast. The orthopaedic physician performed an
internal fixation procedure. During the surgery, the physicians attached a metal plate
with screws to the distal end of the fibula to restore stability to the tibio-fibular joint. A
below-the-knee cast was applied with instructions to not bear any weight for a minimum
of six weeks. The athlete was given a knee scooter to get to and from his classes and
instructed to rest whenever possible to allow the fracture to heal. While in a cast, he
focused on passive range of motion exercises including ankle pumps/circles as
tolerated.
After six weeks of limited activity, the cast was taken off and the athlete was
given a boot to wear and begin partial weight bearing with crutches. During this time,
the rehabilitation staff used effleurage massage to promote healing and increase
metabolic rates in the area. His exercises included range of motion exercises to
decrease the swelling, zero degree partial lunges, weight shifting, plantarflexion on the
total gym, gastroc and soleus stretches, and seated inversion/eversion. Once he
tolerates these stretches and exercises, he will be progressed to proprioceptive
exercises. Six weeks after the athlete’s cast has been removed, the rehabilitation team
plans to begin strength exercises and progress to plyometric and sport specific
exercises. He is expected to return to sport in approximately 4 months as long as he
has full range of motion, adequate strength, and no longer has pain or any lingering
symptoms.
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COURSE OF TREATMENT
After the cast has been removed, the rehabilitation program can begin. First the
athletic training staff began with passive dorsiflexion and plantar-flexion range of motion
exercises. The passive motions can then be progressed to active assistive and then
active range of motion exercises as the athlete is able to tolerate them. During the first
three to four weeks the athletic training staff plan to use both the Normac machine for
compression and the Game Ready machine for ice and compression both before and
after exercises to help reduce edema. For treatment of pain, the athlete can use ice or
medications in addition to gentle massage to the painful area. Once the athlete is able
to perform exercises actively without pain, tubing or resistance bands are added to
begin strengthening the involved musculature. Resistance will be increased as tolerated
by the athlete. When the patient attends his therapy sessions, he will have access to an
ankle isolator and a BAPs board to also help increase his muscular strength. Once his
ankle muscles are stronger, the athlete will progress to proprioceptive exercises in
which he bears partial weight and gradually progresses to full weight bearing exercises.
As proprioception improves, plyometric exercises and sport specific exercises may be
added to help the athlete return to full activity. Once the athlete’s range of motion,
muscle strength, proprioceptive feedback, and sport specific skills are within normal
limits and do not produce symptoms, the athlete will be cleared to begin practicing as
tolerated.
DISCUSSION
Many injury classification methods use the mechanism of injury to determine the
extent of damage. The Weber classification method uses the level of fibular fracture to
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classify the injury.7 A Weber type A injury refers to a fibular fracture below the
syndesmosis, which may be associated with avulsion injuries, whereas a Weber type B
injury where the fracture begins at the joint level and extends upwards and may be
associated with deltoid ligament rupture, and a Weber type C injury occurs above the
joint line, often with a syndesmotic injury and can be associated with an avulsion
fracture or deltoid ligament rupture.2 The Weber classification system has substantial
reliability and reproducibility.7 Weber Type A and Weber Type B fractures occur more
commonly when compared to Weber Type C fractures.8 In a published data review by
Bartonicek, there were reported 60 patients that showed that most fracture dislocations
(88%) showed a Weber type B fracture pattern.9
According to Wang, the Ottawa Ankle Rules assessment can aid with the
diagnosis of fractures in the ankle. In the study, the researchers found that the
sensitivity, specificity, and positive and negative predictive values of applying the
Ottawa Ankle Rules for predicting fractures were 96.8%, 45.8%, 48.4%, and 96.5%
respectively.10
The most common treatment for a fibular fracture in association with an ankle
dislocation is an open reduction and internal fixation.1,4,11 In a study done by Martinez
Velez, he researched the difference between the different plates available for fixing
fibular fractures. He noted that between posterior anti-glide plates and lateral plates,
there was no difference in terms of technical difficulty, surgery time, or functional
results.11 Our athlete received the lateral plate on his fibula and screws to hold the plate
in place. Lateral malleolar or fibular fractures are usually stabilized with a one-third
tubular plate and screws.2 According to Zahn, the number of screws used in the plate
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stabilizing the ankle mortis showed no statistical evidence for any particular group in
their study.12
Several factors influence the dynamics of the healing process for ankle injuries.
According to Richards, smoking, alcohol, and malnutrition all contribute to a poor
prognosis for patients because it adversely affects bone mineral density and the
dynamics of bone and wound healing leading to delayed union and prolonged healing
times.2 Other factors that prolong healing include age, obesity, osteoporosis, and
neuropathy.
The generally accepted treatment for a fibular fracture is to immobilize the
extremity below the knee and insert syndesmosis screws.1 Common with a fibular
fracture, the syndesmosis ruptures distally from the fracture site. As a result of this
rupture, the stability of the ankle joint is decreased.7 For this reason, screws are inserted
into the syndesmosis. This enables the joint to heal anatomically. According to Ricci,
this approach gives the athlete the best chance for a full return to activity. Athletes who
incorporated weight bearing as early as tolerated with a fibular fracture tended to return
to sport more quickly than those who waited for complete healing before beginning
weight bearing.1
Due to very few published studies addressing outcomes in collegiate-level
athletes, the long term consequence is difficult to determine. In Ricci’s study, their
athlete progressed well with their rehabilitation program and was able to return to sport
quickly.1 Ricci and his colleagues believe that their success was due to the athlete’s
young age, the prompt on-field assessment, and early surgical intervention.1
8
After surgery, the athlete was placed in a below-the-knee cast for approximately
six weeks. During this time, it is common for the ankle to decrease in flexibility and the
muscles to atrophy due to being completely mobilized.5 Afterwards, the athlete had the
below-the-knee cast removed and was given a walking boot. He will then be able to
start his rehabilitation process.
In a similar case study, Ricci showed positive results for the following therapeutic
modalities at certain times during the 3.5 month to 9 month period. The results of the
study showed that using a moist hot pack for 15 minutes during months 5-9; ultrasound
(frequency = 3MHz, intensity = .9w/cm2, duty cycle = 50%, time = 6-7 minutes) during
months 5-9; laser (4 J/cm2) during months 4-9; electrical stimulation (pre-mod at 1-10
Hz for 20 minutes) during months 1-3; and high volt electrical stimulation (120 pps for
20 minutes) during months 4-9 showed to significantly help with healing and muscle
strengthening in combination with weight bearing activities as early as tolerated
compared to waiting for the injury to heal before attempting weight bearing activities
during the initial months.1
At three weeks post injury, rehabilitation exercises that have shown positive
results including: passive, assisted active, and active range of motion plantar flexion
and dorsiflexion each performed 3 sets of 10 repetitions as athlete tolerated them.1
At four weeks, Ricci introduced Russian electrical stimulation on the
gastrocnemius and VMO muscles to re-teach the muscles how to fire.1 At five weeks the
researchers increased the exercises from week 4 and added hamstring curls and leg
extensions on a physio ball.1 At six weeks the electrical stimulation and four-way hip
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exercises were increased and the home exercise program included resistive range of
motion exercises.1
After three and a half months the exercises included heel cord stretches, active
assisted range of motion, BAPS board, ankle isolator, HydroWorx, leg extensions on
physio ball with DynaDisc, four-way hip, flexion-extension, hip abduction, adduction
step, straight-leg toe raise, standing toe raise, seated toe raise, 1-legged squats, and
hip external rotation with thera-band exercises. Other treatment techniques included
proprioception training, posterior tibial glide and posterior talar glide joint mobilizations,
isokinetic exercises, and toe raises with Russian stimulation.1 All of these techniques
and exercises provided a strong foundation for the athlete’s quick recover.
UNIQUENESS
Ankle injuries are very common in athletics.13 The ankle has numerous
possibilities when it comes to injuries that can occur to the bony and ligamentous
structures. Ankle dislocation at the talocrural joint coupled with a fracture of the fibula is
commonly reported in the literature.1 Ricci also stated that external rotation with
excessive dorsiflexion is the most common mechanism of injury for ankle injuries in
athletes playing on artificial turf, although this was not the mechanism of injury for our
athlete.
As is the case with most injuries, correct and rapid evaluation is crucial. In this
current case, the athlete’s dislocation was reduced while on the field. Once off the field
and after further evaluation, the athlete was sent for radiographic imaging to confirm a
fracture of the fibula. It is important to reduce an ankle dislocation as soon as possible
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so as to protect the vascular and neurologic pathways in the area. In most cases, acute
dislocations require emergent care.9 The longer the ankle is displaced, the smaller the
window is to ensure vascular and neurologic integrity.1 If the ankle is left dislocated, the
arteries, veins, and nerves may become compromised and permanently damaged. If
more than two thirds of the vascular channels are compromised in an injury, avascular
necrosis of the area usually follows.14
Another factor is that the dislocation may be malpositioned during the reduction
process. The most common error is fibular malpositioning in the tibiofibular incisura.15
Usually, as a result of malpositioning, a secondary surgery is required to correct the
position.15 The athletic trainers had sufficient knowledge of the ankle anatomy and the
conditions that can occur with a talocrural dislocation to understand the importance of
further investigation even after the dislocation was fixed. Being able to recognize these
injuries in the athletic population is essential.
Unfortunately for most people with these kinds of injuries, the resources for
treatment are limited. For example, some rehabilitation clinics do not have a variety of
equipment options to help facilitate the same kind of healing that athletes are
accustomed to. Other concerns for the public include the financial and time commitment
for treatments. Collegiate athletes do not have a busy schedule when they are injured
and usually are covered either by their parent’s insurance or the university’s insurance.
Many non-athletic patients do not have the financial or time capability to attend more
than two sessions per week. This makes the rehabilitation for the general public much
longer than the collegiate athlete.
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CONCLUSIONS
Talocrural dislocations are likely to continue to happen in the athletic population.
A fibular fracture usually accompanies the dislocation due to the athlete’s muscular
strength in the region. The injury will present with intense pain throughout the lower leg
and ankle. In our athlete’s case, his chief complaint was the intense pain in his right
ankle. The athlete may report hearing a snap or pop. The foot and ankle may be
malaligned. In our case, the athlete’s ankle was point out away from the midline of the
body. It is very important during the physical examination to ensure that the distal
pulses and nerves responses are present. If absent it is crucial to get the athlete
emergency care as quickly as possible. Treatment for talocrural dislocations and fibular
fractures will vary based on the individual. When a dislocation occurs, it is important to
diagnosis and reduce the dislocation as soon as possible to protect skin and vascularity.
For fibular fractures, there are various plates and screws that are used to pin the bone
and joint together to allow bone healing to take place. For the more active population,
an aggressive rehabilitation program would be a likely choice due to the resources
usually available to the collegiate athlete population. In this case the athlete has
progressed well in his rehabilitation program and is expected to return to full activity
within approximately four months.
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