Subtalar dislocationMANAGEMENT

ANKLE · 12 SECTIONS

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484 items

☷ Legend

01Approach to the Critical Patient/attcp44

Immediate priorities

›Subtalar dislocation priorities

›Limb threat screen

›Open injury concern

›Neurovascular compromise

›Threatened skin

›Immediate reduction pathway

›If pulseless foot

›Immediate reduction attempt

›If persistent pulseless after reduction, immediate vascular surgery

›If skin blanching or tenting

›Immediate reduction attempt

›If irreducible, urgent orthopedics

›Analgesia and sedation readiness

›Resuscitation bay if airway risk

›Cardiorespiratory monitoring for sedation

›Neurovascular documentation checkpoints

›Pre-reduction status

›Posterior tibial pulse

›Dorsalis pedis pulse

›Capillary refill

›Tibial nerve sensation

›Superficial peroneal nerve sensation

›Deep peroneal nerve sensation

›Motor

›Great toe dorsiflexion

›Great toe plantarflexion

›Post-reduction status

›Repeat full neurovascular exam

›Doppler signals if pulses equivocal

›Imaging time-critical decisions

›Pre-reduction radiographs if stable

›Foot and ankle radiographs if no delay

›Reduction before imaging

›If neurovascular compromise

›If threatened skin

›Consultation and escalation triggers

›Orthopedics

›All subtalar dislocations

›Suspected associated fracture

›Vascular surgery

›Persistent ischemia after reduction

›Trauma team

›High-energy mechanism

›Polytrauma concern

02History/hx34

Mechanism and risk context

›Injury context

›Mechanism pattern

›High-energy inversion or eversion

›Fall from height

›MVC

›Sports torsion

›Time since injury

›Time since deformity noticed

›Time since any attempted reduction

›Associated injury clues

›Midfoot pain

›Ankle pain

›Heel pain

›Knee or hip pain

›Open injury clues

›Wound at medial or lateral hindfoot

›Contamination

›Patient factors

›Baseline function and mobility

›Ambulation status

›Work or sport demands

›Comorbidity and meds

›Diabetes

›Peripheral vascular disease

›Anticoagulants

›Prior injury

›Prior ankle or hindfoot fracture

›Prior ligament surgery

›Red flags

›Numbness or tingling

›Cold foot

›Increasing pain

›Pain out of proportion

›Inability to move toes

03Physical Exam/exam43

Focused limb and skin exam

›Hindfoot exam set

›Deformity pattern

›Medial displacement appearance

›Lateral displacement appearance

›Posterior displacement appearance

›Skin integrity

›Tenting

›Blanching

›Impending skin necrosis

›Fracture blisters

›Open wound

›Swelling distribution

›Subtalar region

›Midfoot region

›Ankle region

›Neurovascular exam

›Perfusion

›Dorsalis pedis pulse

›Posterior tibial pulse

›Capillary refill

›Foot temperature

›Sensory

›Tibial nerve

›Deep peroneal nerve

›Superficial peroneal nerve

›Sural nerve

›Saphenous nerve

›Motor

›Extensor hallucis longus

›Tibialis anterior

›Gastrocnemius-soleus complex

›Compartment syndrome screen

›Pain with passive toe motion

›Tense compartments of foot

›Progressive analgesic requirement

›Joint above and below

›Ankle stability after reduction

›Midfoot tenderness and instability

›Proximal fibula tenderness if twisting mechanism

PITFALLS

›Exam pitfalls

›Normal pulses not excluding intimal injury

›High pain burden masking evolving compartment syndrome

›Missed midfoot injuries with normal ankle radiographs

04Differential Diagnosis/ddx24

Traumatic hindfoot and ankle mimics

›Key alternatives and co-injuries

›Tibiotalar dislocation

›ICD-10 S93.0- ankle dislocation family

›Talus fracture

›Talar neck fracture

›Talar body fracture

›Calcaneus fracture

›Navicular fracture

›Cuboid fracture

›Lisfranc injury

›Ankle fracture-dislocation

›Malleolar fractures

›Syndesmotic injury

›Peroneal tendon dislocation or tear

›Achilles tendon rupture

›Neurovascular emergencies

›Arterial injury of posterior tibial or dorsalis pedis

›Acute compartment syndrome of foot

›Coding and terminology

›ICD-10 commonly used family

›S93.3- dislocation of other and unspecified parts of foot

›External cause codes per mechanism

›SNOMED CT concept mapping

›Subtalar joint dislocation concept mapping per local build

05Laboratory Tests/lt16

When labs add value

›Lab strategy

›No routine labs for isolated closed, stable patient

›Clinical decision based on exam and imaging

›Procedural sedation pathway

›Glucose if diabetes or altered mental status

›Pregnancy test if pregnancy possible and results change imaging or meds

›Open injury or polytrauma pathway

›Complete blood count for bleeding concern

›Electrolytes and creatinine for contrast planning

›Coagulation profile for anticoagulants or major injury

›Rhabdomyolysis or crush concern

›Creatine kinase

›Creatinine

›Interpretation and pitfalls

›Normal labs not excluding compartment syndrome

›Point-of-care glucose preferred for immediate sedation decisions

06Diagnostic Tests/dt48

Scoring Systems

›Classification overview

›Subtalar dislocation direction types

›Medial

›Most common direction

›Typically inversion mechanism

›Lateral

›Higher association with fractures

›Typically eversion mechanism

›Posterior

›Axial load variants

›Anterior

›Rare pattern

›Soft tissue risk tiering

›Closed without skin threat

›Closed with threatened skin

›Open dislocation

Radiographs

›Plain film set

›Pre-reduction films when no delay

›Ankle 3-view

›Foot 3-view

›Calcaneus views as available

›Post-reduction films

›Ankle 3-view

›Foot 3-view

›Subtalar alignment confirmation

›Radiographic pearls

›Evaluate talonavicular congruity

›Evaluate subtalar congruity

›Search for talar neck, talar body, calcaneus fractures

MRI

›MRI indications

›Persistent pain with negative CT and radiographs

›Occult osteochondral injury

›Ligament disruption pattern

›Subacute instability evaluation

›Spring ligament complex

›Deltoid ligament complex

›Contraindications

›Unsafe implanted metal

›Unstable patient

›CT roles

›Post-reduction CT

›High rate of associated fractures reported in subtalar dislocation

›Surgical planning if intra-articular fragments

›CT angiography

›If persistent ischemia after reduction

›If hard signs of vascular injury

›Evidence framing

›ACEP Level C support for CT angiography use when vascular injury suspected based on clinical findings

07Disposition/dispo23

Consultation, admission, follow-up

›Disposition framework

›Orthopedics involvement

›Immediate consult after reduction

›Urgent consult if irreducible

›Admission criteria

›Open dislocation

›Associated fracture requiring operative management

›Neurovascular deficit

›Concern for compartment syndrome

›Uncontrolled pain

›Unable to mobilize safely non-weight-bearing

›Transfer criteria

›No orthopedic coverage for urgent reduction failure or open injury

›Vascular injury concern requiring specialist

›Discharge criteria

›Successful reduction

›Normal neurovascular exam

›Splint tolerance

›Safe non-weight-bearing plan

›Reliable follow-up

›Follow-up timing

›Orthopedics in 3-7 days

›Earlier review if significant swelling or skin risk

08Treatment/t135

Immediate life-saving interventions

›Immediate limb protection bundle

›Elevation

›Heart level or above

›Skin checks if tenting

›Remove constrictors

›Rings or anklets

›Tight footwear

›Analgesia escalation

›IV opioids titration if severe pain

›Regional anesthesia consideration

›If open injury

›Sterile saline-soaked dressing

›Antibiotics pathway

›Tetanus pathway

Immobilization and Splinting

›Post-reduction immobilization

›Splint choice

›Posterior short leg plus stirrup

›Posterior short leg if swelling severe and stirrup not tolerated

›Position targets

›Neutral dorsiflexion

›Avoid excessive inversion or eversion

›Recheck requirements

›Neurovascular exam after splint

›Pain trend after splint

›Weight-bearing status

›Non-weight-bearing until orthopedics review

Reduction

›Reduction indications

›All acute subtalar dislocations

›Threatened skin

›Neurovascular compromise

›Caution triggers

›Open dislocation

›Antibiotics and tetanus as early as feasible without delaying reduction

›Suspected talar neck fracture-dislocation

›Gentle technique

›Early orthopedics involvement

›Analgesia and anesthesia options

›Non-opioid adjuncts

›Acetaminophen PO or IV

›NSAID if no contraindication

›Opioid options

›Fentanyl IV titration

›25-50 micrograms per dose

›Repeat every 3-5 minutes to effect

›Morphine IV titration

›0.05 mg/kg per dose

›Repeat every 5-10 minutes to effect

›Regional anesthesia options

›Popliteal sciatic block

›Ultrasound-guided technique per local credentialing

›Ankle block

›Tibial nerve block

›Deep peroneal nerve block

›Superficial peroneal nerve block

›Sural nerve block

›Saphenous nerve block

›Procedural sedation pathway

›Ketamine IV

›1 mg/kg initial dose

›Additional 0.25-0.5 mg/kg every 5-10 minutes as needed

›Emergence reaction mitigation

›Quiet environment

›Consider low-dose benzodiazepine only if severe agitation

›Propofol IV

›0.5-1 mg/kg initial dose

›Additional 0.25-0.5 mg/kg every 1-3 minutes to effect

›Hypotension readiness

›IV fluids bolus if needed

›Vasopressor per local protocol if refractory

›Technique principles

›Patient position

›Supine

›Knee flexion to relax gastrocnemius-soleus

›Traction and countertraction

›Longitudinal traction on foot

›Countertraction at distal tibia

›Deformity exaggeration

›Gentle increase in deformity to disengage

›Reverse mechanism

›Medial dislocation

›Eversion with traction

›Lateral dislocation

›Inversion with traction

›Talar head pressure

›Direct pressure to guide talonavicular reduction

›Reduction endpoint

›Audible or palpable clunk possible

›Immediate improvement in alignment

›Post-reduction requirements

›Immediate neurovascular re-check

›Pulses

›Sensation

›Motor

›Post-reduction radiographs

›Confirm subtalar and talonavicular congruity

›Post-reduction CT consideration

›Evaluate associated fractures

›Evaluate intra-articular fragments

›Failed reduction pathway

›Common irreducible causes

›Talar head buttonholing through extensor retinaculum

›Tendon interposition

›Posterior tibial tendon

›Peroneal tendons

›Fracture fragment block

›Escalation

›Urgent orthopedics for operative reduction

›Avoid repeated forceful attempts

Open fracture medications and timing

›Open dislocation antibiotic pathway

›First-line for open extremity injury

›Cefazolin IV 2 g

›Repeat every 8 hours

›Severe beta-lactam allergy

›Clindamycin IV 600-900 mg

›Repeat every 8 hours

›Gross contamination or farm injury concern

›Add gentamicin IV 5 mg/kg once daily per local protocol

›Tetanus prophylaxis

›Clean minor wound and immunized

›Booster if last dose more than 10 years

›Dirty wound or open dislocation

›Booster if last dose more than 5 years

›Tetanus immune globulin if unknown or incomplete immunization

DVT prophylaxis when relevant

›VTE risk and prophylaxis planning

›Higher risk scenarios

›Lower limb immobilization with additional risk factors

›Planned surgery

›Prior VTE

›Active cancer

›Prophylaxis alignment with local protocol

›Pharmacologic option if indicated and low bleeding risk

›Mechanical measures if pharmacologic contraindicated

›Documentation

›Risk factors

›Plan and duration

09Special Populations/sp34

Pregnancy

›Pregnancy considerations

›Imaging strategy

›Radiographs with shielding when feasible

›CT when benefits outweigh risks for fracture detection or surgical planning

›Analgesia options

›Acetaminophen preferred

›NSAID avoidance in later gestation per obstetric guidance

›Sedation considerations

›Airway edema risk

›Aspiration risk mitigation

›Obstetric consultation triggers

›Viable gestation with significant trauma mechanism

›Abdominal pain or bleeding

Geriatric

›Older adult considerations

›Lower threshold for imaging beyond radiographs

›CT for subtle fractures

›Skin fragility

›Higher blister and necrosis risk

›Medication safety

›Opioid delirium risk

›Renal dosing for NSAID and antibiotics

›Mobility planning

›Early PT or admission if unsafe non-weight-bearing

Pediatrics

›Pediatric considerations

›Growth plate risk

›Physeal injuries on imaging review

›Sedation dosing

›Weight-based dosing only

›Reduction technique

›Gentle sustained traction

›Avoid repeated attempts

›Nonaccidental trauma consideration

›Inconsistent mechanism

›Delayed presentation

10Background/b37

Epidemiology

›Epidemiology overview

›Rare injury

›Less than 1% of all dislocations reported

›Mechanism distribution

›High-energy trauma common

›Sports mechanisms also reported

›Direction distribution

›Medial most common pattern reported

Pathophysiology

›Anatomy and injury mechanics

›Subtalar joint complex

›Talocalcaneal joint disruption

›Talonavicular joint disruption

›Typical mechanism mapping

›Inversion producing medial dislocation tendency

›Eversion producing lateral dislocation tendency

›Soft tissue injury

›Interosseous talocalcaneal ligament disruption

›Cervical ligament disruption

›Deltoid or lateral ligament complex injury possible

›Complication mechanisms

›Skin necrosis from talar head pressure

›Post-traumatic subtalar arthritis from cartilage injury

›Stiffness from prolonged immobilization

Therapeutic Considerations

›Management rationale

›Early reduction

›Skin viability preservation

›Neurovascular restoration

›Cartilage protection by restoring congruity

›Post-reduction CT rationale

›High associated fracture frequency reported

›Intra-articular fragment detection

›Immobilization duration balancing

›Short-term immobilization for soft tissue healing

›Early range of motion to reduce stiffness when stable

›Evidence and guideline framing

›ACEP Level C framing for emergency reduction based on expert consensus and standard emergency practice

›Class I recommendation style framing for emergent reduction when threatened skin or neurovascular compromise present

11Patient Discharge Instructions/pdi30

copy discharge instructions

›Discharge instructions set

›Diagnosis

›Subtalar dislocation reduced and splinted

›Splint care

›Keep clean and dry

›Do not insert objects inside splint

›Loosen outer wrap if increasing tightness

›Swelling control

›Elevation above heart most of the day for 48-72 hours

›Ice around splint 15-20 minutes at a time

›Activity

›Non-weight-bearing

›Crutches or walker use

›No driving until cleared

›Pain plan

›Acetaminophen as directed

›NSAID as directed if safe

›Opioid only if prescribed and needed

›Return now for

›Increasing pain not controlled

›New numbness or tingling

›Toes turning blue, pale, or cold

›Inability to move toes

›Splint feels too tight despite elevation

›Wet or damaged splint

›Fever

›Wound drainage or foul smell

›Follow-up

›Orthopedics within 3-7 days

›Earlier if worsening swelling or skin concerns

12References/r16

Evidence-based sources and guidance

›Core references

›Tintinalli emergency medicine text

›Subtalar dislocation reduction and post-reduction imaging guidance

›Rockwood and Green fractures in adults

›Patterns, complications, and operative indications

›AO Surgery Reference

›Reduction principles and immobilization strategies

›Orthopedic trauma review literature

›Reported rates of associated fractures and post-traumatic arthritis

›Procedural sedation references

›ACEP clinical policy and guidance on procedural sedation in the ED

›Monitoring and staffing principles

›Adverse event preparedness

›Coding references

›ICD-10-CM code family S93.3- for dislocation of other and unspecified parts of foot

›Final code selection per documentation and laterality

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed March 6, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.