The Importance of Reproducing the Injury

Ankle dislocations are usually the result of high-energy trauma that cause plantar flexion of the ankle combined with an inversion or eversion stress. These dislocations are typically described according to the direction of displacement of the talus and foot in relation to the tibia. Consequently, dislocation may be upward, posterior, medial, lateral, posteromedial, or anterior. 

Posterior dislocation of the talus is the most common form of ankle dislocation. Associated fractures are the rule rather than exception, and ligamentous disruption varies according to the type of dislocation. One of the most dramatic joint dislocations is the open, dislocated ankle. A principal concern, in addition to timely reduction, is the possibility of a neurovascular injury. Radiographs should not delay reduction in cases where vascular compromise or skin tenting is present. After reduction, reassessment of the neurovascular status, splinting, ankle elevation, and post-reduction radiography are accomplished. 

The reduction procedure is accomplished with the patient lying supine. After procedural sedation and analgesia, the knee is flexed to 90 degrees. Distraction of the foot, followed by a gentle force reversing direction of the dislocation is sometimes all that is needed, though a more forceful maneuver may be needed. Many open ankle fractures and dislocations will not be reduced unless the injury mechanism is first recreated. 

This important tenet of orthopedic surgery is frequently overlooked. When that happens, the joint dislocation reduction can be nearly impossible to accomplish. This video shows the initial failures of open ankle fractures and dislocation reductions by emergency medicine and orthopedic residents. Only after the operators regrouped and recreated the mechanism of injury were the open ankle dislocations successfully reduced.

mellick photo.JPG 

Watch a video showing an ankle injury being recreated so that the open dislocation can be reduced​.

Tags: Ankle dislocation, trauma, inversion stress, eversion stress, open fractures, reduction
Published: 10/3/2016 3:35:00 PM







Filed under: Online critical airway training, video-laryngoscopy Tagged: video-laryngoscopy

So Bored I Went Back to the Future (Infectious Diseases of the Past)



You just finished a slow Peds shift during which you saw a whopping 3 patients – viral syndrome, viral syndrome, ibuprofen, PO challenge, and discharge. You feel a little underwhelmed. As you leave the hospital, you decide to call an Uber. A disheveled guy with white hair comes to pick you up in a DeLorean. Instead of taking you home, he takes you back to the future! In this future, the anti-vaxers have taken over the world, and no one vaccinates their children anymore. Autism rates haven’t changed, but your peds shifts in this future are about to become a lot more interesting…


Dad brings in a 7 month-old girl for multiple episodes of watery diarrhea daily for the past week, and it hasn’t been getting better. She also had a few episodes of vomiting, but there is no blood in the stool. Dad states child has been healthy and developing normally. She goes to daycare where other children have had similar symptoms. She is febrile to 101 F with dry mucus membranes. What is the most likely diagnosis?


  • Major cause of infantile gastroenteritis
  • Characterized by profuse, watery diarrhea
  • Treatment: Supportive; make sure patient is well hydrated


10 year-old boy presents with a sore throat and fever for 1 week. It has been becoming progressively worse. He has had difficulty tolerating solids and now even liquids are hard to swallow. Upon physical exam, you notice generalized soft tissue swelling around the neck and throat. You also note a greyish membrane forming around the posterior pharyngeal wall and tonsils. What is this infectious disease?


  • Characterized by pseudomembrane formation in the back of the throat


  • Pseudomembrane is made up of dead cells, fibrin, and organisms; its formation can cause difficulty breathing or swallowing
  • Treatment: Antibiotics (penicillin or erythromycin) and antitoxin


5 year-old boy presents with fevers, chills, cough, and rash. His parents initially thought he just had the cold. They noticed his eyes seem red but figured it was part of the cold. They became worried when they noticed the rash appear on his face, inside his mouth, and then spread inferiorly to his trunk. His fever has not broken, and it has been about 6-7 days since the onset of symptoms. Diagnosis?

Measles: 4 “Co’s” of measles

  • Cough
  • Coryza
  • Conjunctivitis
  • Coplik spots (Koplik’s spots): Red spots with bluish centers on the buccal mucosa


  • Rash: presents last and usually spreads from head to toe


  • Treatment: Supportive


8 year-old boy presents with 3 days of low grade fever and headache. He complains of pain in his right ear. Mom says the right side of his face looks swollen. Diagnosis?


Mumps: Mumps make you swell like a POM-POM

  • Parotitis: Unilateral swelling of parotid gland; can make it painful to masticate


  • Orchitis: Watch out, this can cause infertility in males; swelling of the testicles usually occurs after fever breaks (around 1 week)
  • Meningitis: Aseptic
  • Treatment: Supportive


15 year-old girl presents with generalized “feeling unwell.” She has been experiencing fever for the past 2-3 days along with muscle aches and joint aches. Over the last day, she noted a fine rash on her face that has spread to her trunk. There is no mucosal involvement. Upon exam, you note enlarged cervical chain lymph nodes.

Rubella: AKA German measles

  • Milder than measles; shorter duration
  • Forchheimer spots: Small red lesions on soft palate that usually precede skin rash
  • Rash also spreads from head to toe, very similar to measles but usually described as more erythematous than measles


  • Treatment: Supportive


Chen,S. Measles. Medscape.
Dyne, P. Pediatric Rubella in the Emergency Room. Medscape.
Lo,B. Diphtheria. Medscape.
Nguyen, D. Rotavirus. Medscape.


Remember, what we do in practice may not always be the right answer on the exam. Frustrating, I know, but at least you’re vaccinated against polio.



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