Endgames Picture Quiz

Ankle injury after a fall from a horse

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d2094 (Published 19 July 2011) Cite this as: BMJ 2011;343:d2094
  1. Shreedhar Aranganathan, core trainee year 2 in trauma and orthopaedics1,
  2. Ramasubramanian Dharmarajan, consultant orthopaedic surgeon2
  1. 1North Tees Hospital, Stockton on Tees, TS19 8PE, UK
  2. 2North Cumbria Hospitals NHS Trust, Carlisle, UK
  1. Correspondence to: S Aranganathan ashreedhar{at}gmail.com

A fit and well 25 year old woman with a body mass index of 30 fell off a horse (a height of about 1.2 m) and landed on both feet. She immediately felt severe pain in both ankles and was unable to weight bear. On arrival at the accident and emergency department the only abnormality identified was a clinically deformed right ankle with gross swelling, global tenderness, and restricted range of movement because of severe pain. Anteroposterior (fig 1) and lateral (fig 2) ankle radiographs were taken.


  • 1 What abnormalities can be seen on the radiographs?

  • 2 What is the immediate management?

  • 3 What further investigation would you perform?

  • 4 What are the potential long term complications?


1 What abnormalities can be seen on the radiographs?

Short answer

The radiographs of the right ankle show a total talar dislocation with a lateral malleolar fracture (figs 3 and 4).

Fig 3 Anteroposterior ankle radiograph showing a total talar dislocation (arrow)

Fig 4 Lateral ankle radiograph showing a lateral malleolar fracture (arrow on left) and the dislocated talus (arrow on right)

Long answer

Total talar dislocation is caused by high energy trauma that results in inversion of the foot. It occurs in three stages of inversion.1 2 It is a rare injury with no published evidence of incidence.3

2 What is the immediate management?

Short answer

The neurovascular status of the foot needs to be …

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