Pediatric ankle injuries are a common presentation in the emergency department (ED). A quarter of pediatric ankle fractures show no radiographic evidence of a fracture. Physicians often correlate non-weight bearing and tenderness with an occult fracture. We present this study to predict the probability of an occult fracture using radiographic soft-tissue swelling on initial ED radiographs.

This is a retrospective study at a Level 1 pediatric trauma center from 2021 to 22. Soft-tissue swelling between the lateral malleolus and skin was measured on radiographs, and weight-bearing status was documented. Statistical analysis was conducted using Stata software.

The study period involved 32 patients with an occult fracture, with 8 (25%) diagnosed with a fracture on follow-up radiographs. The probability of an occult fracture was calculated as a function of the ankle swelling in millimeters (mm) using a computer-generated predictive model. False-negative and false-positive rates were plotted as a function of the degree of ankle swelling.

Magnitude of ankle soft-tissue swelling as measured on initial ED radiographs is predictive of an occult fracture. Although weight-bearing status was not a sign of occult fracture, it improves the predictive accuracy of soft-tissue swelling.

Isolated distal fibula fractures represent the majority of ankle fractures. These fractures are often the result of a low-energy trauma with external rotation and supination mechanism. Diagnosis is based on clinical signs and radiographic exam. Stress X-rays have a role in detecting associated mortise instability. Management depends on fracture type, displacement and associated ankle instability. For simple, minimally displaced fractures without ankle instability, conservative treatment leads to excellent results. Conservative treatment must also be considered in overaged unhealthy patients, even in unstable fractures. Surgical treatment is indicated when fracture or ankle instability are present, with several techniques described. Outcome is excellent in most cases. Complications regarding wound healing are frequent, especially with plate fixation, whereas other complications are uncommon.

Acute ankle injuries are frequently diagnosed and treated in emergency departments and outpatient clinics. Recent evidence-based clinical treatment guidelines and systematic review of economic analyses support the use of 3-view (anteroposterior, lateral, and mortise) radiographic evaluation of patients meeting the criteria of the Ottawa ankle rules. Cross-sectional imaging has a limited secondary role primarily as a tool for preoperative planning and as a problem-solving technique in patients with persistent symptoms and suspected of having occult fractures. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

The paradigm of coping with sometimes gross pathology, while having some small and at first sight insignificant lesions demands for accurate radiological detection and orthopaedic treatment makes it interesting and challenging to be involved in the treatment of professional athletes. In the diagnostic process we differentiate between acute, posttraumatic and overuse injuries. We must realize the importance of reproducible routine X-rays as a first step in the diagnostic process. In case of additional diagnostics, appropriate consultation between the orthopaedic surgeon and the radiologist is essential in order to determine the best strategy.

To validate the Ottawa ankle rules protocol for predicting ankle and midfoot fractures in Greek athletes.

A prospective survey in the emergency departments of a district general hospital and a sports injury clinic in Greece over nine months. A clinical evaluation was made of 122 patients with acute ankle and/or midfoot injury, and then radiographs were taken.

Nine ankle and eight midfoot fractures were detected. The sensitivity of the Ottawa ankle rules protocol in predicting fractures in both the malleolar and midfoot zones was 100%. The negative predictive value for each of these areas was also 1.0. Specificity was estimated to be 0.3 for ankle fractures and 0.4 for midfoot fractures. Positive predictive values were 0.16 and 0.28 respectively. A possible reduction of up to 28.7% was found in the need for radiography.

Use of the Ottawa ankle rules protocol in evaluating injured Greek athletes resulted in 100% sensitivity when performed by orthopaedic residents or sports medicine doctors, and had the potential to reduce the use of radiography.

To test whether the reduction in ankle radiograph ordering was sustained during a 12-month period after a formal trial to introduce the Ottawa ankle rules.

A before-after clinical trial of ankle radiograph ordering practice was performed in a university-based ED. All 1,884 (947 "during intervention," 937 "postintervention") adults seen with acute ankle injuries during 2 12-month trial periods were evaluated. The behavioral intervention was the teaching of the Ottawa ankle rules and feedback of compliance with the rules during the intervention period. No further education about the ankle rules or feedback regarding compliance occurred during the postintervention year. Physicians were unaware of any postintervention surveillance. The primary outcome was the proportion of eligible patients referred for an ankle radiograph during the intervention and postintervention periods.

During the intervention period (January 1-December 31, 1993), the proportion of patients who received an ankle radiograph [609 x-rayed of 947 patients seen (64.3%; 95% CI 61.2-67.4%)] did not differ from the proportion who received an x-ray in the postintervention period (January 1-December 31, 1994) [583 x-rayed of 937 patients seen (62.2%; 95% CI 59.1-65.3%), p = 0.65, power > 0.80 to detect a 10% increase in the radiograph ordering rate]. There was also no difference in the radiograph ordering rate in the first 3 months of the postintervention period compared with the last 3 months of the postintervention period (68.8% vs 64.7%, respectively, p > 0.30).

Compliance with the Ottawa ankle rules was sustained during a 12-month postintervention surveillance period when physicians did not know they were being observed. Physicians will continue to use a simple clinical guideline once it has been learned.

To investigate the use of a simple intrasound device in the detection of malleolar fractures in the accident and emergency (A&E) department.

Patients aged 16 to 70 years with ankle injuries presenting within 24 hours were considered for inclusion in the study. Those patients with bony tenderness, inability to weight bear, and swelling were examined with a simple intrasound device before x-ray examination. A positive result of discomfort, pain, withdrawal response, or combinations or these was noted.

The device had a sensitivity of 85% and a specificity of 52% in detecting malleolar fractures.

The use of intrasound in the detection of malleolar fractures cannot be relied upon alone, but it may help to limit the number of x rays taken unnecessarily. A further study is proposed to confirm these findings.

We assessed the impact of ankle radiographs on referring physicians' diagnoses and treatment of acute ankle injuries.

Twenty emergency department physicians prospectively completed questionnaires before and after radiography on 101 patients with acute trauma receiving ankle radiographs. The questionnaires asked physicians to estimate the probability (0-100%) of their most likely diagnosis before and after receiving the radiographic information. We also asked their anticipated and final treatment plans. We calculated the mean gain in diagnostic confidence percentage and the proportion of patients with changed initial diagnoses or anticipated management.

The mean gain in diagnostic certainty from ankle radiographs was 34% (95% confidence interval [CI] = 28-40%). Ankle radiographs changed physicians' initial diagnoses in 37% (95% CI = 28-47%) of the patients. Immediate clinical management changed in 30% (95% CI = 22-40%) of the patients.

Plain ankle radiographs have considerable impact on referring physicians' diagnoses and treatment of acute ankle trauma.

To conduct an incremental cost-effectiveness analysis of implementation of the Ottawa Ankle Rules in emergency departments in the United States and Canada.

A decision analytic approach to technology assessment. Clinical decision rules that allow physicians to be more selective in their use of radiography were compared with current practice in a decision analytic model.

A university hospital adult ED.

ED physicians instructed in the use of the Ottawa Ankle Rules for adult patients with ankle injury.

Radiography, waiting time, lost productivity, and medicolegal costs were calculated. In the United States, the savings varied between US$614,226 and US$3,145,910 per 100,000 patients, depending on the charge rate for radiography. In Ontario, Canada, the total savings were CAN$730,145 per 100,000 patients. One- and two-way sensitivity analyses that varied the rate of missed fractures, cost of radiography, probability of lawsuits, and cost of lawsuits did not change the results substantially.

Implementation of the Ottawa Ankle Rules would result in significant savings of health care dollars despite the cost of missed fractures including litigation costs.

To assess the feasibility and impact of introducing the Ottawa ankle rules to a large number of physicians in a wide variety of hospital and community settings over a prolonged period of time.

Multicentre before and after controlled clinical trial.

Emergency departments of eight teaching and community hospitals in Canadian communities (population 10,000 to 3,000,000).

All 12,777 adults (6288 control, 6489 intervention) seen with acute ankle injuries during two 12 month periods before and after the intervention.

More than 200 physicians of varying experience were taught to order radiography according to the Ottawa ankle rules.

Referral for ankle and foot radiography.

There were significant reductions in use of ankle radiography at all eight hospitals and within a priori subgroups: for all hospitals combined 82.8% control v 60.9% intervention(P < 0.001); for community hospitals 86.7% v 61.7%; (P < 0.001); for teaching hospitals 77.9% v 59.9%; (P < 0.001); for emergency physicians 82.1% v 61.6%; (P < 0.001); for family physicians 84.3% v 60.1%; (P < 0.001); and for housestaff 82.3% v 60.1%; (P < 0.001). Compared with patients without fracture who had radiography during the intervention period those who had no radiography spent less time in the emergency department (54.0 v 86.9 minutes; P < 0.001) and had lower medical charges ($70.20 v $161.60; P < 0.001). There was no difference in the rate of fractures diagnosed after discharge from the emergency department (0.5 v 0.4%).

Introduction of the Ottawa ankle rules proved to be feasible in a large variety of hospital and community settings. Use of the rules over a prolonged period of time by many physicians of varying experience led to a decrease in ankle radiography, waiting times, and costs without an increased rate of missed fractures. The multiphase methodological approach used to develop and implement these rules may be applied to other clinical problems.

To develop decision rules that will predict fractures in patients with ankle injuries, thereby assisting clinicians in being more selective in their use of radiography.

Prospective survey of emergency department patients over a five-month period.

Two university hospital EDs.

One hundred fifty-five adults in a pilot stage and 750 in the main study; all presented with acute blunt ankle injuries.

Thirty-two standardized clinical variables were assessed and recorded on data sheets by staff emergency physicians before radiography.

Variables were assessed for reliability by the kappa coefficient and for association with significant fracture on both ankle and foot radiographic series by univariate analysis. The data then were analyzed by logistic regression and recursive partitioning techniques to develop decision rules for predicting fractures in each radiographic series.

All 70 significant malleolar fractures found in the 689 ankle radiographic series performed were identified among people who had pain near the malleoli and were age 55 years or more, had localized bone tenderness of the posterior edge or tip of either malleolus, or were unable to bear weight both immediately after the injury and in the ED. This rule was 100% sensitive and 40.1% specific for detecting malleolar fractures and would allow a reduction of 36.0% of ankle radiographic series ordered. Similarly, all 32 significant midfoot fractures on the 230 foot radiographic series performed were found among patients with pain in the midfoot and bone tenderness at the base of the fifth metatarsal, the cuboid, or the navicular.

Highly sensitive decision rules have been developed and will now be validated; these may permit clinicians to confidently reduce the number of radiographs ordered in patients with ankle injuries.

The authors' objective was to describe a method for measuring interobserver agreement and to determine the reliability of physical findings used by emergency physicians to assess ankle injury patients. A 3-month prospective survey was designed for use in the emergency departments of two university hospitals. Participants were a convenience sample of 100 adult blunt ankle injury patients. Pairs of emergency staff physicians assessed 22 standardized physical findings in each patient without knowledge of the other assessment. Agreement for each variable was measured by the kappa coefficient, the ratio of actual agreement to potential agreement beyond chance. The variables with the highest interobserver agreement and their kappa values were ability to bear weight (.83); bone tenderness at the base of the fifth metatarsal (.78), at the posterior edge of lateral malleolus (.75), and at the tip of the medial malleolus (.66); and combinations of bone tenderness (.76). Less reliable variables included soft tissue tenderness (.41) or degree of swelling (.18) of the anterior talofibular ligament, ecchymosis (.39), range of motion (.33), bone tenderness at the proximal fibula (-.01), and the anterior drawer sign (-.03). High kappa values indicate that several physical findings, including ability to bear weight and selected sites of bone tenderness, may be reliably assessed in ankle injury patients. This knowledge may give physicians more confidence in their physical examination and allow development of reliable clinical guidelines to diminish the reliance on radiography in ankle injuries.

The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. Return to full occupational function is a primary concern for the injured, including those with ankle sprains. This study compared the effectiveness of three different types of treatment for Grade I and Grade II ankle sprains. The effectiveness was determined by how quickly the patient returned to full duty and if the patient had a recurrence of the injury within one month. A total of 184 subjects (60 in Groups 1 and 3; 64 in Group 2) participated in this study. The treatment groups were: 1) strapping with athletic tape for three days, 2) application of gel cast for three days, and 3) daily strapping for three days. All three groups underwent the same physical therapy program before and after strapping or wrapping. All treatment protocols resulted in a better than 50 percent return to full duty in less than 14 days, with Group 3 showing a return rate of 60 percent in three days or less. The study showed (using log linear analysis) a significant difference at the p < 0.01 level between Groups 1 and 3 and Groups 2 and 3. These results suggest that daily strapping can help reduce lost work time due to ankle sprains. J Orthop Sports Phys Ther 1992;15(1):19-23.

To determine whether the treatment of ankle injuries in an accident and emergency department could be improved by an audit of existing treatment and the creation and use of a protocol.

The study consisted of three parts: a review of the current treatment and published reports on treatment, the formation of a protocol, and a study of treatment after introducing the protocol.

Accident and emergency department of a district general hospital.

550 patients attending the department with ankle injuries over four months.

The review of treatment showed that patients with fractures were detected and treated adequately, but most had radiography. Patients with ligamentous injuries may have been undertreated. After introducing the protocol the number of patients undergoing radiography was reduced from 205 (80%) to 186 (70%) (0.0027 less than p less than 0.01). In 87% of the notes reviewed the protocol had been completed. Sixty six patients with ligamentous injuries were reviewed in the department or soft tissue clinic compared with 20 before the protocol was introduced. There was a 53% reduction in inappropriate referrals to the fracture clinic (13 before v nine after).

Using a protocol can, at little expense, improve the treatment of ankle injuries and reduce the cost of radiology in an accident and emergency department.

Treatment of other conditions may be improved by introducing a protocol.

In a retrospective review of the radiographs of 945 patients whose ankles were X-rayed for acute trauma over a 6 month period 95.3% of the 128 fractures identified were seen on anteroposterior and lateral films. The identification of six additional minor fractures by means of the 15 degrees internal oblique radiograph did not alter the management of individual patients and it is concluded that the routine use of oblique views is not justified. Radiological evidence of soft tissue swelling was present in 125 of the 128 fractures. The three patients in whom it was not seen had clinical evidence of local swelling and bruising. These findings indicate that fractures are highly unlikely to be present in the absence of local soft tissue swelling.

A prospective study was performed to establish definitive guidelines for selective use of radiography in the assessment of inversion ankle injuries. Five hundred patients were included, representing 3.2% of the workload of the department during the study period. There were 379 soft tissue injuries, 56 malleolar fractures, 40 avulsion fractures, 21 fractures at the base of the fifth metatarsal, and four calcaneal fractures. Multiple logistic regression identified distal fibular tenderness, age, and ability to bear weight as the most important clinical variables in predicting important fractures (p less than 0.001). A policy of requesting x ray examination of only those patients with distal fibular tenderness or inability to bear weight or aged over 60, with a further proviso that no foot radiographs should be obtained, would produce a 60% reduction in ankle radiography in this centre without detriment to patient care.