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Ultrasound-assisted triage of ankle trauma can decrease the need for radiographic imaging

Published:October 23, 2013DOI:https://doi.org/10.1016/j.ajem.2013.09.005

      Abstract

      Background

      An ankle sprain is a common injury, and patients are usually examined with plain radiographs to rule out a fracture despite the fact that only a small minority actually have one.

      Purpose

      To investigate if ultrasound (US)-guided triage can decrease the need for radiographic imaging in patients with ankle trauma.

      Hypothesis

      Orthopedic surgeons can use point-of-care US with limited training to triage ankle trauma that requires standard radiographs.

      Methods

      Seven junior orthopedic surgeons underwent a 30-minute standardized training session using a basic US musculoskeletal examination designed to exclude ankle fractures.
      One-hundred twenty-two patients with ankle trauma were included at the emergency department and underwent clinical investigation, including examination according to the Ottawa ankle rules as well as US and standard ankle radiographs. In this study group, radiographs identified 23 significant fractures. Ultrasound-guided triage could not exclude a fracture in 37 patients. All of the 23 fractures seen on radiographs were among the 37 patients where US could not rule out a fracture. Ottawa ankle rules managed to exclude the need for radiographs in 28 of the 122 patients, whereas 85 who underwent the US-guided triage could have avoided a radiograph. Avulsion fractures at the tip of the fibula were not considered significant.

      Conclusion

      This study demonstrates that with limited standardized training a junior, an orthopedic surgeon is able to use US-guided triage during the primary examination at the emergency department to exclude at least significant ankle fractures. This practice could decrease the need for radiographic imaging, avoiding a mandatory radiographic investigation in many patients with ankle trauma. It would also make it possible to treat many patients with ankle trauma more rapidly and to reduce costs and radiation exposure.
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      References

        • Vanden Bekerom M.P.
        • Kerkhoffs G.M.
        • McCollum G.A.
        • Calder J.D.
        • VanDijk C.N.
        Management of acute lateral ankle ligament injury in the athlete.
        Knee Surg Sports Traumatol Arthrosc. 2012;
        • Brooks S.C.
        • Potter B.T.
        • Rainey J.B.
        Treatment for partial tears of the lateral ligament of the ankle: a prospective trial.
        Br Med J (Clin Res Ed). 1981; 282: 606-607
        • Keogh S.P.
        • Shafi A.
        • Wijetunge D.B.
        Comparison of Ottawa ankle rules and current local guidelines for use of radiography in acute ankle injuries.
        J R Coll Surg Edinb. 1998; 43: 341-343
        • Auleley G.R.
        • Kerboull L.
        • Durieux P.
        • Cosquer M.
        • Courpied J.P.
        • Ravaud P.
        Validation of the Ottawa ankle rules in France: a study in the surgical emergency department of a teaching hospital.
        Ann Emerg Med. 1998; 32: 14-18
        • Dunlop M.G.
        • Beattie T.F.
        • White G.K.
        • Raab G.M.
        • Doull R.I.
        Guidelines for selective radiological assessment of inversion ankle injuries.
        Br Med J (Clin Res Ed). 1986; 293: 603-605
        • Bachmann L.M.
        • Kolb E.
        • Koller M.T.
        • Steurer J.
        • ter Riet G.
        Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review.
        BMJ. 2003; 326: 417
        • Graham I.D.
        • Stiell I.G.
        • Laupacis A.
        • et al.
        Awareness and use of the Ottawa ankle and knee rules in 5 countries: can publication alone be enough to change practice?.
        Ann Emerg Med. 2001; 37: 259-266
      1. Beumer A, van Hemert WL, Niesing R, et al. Radiographic measurement of the distal tibiofibular syndesmosis has limited use. Clin Orthop Relat Res 2004:227–34.

      2. P Barbosa KK, F Bonnaire AO foundation online Surgery reference. In: Colton C, ed.: AO foundation; 2006.

      3. Sman AD, Hiller CE, Refshauge KM. Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: a systematic review. Br J Sports Med 2012.

        • Tirado A.
        • Wu T.
        • Noble V.E.
        • et al.
        Ultrasound-guided procedures in the emergency department—diagnostic and therapeutic asset.
        Emerg Med Clin North Am. 2013; 31: 117-149
        • Heegaard W.
        • Hildebrandt D.
        • Spear D.
        • Chason K.
        • Nelson B.
        • Ho J.
        Prehospital ultrasound by paramedics: results of field trial.
        Acad Emerg Med. 2010; 17: 624-630
        • Rippey J.C.
        • Royse A.G.
        Ultrasound in trauma.
        Best Pract Res Clin Anaesthesiol. 2009; 23: 343-362
        • Kubal W.S.
        Imaging of orbital trauma.
        Radiographics. 2008; 28: 1729-1739
        • Marshburn T.H.
        • Legome E.
        • Sargsyan A.
        • et al.
        Goal-directed ultrasound in the detection of long-bone fractures.
        J Trauma. 2004; 57: 329-332
        • Canagasabey M.D.
        • Callaghan M.J.
        • Carley S.
        The sonographic Ottawa Foot and Ankle Rules study (the SOFAR study).
        Emerg Med J. 2011; 28: 838-840
        • Brooke M.
        • Walton J.
        • Scutt D.
        • Connolly J.
        • Jarman B.
        Acquisition and interpretation of focused diagnostic ultrasound images by ultrasound-naive advanced paramedics: trialling a PHUS education programme.
        Emerg Med J. 2012; 29: 322-326
        • Mollura D.J.
        • Azene E.M.
        • Starikovsky A.
        • et al.
        White paper report of the RAD-AID Conference on International Radiology for Developing Countries: identifying challenges, opportunities, and strategies for imaging services in the developing world.
        J Am Coll Radiol. 2010; 7: 495-500
        • Lutz H.
        • Buscarini E.
        World Health Organization. Manual of diagnostic ultrasound. 2nd ed.
        World Health Organization, Geneva, Switzerland2011