Imaging

The Ottawa Ankle Rules have provided a significant advance in the evaluation of ankle injuries in the ED. Previous studies suggested that not all patients who presented to the ED needed radiographs.3 The Ottawa Ankle Rules were derived from an initial series of studies 45 and6 and then were prospectively validated. -Z8 These studies involved over 9000 patient encounters and 200 emergency physicians. Two further studies by the same group found the implementation of the rules to be cost effective and that, once taught, emergency physicians continued to use them. 91° Although these studies were carried out in eight academic and community emergency departments in Canada, other studies at independent sites in the United States, - l2 the United Kingdom,13 and France2 have further validated their use. Additionally, it has been demonstrated that nurses at triage can apply the rules successfully. 1 13 Only two studies have failed to replicate these results,1 15 but these studies were found to have either a flawed methodology or did not accurately assess the rules as developed.

The rules are simple to apply and are illustrated in Fig.268-2. The rules can be used on patients with an injury to the ankle, which is clinically broadly defined as the area of the distal leg and the midfoot subject to twisting injuries. Mechanisms of injury include twisting, direct blunt trauma, and falls. The rules were not developed for patients under the age of 18. Clinical judgment should prevail if the examination is unreliable due to lack of cooperation, intoxication, distracting injuries, or a diminished sensation in the leg. To assess the ability to bear weight, ask the patient to take four steps. If the patient can complete two transfers to the injured ankle, the patient passes the test.

Various objections that have been raised in the United States to applying these rules include, but are not limited to, the malpractice potential of missing any fracture, however insignificant; the patient's expectation of a radiograph and perception of a full assessment; and the physician's perception that the proportion of patients with fractures who present with ankle injuries is higher in the United States. Communication with the patient, such as an explanation of the thoroughness of the clinical examination, and the fact that a chip fracture, if missed, is treated like a sprain, is often effective. The saving of time and money for the patients should help them to accept the completeness of the evaluation. Additionally, studies done in the United States show a similar 15 percent fracture rate as demonstrated in Canada, the United Kingdom, France, and Scandinavia.

An excellent review of radiologic subtleties in the diagnosis of extremity injuries is found in Weissman. 16 Utilization of computed tomography and magnetic resonance imaging in the assessment of ankle injuries, although useful, is not appropriate for the ED.

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