Congress:
EuroSafe Imaging 2016
Keywords:
Action 1 - Clinical decision support, clinical imaging guidelines, Action 1 - Guidelines, implementation policies, and Clinical Decision Support (ESR iGuide)
Authors:
G. Ivanac, E. Divjak, B. Brkljacic
DOI:
10.1594/esi2016/ESI-0023
Conclusion and Recommendations
Ankle injuries are a frequent reason for reporting to ED.
Most of the patients undergo radiography of the ankle although a fracture could be excluded in a significant number of cases based on an appropriate physical examination.
In this short study,
we demonstrated that fracture was found in only 27.68% of patients that underwent imaging.
This is a higher percentage than those mentioned in literature [2,
6],
maybe because our study was performed in the colder part of the year,
when risk of fall is increased due to weather conditions.
Nevertheless,
a large proportion of unnecessary exams was performed which could have been avoided if Ottawa rules were used.
Based on the patient’s history and physical exam findings noted in our database,
we found that the radiography wasn’t indicated in 28.57% of patients.
This correlates well with reduction of number of ED ankle and foot radiographs due to application of Ottawa ankle rules mentioned in literature [4,5].
All of the survey participants were aware of excessive use of radiographic examinations in ED,
this being a problem in other countries as well [6,
7].
Common reason for such practice is the prevention of ankle injury misdiagnosis as well as the prevention of possible legal consequences [6].
However,
the evidence suggests that significant fractures can be diagnosed based on careful clinical examination.
[8],
one of the most important fracture signs being the inability to bear weight [6].
Our survey results correlated well with these findings,
showing that physical examination based on palpatory finding and functional status of the ankle was the basis for further workup.
Inferior tip of the lateral/medial malleoli was the most common region of interest in palpation of the ankle structures.
Only two of the survey participants (16,67%) stated that they use Ottawa ankle rules in everyday practice,
despite the fact their effectiveness was repeatedly confirmed through last 20 years [2,
9,
10].
One of possible reasons could be the lack of national guidelines that would provide the physicians working in ED with both clinical guidance and protection from legal consequences.
The results of our survey are still to be confirmed on a larger sample of ED physicians.
Effort should be made to create guidelines encouraging the use of Ottawa ankle rules in EDs,
as well as other algorithms that would help to determine if radiography is indicated with aim to reduce the unnecessary irradiation exposure,
to reduce the workup costs and time,
providing more effective treatment of ED patients.