METHODS:
We retrospectively reviewed reports and images of 112 random patients who had been referred to ankle radiography from October 2015 to January 2016 due to ankle injury.
Based on patient’s history from the ED,
the authors noted if they found the imaging was necessary or not.
Presence or absence of fracture of ankle bones (Figures 2-4) was also noted and the results were expressed as both absolute numbers and relative percentages.
A survey about reasons of unnecessary imaging of the ankle and use of the Ottawa ankle rules was conducted among 12 physicians working in our ED.
Seven of them were surgery specialists,
one was a surgery resident and four were emergency medicine residents.
The survey consisted of eight multiple choice questions including participant’s specialty,
opinion on if some ankle fractures could be excluded solely by physical examination,
possible reasons for unnecessary imaging,
criteria from physical examination that present indication for ankle imaging,
which regions of ankle are especially important for palpatory examination,
participant’s usage of Ottawa ankle rules in everyday practice,
whether the physical examination or radiography findings have more influence in further treatment and,
finally,
if the participant is satisfied with radiologists’ cooperation.
For some of the questions,
the participants were allowed to choose more than one answer.
The number of participants marking every choice was noted to determine most frequent answers.
RESULTS:
Of total 112 reviewed cases of ankle injury,
bone fracture was present in 31 cases (27.68%).
The radiologists reviewing the cases considered that the radiography was indicated in 80 (71.43%) and unnecessary in 32 cases (28.57%).
No fracture was observed among the cases where radiography was proclaimed unnecessary (Table 1,
Figure 5).
Table 1.
Ankle injury review: Results
TOTAL PATIENTS
|
112
|
Indicated radiographies
|
80
|
Fractures
|
31
|
Not indicated
|
32
|
Fractures
|
0
|
Among the survey participants,
seven of them were surgery specialists,
one was a surgery resident and four were emergency medicine residents (Table 2).
Table 2.
Survey participants
Total participants
|
12
|
Surgery specialists
|
7
|
Surgery residents
|
1
|
Emergency medicine residents
|
4
|
All of the participants agreed that in some cases the patient will be referred to radiography although the fracture could have been excluded based on the patient’s history and physical examination.
Among the reasons for the unnecessary radiographic examination (Table 3,
Figure 6),
most commonly stated are unclear guidelines (6 participants),
and hospital’s ED protocol (5 participants).
Other reasons noted were patients insisting on further workup,
fear of malpractice lawsuits and lack of experience.
Table 3.
Reasons for unnecessary examinations
Reasons for unnecessary examinations
|
Srugery specialists
|
Surgery residents
|
Emergency medicine residents
|
Total
|
Unclear guidelines
|
2
|
1
|
3
|
6
|
Hospital's ED protocol
|
2
|
0
|
3
|
5
|
Patients insisting on further workup
|
3
|
0
|
0
|
3
|
Fear of malpractice lawsuit
|
1
|
0
|
1
|
2
|
Lack of experience
|
1
|
0
|
0
|
1
|
The most important finding leading to radiographic examination (Table 4) is palpatory pain in the ankle region (10 participants),
followed by finding of reduced mobility of the ankle (7 participants) and inability to bear weight (7 participants).
Table 4.
Criteria for referal to radiography
Criteria for referral to radiography
|
Srugery specialists
|
Surgery residents
|
Emergency medicine residents
|
Total
|
Palpatory pain
|
6
|
1
|
3
|
10
|
Reduced mobility
|
3
|
1
|
3
|
7
|
Inability to bear weight
|
4
|
0
|
3
|
7
|
Edema and haematoma
|
2
|
1
|
3
|
6
|
History of ankle distortion
|
1
|
0
|
2
|
3
|
History of impact in ankle region
|
1
|
0
|
1
|
2
|
Region of interest considered to be most important during the palpation for recognizing the fracture (Table 5) were inferior tips of lateral/medial malleoli (6 participants).
Only two participants noted all three regions included in Ottawa ankle rules: the posterior edge of the lateral malleolus,
the posterior edge of medial malleolus and the inferior tip of the lateral/medial malleolus.
Table 5.
Regions of interest during the palpation
Regions of interest during the palpation of the ankle
|
Srugery specialists
|
Surgery residents
|
Emergency medicine residents
|
Total
|
Inferior tip of the lateral/medial malleolus
|
3
|
1
|
2
|
6
|
The anterior edge of the lateral malleolus
|
3
|
1
|
1
|
5
|
The posterior edge of the medial malleolus
|
3
|
0
|
1
|
4
|
The posterior edge of the lateral malleolus
|
2
|
0
|
1
|
3
|
The anterior edge of the medial malleolus
|
1
|
1
|
1
|
3
|
Only two participants answered that they use Ottawa ankle rules in everyday practice.
Seven participants considered physical findings more important than radiological in planning further treatment.
Eight participants found cooperation of ED physicians and radiologists to be satisfactory,
while four found that there is place for improvement.