Bored Review: Oy vay! My ankle! 7/29/14

by sbogoch • July 29, 2014 • 4 Comments

A six-foot-two blond transvestite in size 12, 4-inch Jimmy Choo’s is walking in the mermaid parade when all of a sudden she inverts her ankle and falls to the ground. Graciously she is helped back to her feet by surrounding mermaids and toe-hobbles to the corner. The ankle is swollen and very painful. The nearest hot-dog walla calls EMS. When she arrives in the ED, the bright young clinical monster helps her limp to the stretcher. He notes a grossly swollen, bruised ankle, with no one spot that is more tender than another. There is decreased range of motion. The neurovascular exam is normal. What should this new intern do?

Answer

If you answered, Rest, Ice, Compression, Elevation, you are correct. If you answered, “do an x-ray,” here’s why you’re wrong. The Ottawa Ankle Rules were designed as a clinical decision tool to help reduce ED length of stay and unnecessary x-rays (by 30%!). It is validated and shown to be 100% sensitive for detecting mid-foot and malleolar zone fractures.

You must perform an ankle x-ray if:

1- the patient is unable to walk/hobble 4 steps both at the time of the injury AND in the ED.

2- if there is tenderness in the lateral malleolar zone (6cm length) at the posterior edge of the lateral malleolus.

3- tenderness at the posterior aspect of the medial malleolus in a 6 cm vertical zone.

You must perform a foot xray if:

1- the patient is unable to walk 4 steps at the time of the injury or in the ED.

2- bony tenderness at the navicular bone (medial midfoot).

3- bony tenderness at the base of the 5th metatarsal (lateral midfoot zone).

But….if the patient does not have any one or more of the above criteria, they do not need an x-ray! Give some analgesia, reassurance, compressive dressing and send them on their way!

Stiell, IG et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. 1993 Mar 3;269(9):1127-32.

with respect and admiration for my colleagues,

Dr Sally Bogoch and Dr Andrew Grock

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.