General

Ankle Sprains: Is X-ray Really Necessary?

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11 Aug 2016 - General
 

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Ankle sprains are the most common musculoskeletal injury in the lower limb. This occurs when there is “rolling over” of the ankle in a plantar flexion and inversion position. It involves overstretching and/or tearing of the ankle ligaments. For lateral ankle sprains, the anterior talofibular ligament is most commonly involved. The calcaneofibular and posterior talofibular ligament (in descending order) may also be injured.  Medial ankle sprains occur far less common and involve the deltoid ligament. It usually occurs in a forceful eversion motion and may involve avulsion fracture of the base of the fifth metatarsal. Simply put, medial ankle sprains should raise a higher index of fracture suspicion compared to lateral ankle sprains. In clinical practice, the Ottawa Ankle Rules was designed to guide doctors when to obtain radiography.

 

The Ottawa Ankle Rules state that an ankle x-ray series for the following scenarios:

·      Pain in the malleolus (major criteria) plus any of the following minor criteria:

       o   Bone tenderness at posterior edge or tip of lateral malleolus (lower 6cm of fibula) or medial malleolus (lower 6 cm of fibula)

       o   Inability to take 4 complete steps both immediately and on the emergency room

·      Pain in the midfoot zone (major criteria) plus any of the following minor criteria:

      o   Bone tenderness at navicular or base of 5th metatarsal

      o   Inability to take 4 complete steps both immediately and on the emergency room

Clinical judgment should prevail over the rules if the patient presents with any of the following:

·      Intoxicated

·      Uncooperative

·      Altered leg sensation

·      Gross swelling preventing palpation of malleolus

·      Other distracting painful injuries

 

Of note, a high index of fracture suspicion should also prevail over the Ottawa Ankle Rules.

 

Marinelle Castro I concur. Guidelines are meant to be what the name implies - as a guide. The Ottawa ankle rules still encourages x-ray if there is suspicion of a fracture. There is no hard and fast rules in the management of each patient. Decision making may overrule common practice if the situation calls for it. This commonly happens in the emergency room setting. Making clinical decisions is challenging becaus...
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Marinelle Castro I concur. Guidelines are meant to be what the name implies - as a guide. The Ottawa ankle rules still encourages x-ray if there is suspicion of a fracture. There is no hard and fast rules in the management of each patient. Decision making may overrule common practice if the situation calls for it. This commonly happens in the emergency room setting. Making clinical decisions is challenging becaus...
 (Total 110 words)
International rules and clinical practice guidelines are written to set standards of care for clinical practice. If a physician has to deviate from these standards of care, there has to be a logical reason why. As for ankle sprains, while the basis of Ottawa ankle rules have been constantly validated and clinically used (most especially by orthopedists), principles of clinical practice for an emergency physician are different. Most emergency physicians are inclined to practice "defensive me...
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Virgilio Montero I agree with your comment. You have mentioned rehabilitation after an ankle sprain to prevent another sprain. That is absolutely true. The ankle joint is also responsible for proprioceptive feedback. Once an ankle sprain occurs, proprioception becomes disrupted that leads to risk for another injury. A history of previous ankle sprain without adequate rehabilitation is the most common risk factor ...
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Kathleen Peralta As a rule for the elderly, it is always better to rule out fracture to err on the side of caution. Older individuals often have decreased bone mineral density that makes them susceptible to fracture. If the elderly patient has dementia and could not remember the events leading to a fall, a skull x-ray at the very least should be requested. High index of suspicion for neurologic events (i.e. strok...
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Taking x ray in any type of injury is commonly seen in general practice. I think that's because they just want to be on the safe side, and the patients are also more satisfied when an x ray is taken and when they are reassured that the xray is normal. Even for the slightest trauma I have seen patients coming with X Rays that they have been asked to take by general practitioners. There's really no need to take an xray for each and every ankle joint injury. Doctors have to be sensible. Ass...
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Not necessary x-ray is the first things we should do if there is ankle sprain. Ankle injuries are common, particularly in those involved in running sports or in any activity involving repeated impact on the ankle. Accurate and rapid diagnosis, comprehensive treatment, and rehabilitation are critical in reducing the risk of re-injury or chronic disabling ankle pain. Most injuries result from a sudden twist and result in pain, sometimes with swelling or instability. Prevention of injury should be ...
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Hi Dr. Mark Edmon Tan, as you are talking about sprains and xrays, I would just like to bring up another topic somehow related to this post. As a nurse who looked after patients living with Dementia, I am fully aware that their pain may be interpreted differently, some of them may not even be able to express any discomfort or some may already be used to say that they've got pain in a particular area. If they ...
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