Jack Casey, HMS III Gillian Lieberman, MD

Radiographic Evaluation of Blunt Ankle Trauma

Jack Casey, HMS IV Gillian Lieberman, MD

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Jack Casey, HMS III Gillian Lieberman, MD

Overview
Importance of ankle injuries Imaging when, how, and what to look for Anatomy review Common ankle injuries
Patient cases to illustrate mechanisms of injury and radiologic classification

Focus on radiology
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Jack Casey, HMS III Gillian Lieberman, MD

Historical Context

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Jack Casey, HMS III Gillian Lieberman, MD

Blunt Ankle Trauma

Still A Major Problem
Most common MSK injury Less that 15% of patients have clinically significant fractures Ankle films are 3rd most common radiologic study ordered in many hospitals > $500 million spent annually on ankle radiographs in North America Clinical guidelines can help guide management
Steill et al. JAMA, 1993. Page 4

Jack Casey, HMS III Gillian Lieberman, MD

Indications for Imaging

The Ottawa Ankle Rules
Set of clinical guidelines, designed to have sensitivity of 100% for detecting fractures s/p blunt ankle trauma.
willing to accept trade-off of lower specificity

Expected benefits: Limit radiation exposure, health care costs, ED waiting time. Designed to be easy to use
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Jack Casey, HMS III Gillian Lieberman, MD

Ottawa Ankle Rules

- The basics
Ankle x-ray series is only necessary if there is pain near the malleoli and any of these findings: 1. Inability to bear weight both immediately and in the ED (four steps) 2. Bone tenderness at posterior edge or tip of medial or lateral malleoli.
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Jack Casey, HMS III Gillian Lieberman, MD

Ottawa Ankle Rules

- The basics
Foot x-ray series is only necessary if there is pain in the mid-foot and any of these findings: Inability to bear weight both immediately and in the ED (four steps) 2. Bone tenderness at base of fifth metatarsal or the navicular.
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www.aafp.org/afp/20020901/785.html

Jack Casey, HMS III Gillian Lieberman, MD

Ottawa Ankle Rules

- How good are they?
Systemic review of 27 studies (15,581 patients)
Sensitivity 96.4 - 99.6 % Specificity varied widely (10-79%) Less than 2% of patients who were negative for fx according to ankle rules actually had a fracture. Missed fractures were almost always minor, did not affect long term outcomes.

28% reduction in use of ankle radiography No decrease in patient satisfaction

Bachmann et al. BMJ, 2003. Steill et al. JAMA, 1993.
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Jack Casey, HMS III Gillian Lieberman, MD

Ottawa Ankle Rules - A few limitations

Not applicable to:

<18 y/o Altered mental status Multi-system trauma Chronic/ subacute injuries

Always trust clinical judgment

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Jack Casey, HMS III Gillian Lieberman, MD

Implementing the OAR

Thorough (but brief) H+P
Evaluate skin/ soft tissue. Assess for open fx. Check and document neurovascular status Palpate entire distal 6 cm of both malleoli before asking patient to bear weight Palpate over 5th metatarsal and navicular for tenderness Palpate for tenderness over proximal fibula to exclude potential Maisonneuve fracture

Think about underlying anatomy and mechanism of injury

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Jack Casey, HMS III Gillian Lieberman, MD

Basic Anatomy 1- Bones

Anterior Process of Calcaneus

Interactive Foot and Ankle. Primal Pictures, Ltc.

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Jack Casey, HMS III Gillian Lieberman, MD

Basic Anatomy 2- Ligaments

THREE principal sets of ligaments support the ankle, all of which are essential to its stability.

Greenspan, Orthopedic Radiology

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Jack Casey, HMS III Gillian Lieberman, MD

Basic Anatomy 3- Tendons

Greenspan, Orthopedic Radiology

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Jack Casey, HMS III Gillian Lieberman, MD

Anatomy- Putting it All Together

Bones and connective tissue give rise to ringlike structure surrounding the talus.
Rosens Emergency Medicine: Concepts and Clinical Practice.
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Jack Casey, HMS III Gillian Lieberman, MD

Ankle Injuries-Inversion
Remember RingLike Structure in Conceptualizing Injury.

www.emedicinehealth.com

Greenspan, Orthopedic Radiology

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Jack Casey, HMS III Gillian Lieberman, MD

Ankle Injuries- Eversion

Greenspan, Orthopedic Radiology

Remember RingLike Structure in Conceptualizing Injury.

www.x-strap.com

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Jack Casey, HMS III Gillian Lieberman, MD

Appropriate Views
Must always include:
1) AP 2) Mortise (ankle in 10 - 25 degrees of internal rotation) 3) Lateral

May add additional views in questionable cases (i.e. stress views, comparison views with uninjured ankle)
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Jack Casey, HMS III Gillian Lieberman, MD

Regions of Interest
Bones of ankle joint The fifth metatarsal tuberosity should be seen in at least one projection. Important to visualize anterior process of the calcaneus.

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Jack Casey, HMS III Gillian Lieberman, MD

Normal AP Radiograph

www.rad.washington.edu

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Jack Casey, HMS III Gillian Lieberman, MD

Normal Mortise Radiograph

Foot internally rotated 1035 degrees to allow for improved visualization of the mortise.

www.rad.washington.edu
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Jack Casey, HMS III Gillian Lieberman, MD

AP vs. Mortise Views

AP

Mortise

Images from Greenspan, Orthopedic Radiology

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Jack Casey, HMS III Gillian Lieberman, MD

Normal Lateral Radiograph

Note: ROI not fully included (5th metatarsal absent)

www.rad.washington.edu

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Jack Casey, HMS III Gillian Lieberman, MD

Classifying Fractures
Anatomic Weber (AO) Other

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Jack Casey, HMS III Gillian Lieberman, MD

Anatomic Classification of Fx
Identifying additional sites of fracture is not just an academic exercise as bi/tri malleolar fx usually require othopedics eval, surgical management.

Greenspan, Orthopedic Radiology

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Jack Casey, HMS III Gillian Lieberman, MD

Unimalleolar Fx
Patient 1
s/p eversion injury, fall from 10 feet Small fx, medial malleolus Also note dislocation talus
Image from BIDMC PACS
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Jack Casey, HMS III Gillian Lieberman, MD

Bimalleolar Fx
Patient 2Fall with ankle inversion. Please r/o fracture

Mortise View
Images from BIDMC PACS

AP view
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Jack Casey, HMS III Gillian Lieberman, MD

Patient 3-

Trimalleolar Fx

Eversion injury. r/o fx (ED films)

Images from BIDMC PACS

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Jack Casey, HMS III Gillian Lieberman, MD

Trimalleolar Fx ORIF

Patient 3
(Intra-op)

Images from BIDMC PACS

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Jack Casey, HMS III Gillian Lieberman, MD

Weber Classification of Fx

Based on the level of fibular fracture Used to determine extent of syndesmotic injury. A<B<C
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Jack Casey, HMS III Gillian Lieberman, MD

Weber A
Patient 4- s/p
fall with ankle inversion. r/o fx.

Avulsion fx below joint line

BIDMC PACS.
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Jack Casey, HMS III Gillian Lieberman, MD

Weber B

Spiral fibular fx: assoc. with partial disruption of tibiofibular ligament

www.wheelessonline.com
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Jack Casey, HMS III Gillian Lieberman, MD

Patient 6

Weber C

s/p ankle trauma r/o fx

How would you classify anatomically? Bimalleolar (comminuted)

BIDMC PACS.
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Jack Casey, HMS III Gillian Lieberman, MD

Recap of Classifications
Anatomic- Uni/ Bi/ Tri Malleolar Weber- A/ B/ C

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Jack Casey, HMS III Gillian Lieberman, MD

Fracture 5th Metatarsal

Patient 7
s/p ankle inversion injury. r/o fx

BIDMC PACS

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Jack Casey, HMS III Gillian Lieberman, MD

Fracture 5th Metatarsal

Mechanism of Injury

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Jack Casey, HMS III Gillian Lieberman, MD

Beyond Simple Radiographs

If pain persists in 6-8 weeks, consider other imaging modalities: - MRI (for evaluation of ligaments/ tendons) - CT

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Jack Casey, HMS III Gillian Lieberman, MD

Summary
Indications for Radiographs
Ottawa Ankle Rules:
o 4 sites for bony tenderness, 4 steps o Save time, money, and avoid radiation exposure, without sacrificing quality

Appropriate views, ROI Think about anatomy Always look for additional fx
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Jack Casey, HMS III Gillian Lieberman, MD

Acknowledgements
Gillian Lieberman, MD Pamela Lepkowski Mary Hochman, MD Larry Barbaras

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Jack Casey, HMS III Gillian Lieberman, MD

References
American College of Radiology. ACR appropriateness criteria. Imaging evaluation of suspected ankle fractures. www.acr.org Anis AH et al. Cost-effectiveness analysis of the Ottawa Ankle Rules. Annals of emergency medicine. 1995.; 26:422-428. Bachmann, LM et al. Accuracy of Ottawa ankle rules to exlude fractures of the ankle and the mid-foot: systematic review. BMJ 2003; 326: 417. Greenspan, A. Orthopedic radiology. A practical approach. Lipincott, Williams and Williams. Philadelphia, PA. 2000. Marx: Rosens Emergency Medicine. Concepts and clinical practice. Fifth ed. 2002, Mosby, Inc. Steill IG et al. Implementation of the Ottawa ankle rules. JAMA 1994; 271: 827-832. Steill IG et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA 1993; 269:1127. www.aafp.org/afp/20020901/785.html www.rad.washington.edu www.x-strap.com/pix/eversion.jpg

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