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5/14/2018 Blunt Ankle Trauma - slidepdf.com
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 1
Jack Casey, HMS IVGillian Lieberman, MD
Radiographic Evaluation of
Blunt Ankle Trauma
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 2
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
Page 3
Historical Context
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 4
Blunt Ankle Trauma– Still A Major Problem
• Most common MSK injury• Less that 15% of patients have clinicallysignificant fractures
• Ankle films are 3rd
most common radiologic studyordered in many hospitals
• > $500 million spent annually on ankle
radiographs in North America• Clinical guidelines can help guide management
Steill et al. JAMA, 1993.
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 5
Indications for ImagingThe Ottawa Ankle Rules
• Set of clinical guidelines, designed to have
sensitivity of 100% for detecting fractures s/pblunt 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
Page 6
Ottawa Ankle Rules- The basics
Ankle x-ray series is only
necessary if there is painnear the malleoli and anyof these findings:
1. Inability to bear weightboth immediately and inthe ED (four steps)
2. Bone tenderness atposterior edge or tip of medial or lateral
malleoli.
www.aafp.org/afp/20020901/785.html
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 7
Ottawa Ankle Rules- The basics
Foot x-ray series is only
necessary if there is painin 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.
www.aafp.org/afp/20020901/785.html
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 8
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 longterm 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
Page 9
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
Page 10
Implementing the OAR
• Thorough (but brief) H+PEvaluate skin/ soft tissue. Assess for open fx.
Check and document neurovascular status
Palpate entire distal 6 cm of both malleoli before askingpatient 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 mechanismof injury
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 11
Basic Anatomy 1- Bones
Interactive
Foot andAnkle. PrimalPictures, Ltc.
Anterior Process
of Calcaneus
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 12
Basic Anatomy 2- Ligaments
Greenspan, Orthopedic Radiology
THREE principal sets of
ligaments support the
ankle, all of which areessential to its stability.
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 13
Basic Anatomy 3- Tendons
Greenspan,
Orthopedic
Radiology
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 14
Anatomy- Putting it All TogetherBones and
connectivetissue give
rise to ring-like
structure
surroundingthe talus.
Rosen’s Emergency Medicine: Concepts and Clinical
Practice.
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 15
Ankle Injuries-Inversion
Greenspan, Orthopedic Radiology
Remember Ring-
Like Structure in
ConceptualizingInjury.
www.emedicinehealth.com
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 16
Ankle Injuries- Eversion
Greenspan, Orthopedic Radiology
Remember Ring-
Like Structure in
ConceptualizingInjury.www.x-strap.com
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 17
Appropriate Views
• Must always include:1) AP
2) Mortise (ankle in 10 - 25 degrees of internal rotation)
3) Lateral
• May add additional views in questionablecases (i.e. stress views, comparison views
with uninjured ankle)
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 18
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
Page 19
Normal AP Radiograph
www.rad.washington.edu
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 20
Normal Mortise Radiograph
www.rad.washington.edu
Foot internally rotated 10-
35 degrees to allow forimproved visualization of
the mortise.
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 21
AP vs. Mortise Views
AP Mortise
Images from Greenspan, Orthopedic Radiology
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 22
Normal Lateral RadiographNote: ROI not
fully included (5th
metatarsal absent)
www.rad.washington.edu
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 23
Classifying Fractures
• Anatomic• Weber (AO)
• Other
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 24
Anatomic Classification of Fx
Identifying additional sites of
fracture is not just anacademic exercise– as bi/tri
malleolar fx usually require
othopedics eval, surgical
management.
Greenspan,
OrthopedicRadiology
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 25
Unimalleolar FxPatient 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
Page 26
Bimalleolar FxPatient 2-
“Fall with ankleinversion. Please
r/o fracture”
Images from BIDMC PACS
Mortise View AP view
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 27
Trimalleolar Fx
Patient 3-“Eversion
injury. r/o fx”(ED films)
Images from BIDMC PACS
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 28
Trimalleolar Fx ORIF
Images from BIDMC PACS
Patient 3
(Intra-op)
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 29
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
Page 30
Weber APatient 4- s/p
fall with ankleinversion. r/o fx.
BIDMC PACS.
Avulsion fx
below joint line
J k C HMS III
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 31
Weber B
www.wheelessonline.com
Spiral fibular fx:
assoc. with partial
disruption of tibiofibular ligament
J k C HMS III
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 32
Weber C
How would you classify anatomically?
Patient 6—
“s/p ankle
trauma r/o fx”
Bimalleolar (comminuted)
BIDMC PACS.
J k C HMS III
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 33
Recap of Classifications
• Anatomic- Uni/ Bi/ Tri Malleolar
• Weber- A/ B/ C
Jack Casey HMS III
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 34
Fracture 5
th
Metatarsal
BIDMC PACS
Patient 7—
“s/p ankle
inversion injury.
r/o fx”
Jack Casey HMS III
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 35
Fracture 5
th
Metatarsal
Mechanism of Injury
Jack Casey HMS III
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 36
Beyond Simple Radiographs
If pain persists in 6-8 weeks, consider otherimaging modalities:
- MRI (for evaluation of ligaments/ tendons)
- CT
Jack Casey HMS III
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 37
Summary
• Indications for RadiographsOttawa Ankle Rules:
o 4 sites for bony tenderness, 4 steps
o Save time, money, and avoid radiation exposure, withoutsacrificing quality
• Appropriate views, ROI
• Think about anatomy
• Always look for additional fx
Jack Casey HMS III
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Jack Casey, HMS III
Gillian Lieberman, MD
Page 38
Acknowledgements
• Gillian Lieberman, MD• Pamela Lepkowski
• Mary Hochman, MD• Larry Barbaras
Jack Casey, HMS III
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Gillian Lieberman, MD
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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 ankleand the mid-foot: systematic review. BMJ 2003; 326: 417.
• Greenspan, A. Orthopedic radiology. A practical approach. Lipincott, Williams andWilliams. Philadelphia, PA. 2000.
• Marx: Rosen’s 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