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?
AnswerYou 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!Â
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
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sbogoch
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4 Comments
adam.aluisio · July 29, 2014 at 3:00 pm
SR data from a number of trials also shows that had this trany been an ambulatory pediatric patient (>2 years of age) you can still use the OAR with Pooled sensitivity of 99% (97 to 99) and a -LR of 0.11 (0.05 to 0.26).
WTF is a “Walla”?
Crocco A. Evid Based Med 2009;14:184 doi:10.1136/ebm.14.6.184
Meyers A, et al. Evid Based Med 2009;14:184 doi:10.1136/ebm.14.6.184
http://adc.bmj.com/content/90/12/1309.full.pdf+html
dwr · July 29, 2014 at 11:03 pm
this is subtle. here’s the thing: “to walk: move at a regular and fairly slow pace by lifting and setting down each foot in turn, never having both feet off the ground at once.” argument would be that in the ED, the awesome clinical monster helped her, and at the scene she “toe-hobbled.” as i read it, it seems she never actually set that foot down. makes me think she didn’t truly hobble (“walk in an awkward way, typically because of pain from an injury.”) in other words, to hobble you have to walk, and to walk you actually have to have your foot on the ground (not just your toes). yes, i know, the toes are part of the foot, but they are not the whole foot. thus, she meets criteria and gets both an ankle and foot film. which kind of makes sense when you consider the 4″ heels.
Nathan · July 30, 2014 at 10:01 am
The decision time actually specifies “ability to bear weight”, so the definition of the word walk is not really relevant. I would consider her to be bearing weight despite her method of ambulation and poor choice in footwear.
aquinn · July 30, 2014 at 9:59 am
Though not part of the Ottawa ankle rules, when examining the patient with an inversion ankle injury, make sure you palpate the fibular head and compress the calf to compress the interosseous membrane. Any pain over the fibular head should raise suspicion for a maissoneuve fracture.