Journal reading. Introduction. Introduction. Ottawa Ankle Rules. Method

Size: px

Start display at page:

Download "Journal reading. Introduction. Introduction. Ottawa Ankle Rules. Method"

Rudolf Stanley
5 years ago
Views:

1 Journal reading Presenter: PGY 林聖傑 Supervisor: Dr. 林俊龍 The accuracy of ultrasound evaluation in foot and ankle trauma Salih Ekinci, MD American Journal of Emergency Medicine 31 (2013) Foot and ankle injury most common in clinical practice Usually not life threatening, but affected limb functions can be endangered early diagnosis and treatment can prevent long term complication US imaging: cheap irradiation free dynamic analysis that can detect small change comparison with asymptomatic symmetric body part visualizing a large number of joints in a short period Limited studies and data concerning the standardization of foot and ankle US scan methods. Goal Determine the accuracy of US scanning in patients with foot and ankle trauma admitted to the emergency department with bone injuries Method Prospective evaluation US vs Radiography Enrolled from May 2011 to June 2012 Ottawa Ankle Rules Ankle X ray is only required if there is any pain in the malleolar zone and any one of the following: Bone tenderness along the distal 6cm of the posterior edge of the tibia or tip of the medial malleolus, OR Bone tenderness along the distal 6cm of the posterior edge of the fibula or tip of the lateral malleolus, OR An inability to bear weight both immediately and in the emergency department for four steps. Additionally, the Ottawa foot rules indicate whether a foot X ray series is required. It states that it is indicated if there is any pain in the midfoot zone and any one of the following: Bone tenderness at the base of the fifth metatarsal (for foot injuries), OR Bone tenderness at the navicular bone (for foot injuries), OR An inability to bear weight both immediately and in the emergency department for four steps.

Method Record Sex Age Trauma form (sprains or blunt) Cause (walking, running, sports, traffic accident) Buckling mechanism (inversion, eversion) Physical examination Method US first by primary

2 Method Record Sex Age Trauma form (sprains or blunt) Cause (walking, running, sports, traffic accident) Buckling mechanism (inversion, eversion) Physical examination Method US first by primary physician Another physician: Order necessary radiologic examinations and treatments The US performed did not see the X rays Method Ankle injury AP, lateral, Mortis X ray Foot injury AP, lateral X ray Injury to metatarsals (MTs) oblique X ray All the radiographic images were interpreted by an orthopedic specialist in terms of fracture, and these were added to the records Method Continuous variables Presented as mean and SD Comparison Mann Whitney U test Categorical data Presented as frequency and percentage Comparisons χ2 and Fisher exact test 219 patients were admitted with injury in the foot and ankle Exclusion 14 were younger than 16 5 were unstable 4 had open fractures or dislocations 3 had chronic foot or ankle problems 5 did not want to participate in the study 57 were excluded because of failure to comply with Ottawa Ankle Rules (OAR) 131 patients were included in the study 103: sprains, 28: blunt trauma

$2%) by radiography 17: sprains 3: blunt trauma Patients with fractures were older (P=.$ 009) Fracture was detected in 21 patients (16%) by US evaluation Radiographic examination: criterion

009) Fracture was detected in 21 patients (16%) by US evaluation Radiographic examination: criterion

3 Fractures were detected in 20 patients (15.2%) by radiography 17: sprains 3: blunt trauma Patients with fractures were older (P=.009) Fracture was detected in 21 patients (16%) by US evaluation Radiographic examination: criterion standard Sensitivity: 100% (95% CI, ) Specificity: 99.1% (95% CI, ) Positive predictive value: 95.2% (95% CI, ) Negative predictive value: 100% (95% CI, )

$1 week later Almost all patients with main complaint of pain in the foot or ankle are exposed to radiographic examinations Despite the widespread use of OAR, fractures are seen$ Ultrasound is an imaging technique used for many years to examine musculoskeletal tissues For prompt diagnosis, focused US on symptomatic parts of the body is preferable When

Ultrasound is an imaging technique used for many years to examine musculoskeletal tissues For prompt diagnosis, focused US on symptomatic parts of the body is preferable When

$Canagasabey et al US sensitivity and specificity in diagnosing fractures were 90.$

4 1 week later Almost all patients with main complaint of pain in the foot or ankle are exposed to radiographic examinations Despite the widespread use of OAR, fractures are seen in less than 15% of these patients. Ultrasound is an imaging technique used for many years to examine musculoskeletal tissues For prompt diagnosis, focused US on symptomatic parts of the body is preferable When symptoms are diffuse or there is another anatomical region with more severe pain, focused US examination may give incorrect results routine wide US examinations are preferred Canagasabey et al US sensitivity and specificity in diagnosing fractures were 90.9% in patients 16 years or older Trinh et al, lateral ankle fractures US sensitivity was 100% and specificity was 88.9% Simanovsky et al, pediatric patients US sensitivity and specificity for detecting ankle fracture 100% and 96%. In studies, most ankle fractures were malleolar and 60% to 70% were unimalleolar Cakir et al 5 MT fractures in 56% of the patients with isolated MT fractures as a result of foot fractures

5 Limitations US examination was done by 1 physician Not include all patients admitted to the ED Major limitation Did not measure the duration of US application specific position US first, then X ray Not able to compare the rapidity of diagnosis Not able to quantify the effect of imaging modality on overall length of stay Conclusion US scanning is an effective method that can be applied in the emergency department to adult age groups to diagnose foot or ankle fractures Because it is irradiation free a high rate of satisfaction in patients Safely be applied in pregnant women and pediatric age groups Conclusion Further studies The evaluation of the effects of US use for the time passed in the emergency department The diagnosis time in patients with foot and ankle trauma Take a breath Ultrasound assisted triage of ankle trauma can decrease the need for radiographic imaging Henrik Hedelin, MD American Journal of Emergency Medicine 31 (2013) Ankle sprains: approximately 25% of all musculoskeletal injuries Excluding a fracture is an important clinical decision different treatment Most ankle fractures: surgery, immobilization, Sprains: early mobilization Most ankle trauma patients X ray to exclude an ankle fracture despite the fact that 85% do not have a fracture.

6 The Ottawa ankle rules (OARs) Widely accepted to decrease the overuse of radiographic imaging But only reduce the number of radiographs on patients without a fracture by approximately 30% to 40% sensitivity of 95% to 100% but only a modest specificity The use of ultrasound (US) by nonradiologists has increased dramatically over the last 10 years FAST, pneumonia in children, ocular trauma In the orthopedic field, earlier studies: US can be safely used by paramedics in the prehospital setting to diagnose long bone fractures US was used to establish the diagnosis of ankle fractures Goal Examine the use of point of care US as a triage tool in the ED by Junior orthopedic surgeons To determine if US could safely be used to exclude ankle fractures in a mixed group of adult patients with ankle trauma Methods 7 junior orthopedic surgeons When one of the study physicians was on call Included patients with ankle trauma at ED Trained by a senior radiologist in basic US examination skills standardized 30 minute training model From October 2011 to October 2012 Soft tissue and ligamentous injuries were not included Exclusion criteria open or grossly displaced fractures patients with dementia or other cognitive impairment Methods Protocol Entire length of the fibula and the distal 15 cm of the tibia The probe both longitudinal and perpendicular to the axis of the bone Posterior distal part of the tibia visualized from the lateral side behind the fibula Cortex and subperiosteal bleeding About 4 8 minutes Methods Significant fracture definition Any fracture of the ankle or proximal fibula All fractures of the medial malleolus were considered significant Except avulsion fractures of the tip of the fibula

Methods Patients were admitted Normal routine OAR examination and the US examination of the ankle and lower leg

OAR: orthopedic surgeon The radiologist was blind to any US findings and whether a patient was included in the study or

$were both defined as significant fracture no significant fracture uncertain/other result US: could not obtain good$

7 Methods Patients were admitted Normal routine OAR examination and the US examination of the ankle and lower leg Standard radiographs of the ankle regardless of clinical and US finding Radiograph interpretation: radiologist US and OAR: orthopedic surgeon The radiologist was blind to any US findings and whether a patient was included in the study or not Methods The OAR examinations was defined as Positive: need radiograph Negative The US and radiographic examinations were both defined as significant fracture no significant fracture uncertain/other result US: could not obtain good enough images Radiographs: more complicated results 122 patients 64 women and 58 men mean age of 42 years ranging from 18 to 92 years

$Radiographs identified 23 significant fractures, all of them were interpreted as fracture or uncertain/other finding by the US triage doctor There were 13 uncertain/other findings and 24 fractures on$

8 Radiographs identified 23 significant fractures, all of them were interpreted as fracture or uncertain/other finding by the US triage doctor There were 13 uncertain/other findings and 24 fractures on the US examination, giving a total of 14 potentially unnecessary radiographs = 85 (could avoid radiograph) The OARs classified 28 patients as not needing a radiograph. None of these had significant fracture on radiographs. Radiographs: 13 avulsion fractures 8 were noted by US, 2 as uncertain finding In 9 cases, US showed a suspected avulsion fracture that could not be verified with plain radiographs Limited training appears to be sufficient to teach the basic skills needed for Junior physicians to establish the diagnosis of significant ankle fractures Most common critique US is an instrument requiring much training and experience Not a replacement for the OAR but rather an addendum depend on facilities available Ultrasound is probably as sensitive to establish the diagnosis of avulsion fractures of the fibula tip as radiographs In some locations, US is available, whereas x ray services are not US examination can be used to exclude fracture Limitation not a consecutive number of cases, and the inclusion is distributed over 1 year Conclusion Point of care US in the hands of in training physicians can be used to safely triage patients with ankle trauma Ultrasound guided triage seems to be able to decrease the number of radiographs more than the OARs

CLINICAL PRESENTATION AND RADIOLOGY QUIZ QUESTION

Donald L. Renfrew, MD Radiology Associates of the Fox Valley, 333 N. Commercial Street, Suite 100, Neenah, WI 54956 12/08/2012 Radiology Quiz of the Week # 102 Page 1 CLINICAL PRESENTATION AND RADIOLOGY