Ultrasound as an Adjunct to X-ray in Evaluating for Ankle Fractures

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SONOSIM SUMMARY: Ultrasound is a powerful adjunct in the emergency department for the evaluation of patients with acute musculoskeletal injuries. A study conducted last year at a prominent orthopedic emergency department (ED) in Sweden showed that emergency ultrasound (EUS) can be an effective tool for triaging ankle injuries. In this study, musculoskeletal ankle ultrasound and standard radiographic images were obtained for all ED patients with any ankle injury. Bedside ultrasounds were performed by junior orthopedic surgeons with limited ultrasound training. Results showed that for all patients in which an ankle fracture was diagnosed using X-ray, bedside ultrasonography was able to distinguish a definitive fracture as well, or was indeterminate or not able to rule out fracture. Moreover, emergency ultrasound was found to be more effective than X-ray for diagnosing ankle avulsion fractures, with EUS showing nearly twice the amount of suspected avulsion fractures as compared to X-ray alone. The results of this study suggest that ultrasound may play a prominent role in future ED care of patients with musculoskeletal injuries.
 
Hedelin H, Goksör LA, Karlsson J, et al. Ultrasound-assisted triage of ankle trauma can decrease the need for radiographic imaging. Am J Emerg Med. 2013 Dec;31(12): 1686-1689

Ultrasound of ankle performed in emergency room

Abstract

Background

An ankle sprain is a common injury, and patients are usually examined with plain radiographs to rule out a fracture despite the fact that only a small minority actually have one.

Purpose

To investigate if ultrasound (US)-guided triage can decrease the need for radiographic imaging in patients with ankle trauma.

Hypothesis

Orthopedic surgeons can use point-of-care US with limited training to triage ankle trauma that requires standard radiographs.

Methods

Seven junior orthopedic surgeons underwent a 30-minute standardized training session using a basic US musculoskeletal examination designed to exclude ankle fractures.

One-hundred twenty-two patients with ankle trauma were included at the emergency department and underwent clinical investigation, including examination according to the Ottawa ankle rules as well as US and standard ankle radiographs. In this study group, radiographs identified 23 significant fractures. Ultrasound-guided triage could not exclude a fracture in 37 patients. All of the 23 fractures seen on radiographs were among the 37 patients where US could not rule out a fracture. Ottawa ankle rules managed to exclude the need for radiographs in 28 of the 122 patients, whereas 85 who underwent the US-guided triage could have avoided a radiograph. Avulsion fractures at the tip of the fibula were not considered significant.

Conclusion

This study demonstrates that with limited standardized training a junior, an orthopedic surgeon is able to use US-guided triage during the primary examination at the emergency department to exclude at least significant ankle fractures. This practice could decrease the need for radiographic imaging, avoiding a mandatory radiographic investigation in many patients with ankle trauma. It would also make it possible to treat many patients with ankle trauma more rapidly and to reduce costs and radiation exposure.

To read the complete article, visit The Journal of Emergency Medicine website by clicking here.

SonoSim Keywords: Ultrasound, Emergency Ultrasound, EUS, Ankle Trauma, MSK Ultrasound.

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