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1、AnklefracturesandtheOttawaanklerulesIthanD.Peltan,MSIVGillianLieberman,MDHarvardMedicalSchoolAgenda¢FocusedH&Pfortheinjuredankle¢Epidemiologyofankleinjury¢Ottawaanklerules¢Grossandradiologicankleanatomy¢Approachtoinjuredankleradiographs¢Examplesofanklefractures2Patient#1:Hi
2、storyA52-year-oldmanwithnoPMHpresentstotheemergencyroom3hoursaftertrippingoverhiswife’scatand“rolling”hisleftankle.Thepainisworstontheoutsideofhisankle,whichismoderatelyswollen.Whenthepaindidn’timprove,hiswifehelpedhimintoacabwhichbroughthimtoBIDMC.3Ankleinjury:Focusedhisto
3、ry¢Mechanism¢SignificantPMH¢Timing–Diabetes–Peripheralsensory¢Audibleinjuryimpairment¢Associatedinjuries–Steroids¢Distalsensation,–Immunosuppressiontingling¢Previousinjuries¢Abletoambulate4Ankleinjury:Focusedexam¢Vitals¢General¢MSK–Appearance/deformity–ROM–Pointtenderness–V
4、ascular:Pulses,capillaryrefill–Neuro:sensation,distalmotor–Ambulatefoursteps¢Don’tforgetnearbyandcontralateraljoints!5Patient#1:PhysicalexamT98.2HR102BP152/92Knee,hipandbonesaboveankleallOK.Leftankleswollenandtendertopalpation.Active/passiveROMlimitedbypain.Neurovascularlyi
5、ntact:DP/PTpulsesintact,capillaryrefill<2s,toesarewarmwithintactsensationtolighttouch.Abletowiggletoes.6Patient#1:A&Phttp://dms.dartmouth.edu/admissionsResident:Great.Whatdoyouwanttodonext?Student:Ananklefilm?Attending:Dowereallyneedone?Canyoumakeanevidence-baseddecision?7A
6、ssessingtheneedforankleradiographs8Epidemiology:Ankleinjuries¢1.8millionEDvisitsperyearnationally¢Chiefcomplaintfor4.3%ofEDpatientsbutashighas10%atsomecenters¢Butjust15%ofpatientspresentingwithanankleinjurypatientshaveafractureHeyworth,2003McCraig,20049Epidemiology:Ankleinj
7、uriesatBIDMC¢BIDMC—2007–4,375anklefilms–3.5%ofallplainfilms–$85perfilm¢Canestimate2,200EDvisits/yearforankleinjuriesatBIDMCPACS,BIDMC10TheOttawaanklerulesmedial11Bachmannetal.BMJ,2003.OAR:SensitivityandspecificitySensitivity:98-100%Specificity:20-40%Bachmannetal.BMJ,2003.12
8、OAR:TestcharacteristicsSensitivityExcellentNegativepredictivevalueExcellentSpecifi
