Tuesday, October 16, 2012

Ankle Injuries: Do I Need An X-Ray?

Even if you're not a Yankees fan, you have to feel Derek Jeter's pain. Over the weekend, Jeter broke his ankle on a routine play, will miss the rest of the playoffs and may need surgery to correct the injury. Seeing such a class act and team leader go down is tough.

All of us have turned our ankle at some time as well. Be it running the bases, coming down from a rebound, sprinting down the soccer pitch, or simply stepping off the curb, we likely have rolled an ankle at some point. Ankle sprains themselves can be extremely painful, but when is the injury bad enough we may have broken something? Should you go to the ER and get an xray to be sure?

First off, sprains and breaks can both be disabling. To define a sprain, we are talking about injuring ligaments about the ankle, usually on the lateral (outside) part of the foot. This is because these ligaments are more mobile than the inside of the ankle.

Fractures are breaks of bones in the ankle and foot, again, usually on the lateral side of the foot, because the usual mechanism of injury is rolling the ankle in this direction.

So, When Should I Go Get An X-Ray?
Deciding to go the hospital after an ankle injury can sometimes be tough. If it's just a sprain, there's not a lot to be done, other than rest, elevate, and ice. If it's broken, you may need casting, an operation, who knows?
The cost, though, of blindly x-raying every ankle injury also adds up quickly, in dollars and exposure to radiation. In Ontario, x-raying every injury versus being more selective, could cost upwards of $730,000 per 100,000 patients seen. Therefore, over 20 years ago, a group of ER docs in Ottawa came up with a set of rules to decide when someone should get an x-ray, versus knowing nothing would be broken clinically. This ground breaking study, led to the Ottawa Ankle Rules, and is an extremely useful guide for the patient trying to decide when it is necessary to get assessed.

Basically, the rules are as follows.

  • You should have an xray if you CAN NOT transfer weight to the injured ankle/foot TWICE, either immediately, OR in the ER.
  • You should have an xray if you have TENDERNESS over the POSTERIOR (back part) of the EITHER malleolus (ankle bone).
  • You should have an xray if you have TENDERNESS at the BASE of the 5th Metatarsal (baby digit), or the Navicular (bone on the instep of the foot).

That's it. If you CAN walk on the foot, no matter how sore, AND there is NO tenderness over any of the bones listed above, you can skip the x-ray. Get ice on it, keep it elevated, and give it some time.
Having said all that, of course, if things aren't settling over the next few days, get it looked at. 

These rules have been HIGHLY validated, and virtually 100% sensitive. They have gone a long way to cost savings for the health system, and have saved many unnecessary xrays.

Here's hoping Jeter is back in full form next year!

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