SLR - April 2014 - Anna McLemore
Reference: Divecha H, Javed S, Zubairy A. Ankle Injury Manipulation Before or After X-ray – Does it Influence Success? Injury. 2014 March 45:3 583-85
Scientific Literature Review
Reviewed By: Anna McLemore, DPM
Residency Program: Temple University Hospital, Philadelphia PA
Podiatric Relevance: It is widely understood that one of the most common reasons to visit the emergency department (ED) is ankle trauma. In fact, many retrospective studies estimate that one out of every three ED patients is presenting with an ankle injury. Podiatrists, for this reason, need to be well versed and efficient in their management of a variety of ankle injuries. Due to the importance of skin integrity and neurovascular supply, many EDs have started reducing ankle fractures prior to initial X-ray to expedite treatment. The aim of this paper was to propose that X-ray prior to ankle manipulation, despite the delay, would improve patient experience and decrease complications.
Methods: Medical records from 197 patients that were admitted to the orthopedic ward for an ankle injury between November 2009 to July 2012 were reviewed. They recorded if reduction was performed before or after X-ray, any delays to surgery, and total length of stay. Outcome measures were: re-manipulation, delay to surgery and need for open reduction internal fixation (ORIF). Statistical analysis was performed on these outcome measures and a comparison between injuries reduced before or after X-ray was obtained.
Results: Out of 197 ankle injuries, 90 were manipulated in the ED and 31 of these 90 were manipulated prior to radiographic evaluation. A significant difference was found between re-manipulation of these groups and it was 2.7 times more likely to need re-reduction if X-rays were obtained after initial reduction. It is important to note that the reason for initial reduction without X-rays was documented and the major reason was “no reason.” This means that an increased risk for skin degradation and neurovascular compromise was not typically documented as a reason for haste reduction. There were no significant differences between delayed surgeries or the need for ORIF.
Conclusions: The reason for reduction prior to X-ray is based on the belief that a delay in reduction will increase the risk of skin breakdown, soft tissue damage and swelling leading to delays to surgery. In this prospective study there were no significant differences shown in the need for, or time to ORIF and overall no differences in the length of stay. This study, however, did show a significant difference in the need for re-manipulation of ankle injuries if the initial injury was reduced prior to obtaining an X-ray. The researchers conclude that if X-rays had been performed first, these failed attempts along with the risks of sedation and patient discomfort could have been avoided. Therefore, patients presenting with deformed ankle injuries should have adequate X-rays performed quickly and before a ‘blind’ attempt at reduction.