The influence of imaging protocols on complex ankle fracture manipulation in the ED: A before and after study

Ankle injuries that present to the ED with instability of the joint due to multiple fractures/disruption of the mortise need to be re-aligned promptly to minimise complications. A protocol change was introduced whereby mobile radiographs would be performed in the ED resuscitation room during manipulation of a complex ankle injury. The aim of this study was to determine if the overall time to definitive reduction had reduced for these patients, improving patient flow.

Data was collected from patients attending the ED with a complex or unstable ankle injury in a UK single-centre over 6-months periods, pre pathway introduction (2019), immediately post change (2021) and 2 years post implementation (2023).

In excess of 3000 patients had ankle radiographs performed in each cohort of data collection with an average of 2.9 % of injuries categorised as complex or unstable and requiring manipulation, consistent across the cohorts (p = 0.246). Increasing compliance with the new pathway was evident over time with a significant time reduction demonstrated from initial ED presentation to final post manipulation imaging if mobile radiographs were obtained with the mean time 113 min quicker than those performed in the radiology department in 2023 (p = 0.00).

Although it takes time to embed new pathways and changes in practice, this study demonstrated that a simple change in imaging provision had a positive impact for patients with a complex ankle injury.

Providing post manipulation radiographs in the ED resuscitation room allowed earlier confirmation of restored anatomical alignment for patients with a complex ankle injury and enabled clinicians to perform multiple manipulation attempts, if necessary, under the same sedation episode.