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Prospective evaluation of history and physical examination: variables to determine radiography in acute ankle
P R Stricker1, K P Spindler, K B Gautier
1Vanderbilt Sports Medicine Center, Nashville, Tennessee 37212, USA.
Objective:
This study investigated history and physical findings among 74 patients with acute ankle injuries in order to determine factors significantly associated with fractures, excluding avulsion fragments < 3 mm in size, and syndesmosis injuries and to determine factors that necessitate radiography.
Design:
This was a prospective study performed during a 12-month period. After recording history and physical examination data, a gestalt prediction of a positive or negative radiographic result was made before the patient underwent ankle radiography. Analysis then determined factors important for radiography.
Patients And Setting:
Patients who presented to a sports medicine center with an acute ankle injury were enrolled in the study after meeting the enrollment criteria.
Main Outcome Measures:
Before analysis, predictions for injury were based on accepted indicators. Outcome measures, factors that would indicate the need for radiography, were formulated after data collection and statistical analysis.
Results:
Radiographic findings showed nine fractures and three widened syndesmoses as well as 15 minor ligamentous avulsions. Statistical analysis showed significant association (p < 0.05) of fracture with previous ankle fracture, syndesmosis pain with external rotation stress testing, and pain along the middle third of the distal fibula, from anterior to posterior. Syndesmosis injuries had a significant association with pain during external rotation stress testing.
Conclusions:
Although additional investigation with larger patient numbers would be beneficial, this study highlights the importance of history of previous fracture, pain on the distal mid-fibula or mid-tibia, and pain with external rotation. Furthermore, if these three variables are prospectively applied as criteria for radiography, a 55% reduction in radiography would result with 100% sensitivity. Finally, experienced sports medicine physicians had a 100% sensitivity, 68% specificity, 100% negative predictive value, and 39% positive predictive value for prediction of clinically significant fractures or syndesmosis injuries.