ACR logo

Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Czajka CM, Tran E, Cai AN, DiPreta JA. Ankle sprains and instability. [Review]. Med Clin North Am. 98(2):313-29, 2014 Mar. Review/Other-Dx N/A To review ankle sprains and instability. No results stated in abstract. 4
2. Lambers K, Ootes D, Ring D. Incidence of patients with lower extremity injuries presenting to US emergency departments by anatomic region, disease category, and age. Clin Orthop Relat Res. 2012;470(1):284-290. Review/Other-Dx 119,815 patients To determine the anatomic regions, disease categories, and circumstances that account for the highest incidence of leg problems among patients presenting to emergency departments in the United States. The authors identified 112 unique combinations of disease categories and anatomic regions. Strains and sprains accounted for 36% of all lower extremity injuries. The injury with the greatest incidence was an ankle sprain (206 per 100,000; 95% CI, 181-230). Younger patients were more likely to have ankle sprains, foot contusions/abrasions, and foot strains/sprains. Older patients were more likely to have lower trunk fractures and lower trunk contusions/abrasions. The most common incidence for injury was at home (45%). 4
3. Curr S, Xyrichis A. Does nurse-led initiation of Ottawa ankle rules reduce ED length of stay?. [Review]. Int Emerg Nurs. 23(4):317-22, 2015 Oct. Review/Other-Dx 4 studies To examine the best available evidence on the impact of Ottawa ankle rules (OAR) on emergency department (ED) length of stay (LoS) following standard systematic review methodology. All four studies point towards a reduction in LoS following OAR introduction. The quality of the body of evidence is considered to be low due to moderate risk of bias and indirectness between the studies. 4
4. Nazarenko A, Beltran LS, Bencardino JT. Imaging evaluation of traumatic ligamentous injuries of the ankle and foot. [Review]. Radiologic Clinics of North America. 51(3):455-78, 2013 May. Review/Other-Dx N/A To discuss imaging evaluation of traumatic ligamentous injuries of the ankle and foot. No results stated in abstract. 4
5. Seah R, Mani-Babu S. Managing ankle sprains in primary care: what is best practice? A systematic review of the last 10 years of evidence. Br Med Bull. 2011;97:105-135. Review/Other-Dx 33 articles To summarize the best available evidence in the last decade for managing ankle sprains. Ankle sprains occur commonly but their management is not always readily agreed. The OAR are ubiquitous in the clinical pathway and can be reliably applied by emergency care physicians, primary care physicians and triage nurses. For mild-to-moderate ankle sprains, functional treatment options (which can consist of elastic bandaging, soft casting, taping or orthoses with associated coordination training) were found to be statistically better than immobilization for multiple outcome measures. For severe ankle sprains, a short period of immobilization in a below-knee cast or pneumatic brace results in a quicker recovery than tubular compression bandage alone. Lace-up supports are a more effective functional treatment than elastic bandaging and result in less persistent swelling in the short term when compared with semi-rigid ankle supports, elastic bandaging and tape. Semi-rigid orthoses and pneumatic braces provide beneficial ankle support and may prevent subsequent sprains during high-risk sporting activity. Supervised rehabilitation training in combination with conventional treatment for acute lateral ankle sprains can be beneficial, although some of the studies reviewed gave conflicting outcomes. Therapeutic hyaluronic acid injections in the ankle are a relatively novel non-surgical treatment but may have a role in expediting return to sport after ankle sprain. There is a role for surgical intervention in severe acute and chronic ankle injuries, but the evidence is limited. 4
6. Lin CW, Uegaki K, Coupe VM, Kerkhoffs GM, van Tulder MW. Economic evaluations of diagnostic tests, treatment and prevention for lateral ankle sprains: a systematic review. [Review]. BJSM online. 47(18):1144-9, 2013 Dec. Review/Other-Dx 10 studies To assess and summarize the economic evidence regarding diagnostic tests, treatment and prevention for lateral ankle sprains. A total of 230 records were identified; 10 studies were included. 5 studies conducted a full economic evaluation and 5 studies involved cost analyses. Lack of blinding was the main risk of bias. The methodological quality of the full economic evaluations was fairly good. Valuation of costs, measurement of outcomes and sensitivity analysis were points for improvement. Single studies showed that the OAR was cost effective for diagnosing lateral ankle sprains in the emergency setting compared with existing hospital protocols; acute treatment with anti-inflammatory medication and the plaster cast for severe sprains appeared cost effective; and neuromuscular training was cost effective in preventing ankle re-injury. 4
7. Tajmir S, Raja AS, Ip IK, et al. Impact of Clinical Decision Support on Radiography for Acute Ankle Injuries: A Randomized Trial. West J Emerg Med. 18(3):487-495, 2017 Apr. Experimental-Tx 66 providers To examine the impact of electronic point-of-care clinical decision support (CDS) on adherence to the Ottawa Ankle Rules (OAR), as well as use and yield of foot and ankle radiographs in patients with acute ankle injury. Of 14,642 patients seen at urgent care during the study period, 613 (4.2%, representing 632 visits) presented with acute ankle injury and were eligible for application of the OAR; 374 (59.2%) of these were seen by control-group providers. In the intervention group, CDS adherence was higher for both ankle (239/258=92.6% vs. 231/374=61.8%, p=0.02) and foot radiography (209/258=81.0% vs. 238/374=63.6%; p<0.01). However, ankle radiography use was higher in the intervention group (166/258=64.3% vs. 183/374=48.9%; p<0.01), while foot radiography use (141/258=54.6% vs. 202/374=54.0%; p=0.95) was not. Radiography yield was also higher in the intervention group (26/307=8.5% vs. 18/385=4.7%; p=0.04). 2
8. Dowling S, Spooner CH, Liang Y, et al. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. Acad Emerg Med. 16(4):277-87, 2009 Apr. Meta-analysis 12 studies (n=3,130) Systematic review to determine the diagnostic accuracy of the OAR to exclude ankle and midfoot fractures in children and the extent to which x-ray use could be reduced without missing significant fractures. Pooled sensitivity was 98.5% (95% CI, 97.3–99.2). 4/10 missed fractures were characterized: 1 Salter-Harris-I, 1 Salter-Harris-IV, and 2 “insignificant fractures” (either Salter-Harris-I or avulsion fractures <3 mm). The pooled estimate for rate of x-ray reduction was 24.8% (95% CI, 23.3%–26.3%; range = 5%–44%). OAR appears to be a reliable tool to exclude fractures in children >5 years of age presenting with ankle and midfoot injuries. Employing the OAR would significantly decrease x-ray use with a low likelihood of missing a fracture. Good
9. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. 1992;21(4):384-390. Observational-Dx 155 adults To develop decision rules that will predict fractures in patients with ankle injuries, thereby assisting clinicians in being more selective in their use of radiography. All 70 significant malleolar fractures found in the 689 ankle radiographic series performed were identified among people who had pain near the malleoli and were age 55 years or more, had localized bone tenderness of the posterior edge or tip of either malleolus, or were unable to bear weight both immediately after the injury and in the emergency department. This rule was 100% sensitive and 40.1% specific for detecting malleolar fractures and would allow a reduction of 36.0% of ankle radiographic series ordered. Similarly, all 32 significant midfoot fractures on the 230 foot radiographic series performed were found among patients with pain in the midfoot and bone tenderness at the base of the fifth metatarsal, the cuboid, or the navicular. 3
10. Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. 1993;269(9):1127-1132. Observational-Dx First stage 1,032 of 1,130 eligible patients: Second stage 453 of 530 eligible patients To validate and refine previously derived clinical decision rules that aid the efficient use of radiography in acute ankle injuries. Survey prospectively administered in two stages: validation and refinement of the original rules (first stage) and validation of the refined rules (second stage). OAR is 100% sensitive for fractures, reliable, and has the potential to allow physicians to safely reduce the number of radiographs ordered in patients with ankle injuries by one-third. 1
11. Leddy JJ, Smolinski RJ, Lawrence J, Snyder JL, Priore RL. Prospective evaluation of the Ottawa Ankle Rules in a university sports medicine center. With a modification to increase specificity for identifying malleolar fractures. Am J Sports Med. 1998;26(2):158-165. Observational-Dx 132 patients To prospectively evaluate the OAR over 1 year for their ability to identify clinically significant ankle and midfoot fractures and to reduce the need for radiography. There were 11 clinically significant fractures (fracture rate, 8.3% per year). In these 132 patients, the OAR would have reduced the need for radiography by 34%, without any fractures being missed (sensitivity 100%, specificity 37%). In 78 patients, the specificity for malleolar fracture for the new rule was significantly greater than that of the OAR malleolar rule (59% vs 42%), sensitivity remained 100%, and the potential reduction in the need for radiography (54%) was significantly greater. 2
12. Keogh SP, Shafi A, Wijetunge DB. Comparison of Ottawa ankle rules and current local guidelines for use of radiography in acute ankle injuries. J R Coll Surg Edinb. 1998;43(5):341-343. Observational-Dx 252 patients To assess any advantage of the OAR vs local guidelines for radiography of the acutely injured ankle or midfoot. 22 fractures were diagnosed radiologically. Both guidelines had a sensitivity of 1.0 in detecting fractures and a negative predictive value of 1.0. OAR guidelines produced a specificity of 0.48 and a PPV of 0.15. Local guidelines produced a specificity of 0.19 and a PPV of 0.1. Following OAR produced a highly significant reduction (X = 74.0 P<0.001) in radiography of 37%, and no fractures were missed. This could potentially save the department approximately 7500 Pounds per annum. 3
13. Jonckheer P, Willems T, De Ridder R, et al. Evaluating fracture risk in acute ankle sprains: Any news since the Ottawa Ankle Rules? A systematic review. [Review]. Eur J Gen Pract. 22(1):31-41, 2016. Review/Other-Dx 22 studies To review systematically the current evidence on the most accurate method to assess the fracture risk after an ankle sprain in adults. One systematic review and 21 primary studies were selected. Sensitivity and specificity of the Ottawa ankle rules (OAR) range from 92-100% and from 16-51%, respectively. To improve the OAR specificity, other tools are proposed such as the Bernese ankle rules. Vibrating tuning fork test and ultrasound could be useful in patient with OAR positive to decrease the need for radiographs. No evidence was found in favour of the use of magnetic resonance imaging (MRI) or computed tomography (CT) in the acute phase of ankle sprain. 4
14. Barelds I, Krijnen WP, van de Leur JP, van der Schans CP, Goddard RJ. Diagnostic Accuracy of Clinical Decision Rules to Exclude Fractures in Acute Ankle Injuries: Systematic Review and Meta-analysis. [Review]. J Emerg Med. 53(3):353-368, 2017 Sep. Review/Other-Dx 18 studies To examine which clinical decision rules are the most accurate for excluding ankle fracture after acute ankle trauma. Eighteen studies satisfied the inclusion criteria. These included six ankle decision rules, specifically, the Ottawa Ankle Rules, Tuning Fork Test, Low Risk Ankle Rule, Malleolar and Midfoot Zone Algorithms, and the Bernese Ankle Rules. Meta-analysis of the Ottawa Ankle Rules (OAR), OAFR, Bernese Ankle Rules, and the Malleolar Zone Algorithm resulted in a negative likelihood ratio of 0.12, 0.14, 0.39, and 0.23, respectively. 4
15. Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. [Review] [17 refs]. BMJ. 326(7386):417, 2003 Feb 22. Review/Other-Dx 32 studies met inclusion criteria; 27 studies (15,581 patients) for pooled analysis Systematic review to examine the accuracy of OAR for excluding fractures of the ankle and mid-foot. Pooled negative likelihood ratios for the ankle and mid-foot were 0.08 (95% CI, 0.03–0.18) and 0.08 (0.03–0.20), respectively. The pooled negative likelihood ratio for both regions in children was 0.07 (0.03–0.18). Applying these ratios to a 15% prevalence of fracture gave a <1.4% probability of actual fracture in these subgroups. Evidence supports the (OAR) as an accurate instrument for excluding fractures of the ankle and mid-foot. The instrument has a sensitivity of almost 100% and a modest specificity, and its use should reduce the number of unnecessary radiographs by 30%-40%. 4
16. Lee WW, Filiatrault L, Abu-Laban RB, Rashidi A, Yau L, Liu N. Effect of Triage Nurse Initiated Radiography Using the Ottawa Ankle Rules on Emergency Department Length of Stay at a Tertiary Centre. CJEM, Can. j. emerg. med. care. 18(2):90-7, 2016 Mar. Review/Other-Dx 146 patients To determine the effect of triage nurse initiated radiographs using the Ottawa Ankle Rules (OAR) on emergency department (ED) throughput. We hypothesized OAR use would reduce median ED length of stay (LOS) by 25 minutes or more. Of 176 patients with blunt ankle injury screened, 146 were enrolled (83.0%); baseline characteristics in the two groups were similar. The median/mean ED LOS in the control and OAR groups were 128/143 minutes and 108/115 minutes respectively (median difference 20 minutes; p=0.003). Agreement in OAR use between emergency physicians and nurses was moderate (kappa 0.46/0.77 for foot/ankle rule components), and satisfaction of both nurses and participants was high. 4
17. Ho JK, Chau JP, Cheung NM. Effectiveness of emergency nurses' use of the Ottawa Ankle Rules to initiate radiographic tests on improving healthcare outcomes for patients with ankle injuries: A systematic review. [Review]. Int J Nurs Stud. 63:37-47, 2016 Nov. Review/Other-Dx 9 studies To review the most accurate evidence available on the extent to which emergency nurses' use of the Ottawa Ankle Rules to initiate radiographic tests improves healthcare outcomes for patients with ankle injuries. The search of databases and other sources yielded 1603 records. The eligibility of 17 full-text articles was assessed, and nine studies met the inclusion criteria. All nine studies were subjected to narrative analysis, and five were meta-analysed. All of the studies investigated the use of the refined Ottawa Ankle Rules. The results indicated that emergency nurses' use of the refined Ottawa Ankle Rules minimised unnecessary radiographic-test requests and reduced patients' length of stay in emergency departments. However, the use of these rules in urgent-care departments did not reduce unnecessary radiographic-test requests or patients' length of stay. The implementation of the refined Ottawa Ankle Rules by emergency nurses with different backgrounds, including nurse practitioners or general emergency nurses was found to reduce patients' length of stay in emergency departments. 4
18. Derksen RJ, Knijnenberg LM, Fransen G, Breederveld RS, Heymans MW, Schipper IB. Diagnostic performance of the Bernese versus Ottawa ankle rules: Results of a randomised controlled trial. Injury. 46(8):1645-9, 2015 Aug. Observational-Dx 203 patients To compare the diagnostic accuracy and reproducibility of Ottawa ankle rules (OAR) and the Bernese ankle rule (BAR); to assess the ability of triage nurses to accurately interpret the BAR. A total of 203 patients with ankle trauma were included. For the OAR obtained by the ED residents, the sensitivity and specificity were 0.97 and 0.29, respectively. For the BAR, the sensitivity and specificity of the ED residents were 0.69 and 0.45, respectively. For the triage nurses, the OAR sensitivity and specificity were 0.86 and 0.25, respectively. The BAR sensitivity and specificity for the nurses were 0.86 and 0.40, respectively. The reproducibility of the OAR was 0.45, and for the BAR, it was 0.48. 3
19. Eggli S, Sclabas GM, Zimmermann H, Exadaktylos AK. The Bernese ankle rules: a fast, reliable test after low-energy, supination-type malleolar and midfoot trauma. J Trauma. 2005;59(5):1268-1271. Observational-Dx 364 patients The authors introduced a new indirect stress technique to examine the ankle and the midfoot after low-energy, supination-type trauma, avoiding direct palpation of the injured region. In 354 prospectively documented patients, the Bernese ankle test produced a sensitivity of 100% and a specificity of 91%. 3
20. Polzer H, Kanz KG, Prall WC, et al. Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm. Orthop Rev (Pavia). 2012;4(1):e5. Review/Other-Dx N/A To systematically search the current literature, classify the evidence, and develop an algorithm for the diagnosis and treatment of acute ankle injuries. According to the currently available literature, the following recommendations have been formulated: i) the OAR should be applied in order to rule out fractures; ii) physical examination is sufficient for diagnosing injuries to the lateral ligament complex; iii) classification into stable and unstable injuries is applicable and of clinical importance; iv) the squeeze-, crossed leg- and external rotation test are indicative for injuries of the syndesmosis; v) MRI is recommended to verify injuries of the syndesmosis; vi) stable ankle sprains have a good prognosis while for unstable ankle sprains, conservative treatment is at least as effective as operative treatment without the related possible complications; vii) early functional treatment leads to the fastest recovery and the least rate of re-injury; viii) supervised rehabilitation reduces residual symptoms and re-injuries. 4
21. Dunlop MG, Beattie TF, White GK, Raab GM, Doull RI. Guidelines for selective radiological assessment of inversion ankle injuries. Br Med J (Clin Res Ed). 1986;293(6547):603-605. Review/Other-Dx 500 patients Prospective study was performed to establish definitive guidelines for selective use of radiography in the assessment of inversion ankle injuries. There were 379 soft tissue injuries, 56 malleolar fractures, 40 avulsion fractures, 21 fractures at the base of the fifth metatarsal, and 4 calcaneal fractures. Multiple logistic regression identified distal fibular tenderness, age, and ability to bear weight as the most important clinical variables in predicting important fractures (P<.001). A policy of requesting x-ray examination of only those patients with distal fibular tenderness or inability to bear weight or aged over 60, with a further proviso that no foot radiographs should be obtained, would produce a 60% reduction in ankle radiography in this center without detriment to patient care. 4
22. Mosher TJ, Kransdorf MJ, Adler R, et al. ACR Appropriateness Criteria acute trauma to the ankle. J. Am. Coll. Radiol.. 12(3):221-7, 2015 Mar. Review/Other-Dx N/A To provide evidence-based guidelines for the diagnosis of acute trauma to the ankle. No results stated in abstract. 4
23. Diehr P, Highley R, Dehkordi F, et al. Prediction of fracture in patients with acute musculoskeletal ankle trauma. Med Decis Making. 1988;8(1):40-47. Review/Other-Dx 587 patients To find clinical predictors for the presence of fracture in patients presenting with ankle trauma, and to develop and describe a rule that can decrease x-ray utilization without adversely affecting patient care. The association of each variable with the final diagnosis of fracture, rupture, or sprain was tested; 21 variables were significant predictors of fracture (vs sprain and rupture) and 15 were not significantly associated with final diagnosis. 4
24. American College of Radiology. ACR Appropriateness Criteria®: Acute Trauma to the Foot. Available at: https://acsearch.acr.org/docs/70546/Narrative/ Review/Other-Dx NA Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. No abstract available. 4
25. McLaughlin SA, Binder DS, Sklar DP. Ottawa ankle rules and the diabetic foot. Ann Emerg Med. 1998;32(4):518. Review/Other-Dx N/A Letter to editor commenting on the role of OAR in a diabetic woman. Diabetic patients with sensory neuropathy should be part of the exclusion criteria for use of OAR. 4
26. Coll AP. Ottawa rules, OK? Rules are different in diabetes. BMJ. 2009;339:b3507. Review/Other-Dx N/A A comment on Ottawa rules. No results stated in abstract. 4
27. Hastie GR, Divecha H, Javed S, Zubairy A. Ankle injury manipulation before or after X-ray--does it influence success?. Injury. 45(3):583-5, 2014 Mar. Observational-Dx 197 patients To test the hypothesis that performing ankle injury X-rays before an attempt at an initial reduction in the ED would confirm the type of injury present, exclude other not-uncommon differentials (subtalar/talonavicular dislocation), allow for appreciation of the fracture-dislocation geometry and guide the manipulation. Outcomes (re-manipulation, delay to surgery and need for open reduction and internal fixation (ORIF)) were compared between injuries manipulated before or after X-ray. Re-manipulation was found to be significant (44% before X-ray vs. 18% after X-ray; chi-squared test: p = 0.03; relative risk (RR) = 2.72; 95% confidence interval (CI): 1.15–6.44). Delay to surgery and need for ORIF were not statistically different. 3
28. Nikken JJ, Oei EH, Ginai AZ, et al. Acute ankle trauma: value of a short dedicated extremity MR imaging examination in prediction of need for treatment. Radiology. 2005;234(1):134-142. Experimental-Dx 197 patients To assess predictive value of a short MRI examination with or instead of radiography performed in patients with acute ankle trauma to identify those who require additional treatment versus those who do not and can be discharged without further follow-up. In univariable analysis, age (OR, 1.02; 95% CI, 1.00, 1.04), radiographic results (OR, 7.92; 95% CI, 3.17, 19.8), and positive or uncertain results in patients who underwent MRI vs patients who did not (OR, 2.42; 95% CI, 1.25, 4.70) were predictive of treatment. In the multivariable analysis, positive or uncertain MRI results (OR, 2.61; 95% CI, 1.28, 5.30) contributed significantly to prediction of subsequent treatment. Negative MRI results did not contribute significantly (OR, 0.66; 95% CI, 0.27, 1.61). 1
29. Meehan TM, Martinez-Salazar EL, Torriani M. Aftermath of Ankle Inversion Injuries: Spectrum of MR Imaging Findings. [Review]. Magnetic Resonance Imaging Clinics of North America. 25(1):45-61, 2017 Feb. Review/Other-Dx N/A To examine a range of MR imaging findings that may be present in patients with lateral ankle pain following an acute or chronic inversion injury. No results stated in abstract. 4
30. Wang X, Chang SM, Yu GR, Rao ZT. Clinical value of the Ottawa ankle rules for diagnosis of fractures in acute ankle injuries. PLoS ONE. 8(4):e63228, 2013. Observational-Dx 183 patients To assess the applicability of the Ottawa ankle rules (OAR) in China, to examine their accuracy for the diagnosis of fractures in patients with acute ankle sprains, and to assess their clinical utility for the detection of occult fractures. 183 patients with ankle injuries were enrolled in the study and 63 of these injuries involved fractures. The pooled sensitivity, specificity, positive predictive value and negative predictive value of the OAR for detection of fractures of the ankle were 96.8%, 45.8%, 48.4% and 96.5%, respectively. Our results suggest that clinical application of the OAR could decrease unnecessary radiographs by 31.1%. Of the 21 patients with positive OAR results and negative radiographic findings who underwent 3D-CT examination, five had occult fractures of the lateral malleolus. 3
31. Brandser EA, Berbaum KS, Dorfman DD, et al. Contribution of individual projections alone and in combination for radiographic detection of ankle fractures. AJR Am J Roentgenol. 2000;174(6):1691-1697. Observational-Dx 433 ankle radiographs series To determine whether the standard 3-view ankle radiographic series could be replaced by a 2-view combination, and if so, which 2-view combination (anteroposterior with lateral or mortise with lateral) would be superior. The data provide little support for preferring either 2-view combination (anteroposterior-lateral or mortise-lateral) for any type of fracture. The 3-view combination does detect significantly more fractures than some 2-view combinations in some locations, and there is a statistically significant cost in diagnostic accuracy for eliminating the anteroposterior or mortise view. 3
32. Petscavage J, Baker SR, Clarkin K, Luk L. Overuse of concomitant foot radiographic series in patients sustaining minor ankle injuries. Emerg Radiol. 2010;17(4):261-265. Review/Other-Dx 243 patients To retrospectively review radiographic studies of all patients over a period of 18 months who simultaneously had ankle and foot radiographs performed for acute complaints limited to the ankle alone. Of the 243 patients who met the inclusion criteria, 55 patients had fractures, 46 in or near the ankle joint, and 9 which were located at the base of the fifth metatarsal bone. No fractures or dislocations were noted elsewhere in the foot. All of the fifth metatarsal fractures were evident on adequately performed ankle series. The findings suggest that films of the foot are not necessary when trauma is limited to the ankle and when an appropriately performed ankle series has been completed. 4
33. Antoci V Jr, Patel SP, Weaver MJ, Kwon JY. Relevance of adjacent joint imaging in the evaluation of ankle fractures. Injury. 47(10):2366-2369, 2016 Oct. Review/Other-Dx 1045 radiographs To investigate the relevance of adjacent joint imaging in the evaluation of ankle fractures. Adjacent joint imaging (n=1045 radiographs) of either the knee or foot was obtained in 873 patients (63.7%). Of those, 75/761 patients (9.9%) demonstrated additional fractures proximal to the ankle joint, most commonly of the proximal fibula. Twenty-two of 284 (7.7%) demonstrated additional fractures distal to the ankle joint, most commonly of the metatarsals. Tenderness to palpation demonstrated sensitivities of 0.92 and 0.77 and positive predictive values of 0.94 and 0.89 for the presence of proximal and distal fractures, respectively. Additionally, 19/22 (86.4%) of patients sustaining foot fractures had their injury detectable on initial ankle X-rays. Overall, only 5.5% (75/1370) of patients sustained fractures proximal to the ankle and only 0.2% (3/1370) of patients had additional foot fractures not evident on initial ankle X-rays. 4
34. Hastie GR, Akhtar S, Butt U, Baumann A, Barrie JL. Weightbearing Radiographs Facilitate Functional Treatment of Ankle Fractures of Uncertain Stability. J Foot Ankle Surg. 54(6):1042-6, 2015 Nov-Dec. Review/Other-Dx 43 patients To report our initial experience of treating undisplaced malleolar fractures of uncertain stability in functional braces using weightbearing radiographs to judge the stability. All fractures healed without displacement. The risk of displacement was 0% (95% confidence interval 0% to 9.5%). 4
35. Slaar A, Karsten IH, Beenen LF, et al. Plain radiography in children with spoke wheel injury: A retrospective cohort study. Eur J Radiol. 84(11):2296-300, 2015 Nov. Review/Other-Dx 320 children To evaluate the type of radiographs that are obtained in children with bicycle spoke injury (BSI), (2) to assess in which anatomical regions fractures occur and (3) to evaluate on which radiographs a fracture can be detected in children with BSI. In 99 of the 320 children (31.4%) evaluated with radiography following BSI a fracture was diagnosed. In almost two third of the patients (63%) radiographic imaging of two or more anatomical regions was performed. In 98 children (99%) the fracture was located at the distal tibia or fibula. All fractures were diagnosed on a radiograph of the ankle or lower leg (including the ankle region). No fractures of the foot were diagnosed. 4
36. Valderrabano V, Perren T, Ryf C, Rillmann P, Hintermann B. Snowboarder's talus fracture: treatment outcome of 20 cases after 3.5 years. Am J Sports Med. 33(6):871-80, 2005 Jun. Observational-Tx 20 patients The authors recorded details of the treatment and evaluation of patients who sustained a lateral process of the talus fracture while snowboarding. The injury pathomechanism was documented. The injury mechanism included axial impact (100%), dorsiflexion (95%), external rotation (80%), and eversion (45%). Using the American Orthopaedic Foot and Ankle Society hindfoot score, the patients obtained a mean of 93 points; the surgically treated group (n = 14) scored higher (97 points) than did the nonoperative group (n = 6; 85 points) (P<.05). Degenerative disease of the subtalar joint was found in 3 patients (15%; operative, 1 patient; nonoperative, 2 patients). All but 4 (20%, all after nonsurgical treatment) patients reached the same sport activity level as before injury. 2
37. von Knoch F, Reckord U, von Knoch M, Sommer C. Fracture of the lateral process of the talus in snowboarders. J Bone Joint Surg Br. 89(6):772-7, 2007 Jun. Review/Other-Dx 23 snowboarders To investigate the clinical and radiological outcome after unilateral fracture of the lateral process of the talus in snowboarders with a mean follow-up of 3.5 years (12 to 76 months). The nonoperative group of 7 with a minimally-displaced fracture scored higher (98 points) than the operative group of 16 with displaced or unstable fractures (93 points). In 88% of operative cases, significant concomitant hindfoot injuries were found at operation. All but 8 (35%) patients (6 operative and 2 nonoperative) regained their pre-injury level of sporting activity. Subtalar osteoarthritis was present in 9 (45%) of the 20 patients available for radiological review, including 1 late-diagnosed nonoperative case and 8 operative cases with associated injuries or fracture comminution. The outcome after fracture of the lateral process of the talus in snowboarders is favorable provided an early diagnosis is made and adequate treatment, which is related to the degree of displacement and associated injuries, is undertaken. 4
38. Jentzsch T, Hasler A, Renner N, et al. The V sign in lateral talar process fractures: an experimental study using a foot and ankle model. BMC Musculoskeletal Disorders. 18(1):284, 2017 Jul 03. Observational-Dx 108 radiographs To investigate the performance of V sign assessment under different ankle positions and varying fracture patterns of the lateral talar process. The interobserver agreement on the V sign and type of fracture were fair (? = 0.35, 95% CI 0.18-0.53, p < 0.001 and ? = 0.37, 95% CI 0.26-0.48, p < 0.001). The mean sensitivity, specificity, PPV, NPV, and likelihood ratio for the detection of the V sign were 77% (95% CI 67-86%), 59% (95% CI 39-78%), 85% (95% CI 75-92%), 46% (95% CI 29-63%), and 2. The mean uncertainty in the V sign detection was 38%. The V sign identification stratified by ankle position and fracture type showed significant better results with increasing inversion (p = 0.035 and p = 0.011) and type B fractures (p = 0.001 and p = 0.013). 3
39. Kwak YH, Lim JY, Oh MK, Kim WJ, Park KB. Radiographic diagnosis of occult distal fibular avulsion fracture in children with acute lateral ankle sprain. J Pediatr Orthop. 35(4):352-7, 2015 Jun. Review/Other-Dx 78 patients To determine the incidence of associated occult avulsion fracture in children with lateral ankle sprain and the efficacy of identifying fractures using anterior talofibular ligament view Twenty patients were diagnosed with occult distal fibular avulsion fracture. Ten patients were diagnosed in anterior talofibular ligament view and others were diagnosed in the follow-up radiography. Displacement was highest on the anterior talofibular ligament view. 4
40. Schock HJ, Pinzur M, Manion L, Stover M. The use of gravity or manual-stress radiographs in the assessment of supination-external rotation fractures of the ankle. J Bone Joint Surg Br. 2007;89(8):1055-1059. Observational-Dx 29 patients To compare the clinical efficacy and discomfort to the patient associated with the examination of both manual- and gravity-stress in the diagnosis of SER-IV equivalent injuries of the ankle. Both examinations in 29 patients with SER fractures were undertaken. Of these, 16 (55%) were stress-positive, i.e. and had widening of the medial clear space of >4 mm with a mean medial clear space of 6.09 mm (4.4 to 8.1) on gravity-stress and 5.81 mm (4.0 to 8.2) on manual-stress examination, and 13 patients (45%) were stress-negative with a mean medial clear space of 3.91 mm (3.3 to 5.1) and 3.61 mm (2.6 to 4.5) on examination of gravity- and manual-stress respectively. The mean absolute visual analgoue scale score for discomfort in the examination of gravity stress was 3.45 (1 to 6) and in the manual-stress procedure 6.14 (3 to 10). 3
41. Switaj PJ, Weatherford B, Fuchs D, Rosenthal B, Pang E, Kadakia AR. Evaluation of posterior malleolar fractures and the posterior pilon variant in operatively treated ankle fractures. Foot Ankle Int. 35(9):886-95, 2014 Sep. Review/Other-Dx 270 patients To report the relative frequency of the posterior malleolar fracture and posterior pilon variant in a large consecutive series of operative ankle fractures and to investigate the patient and fracture characteristics associated with these fractures. The relative frequency of posterior malleolus fracture was 50%. The relative frequency of the posterior pilon variant was 20%. No significant difference was noted with respect to the frequency of posterior malleolar or posterior pilon variant between the subgroups of the AO/OTA and Lauge-Hansen classification systems when compared to the overall fracture distribution. Patients with posterior malleolar fractures and posterior pilon variants were significantly older. Females were significantly more likely than men to sustain posterior malleolar fractures and posterior pilon variants. Patients with diabetes trended toward a greater risk of both types of fractures. Interobserver reliability data revealed substantial agreement for posterior malleolar fractures and posterior pilon variants. 4
42. Lepojarvi S, Niinimaki J, Pakarinen H, Leskela HV. Rotational Dynamics of the Normal Distal Tibiofibular Joint With Weight-Bearing Computed Tomography. Foot Ankle Int. 37(6):627-35, 2016 Jun. Observational-Dx 32 patients To investigate the normal anatomy and rotational dynamics of the distal tibiofibular joint under physiological conditions on weight-bearing cone beam computed tomography (WBCT). In the neutrally loaded ankle, the fibula was located anteriorly in the tibial incisura in 88% of the subjects. When the ankle was rotated, mean anteroposterior motion was 1.5 mm and mean rotation of the fibula was 3 degrees. There was no significant change in tibiofibular clear space (TFCS) between internal and external rotation. Large intersubject variation was detected, but intrasubject variation between ankles was less than 1 mm and 1 degree. 4
43. Clark TW, Janzen DL, Ho K, Grunfeld A, Connell DG. Detection of radiographically occult ankle fractures following acute trauma: positive predictive value of an ankle effusion. AJR Am J Roentgenol. 1995;164(5):1185-1189. Observational-Dx 33 patients To determine if the presence of an ankle effusion on radiographs after acute ankle trauma is predictive of occult ankle fracture when no fracture is visible on the standard radiographic series. 11/33 patients with ankle effusions and otherwise normal radiographs had occult fractures identified with tomography. The fracture sites were as follows: osteochondral fracture of talar dome (n = 4), neck of talus (n = 1), medial malleolus (n = 1), anterior tibial rim (n = 1), posterior tibial rim (n = 1), tibial plafond (n = 1), lateral malleolus (n = 1), and anterior process of calcaneus (n = 1). The radiographic size of an ankle effusion was predictive of occult fracture. An ankle effusion measuring =13 mm in anterior plus posterior capsular distension had an 82% sensitivity and 91% specificity for underlying fracture. The PPV of an ankle effusion =13 mm was 82%. 3
44. Clark TW, Janzen DL, Logan PM, Ho K, Connell DG. Improving the detection of radiographically occult ankle fractures: positive predictive value of an ankle joint effusion. Clin Radiol. 1996;51(9):632-636. Observational-Dx 26 patients To assess the value of an ankle effusion on radiographs as a predictor of radiographically occult fracture after acute ankle trauma. 12 patients (46%) had radiographically occult fractures identified with CT. Fracture sites included: posterior or lateral malleoli (n = 4), calcaneus (n = 1), or talus (n = 7). Ankle effusion size was 11.2 mm in the group without fracture and 17.1 mm in the group with fracture (P<0.0001). The PPV of an effusion =15 mm was 83%. CT detected significant soft-tissue injuries in 4 (15%) patients including peroneal retinaculum tear (n = 1), anterior talofibular ligament avulsion (n = 1), and tears of the peroneus longus (n = 1) and tibialis posterior (n = 1) tendons. 3
45. Burton T, Sloan J. Comminuted fracture of the talus not visible on the initial radiograph. Emerg Med J. 20(1):E1, 2003 Jan. Review/Other-Dx 1 patient A case is presented of a patient with a comminuted fracture of the body of the talus with nondiagnostic initial standard ankle radiographs. Accident and emergency doctors should be aware of this injury, and be suspicious that patients with an appropriate mechanism of injury and pronounced pain may require further investigation despite normal standard ankle radiographs, as an occult fracture of the talus may be present. 4
46. Rodop O, Mahirogullari M, Akyuz M, Sonmez G, Turgut H, Kuskucu M. Missed talar neck fractures in ankle distortions. Acta Orthop Traumatol Turc. 44(5):392-6, 2010. Review/Other-Dx 8 patients To evaluate the follow-up and treatment outcomes of subjects with missed fractures, which were not diagnosed with radiographs obtained for ankle distortion, but with advanced imaging studies. The talar neck fracture was diagnosed with CT in 1 patient and with MRI in the remaining 7 patients. Mean follow-up time was 6 months (range 3-8 months), and mean American Orthopedic Foot and Ankle Society score at last follow-up was 93.7 (range 80-100). 4
47. Hou Z, Zhang L, Zhang Q, et al. The "communication line" suggests occult posterior malleolar fracture associated with a spiral tibial shaft fracture. Eur J Radiol. 2012;81(3):594-597. Review/Other-Dx 96 patients To demonstrate radiographical characteristics of the relationship between distal spiral tibial shaft fractures and associated occult posterior malleolar fractures that confirmed by CT and MRI. The spiral tibia fracture line was contiguous with posterior malleolar fractures in 89 of 96 cases after evaluation with the CT and MRI. The line connecting the two injuries, which occurs between the medial inferior apex of the spiral tibia fracture line and the posterior superior apex of the posterior malleolar fractures was identified as the "communication line". In 47 of the 89 conjunction fractures, the "communication line" was detectable preoperatively and in 12 cases postoperatively by anteroposterior radiograph. By using the CT and MRI scans, the authors found that no "communication line" was present in only 7 cases. 4
48. Haapamaki VV, Kiuru MJ, Koskinen SK. Ankle and foot injuries: analysis of MDCT findings. AJR Am J Roentgenol. 183(3):615-22, 2004 Sep. Observational-Dx 388 patients Retrospective study to assess MDCT findings and the advantages of MDCT compared with radiography in patients referred to a level 1 trauma center for diagnostic evaluation of acute ankle and foot trauma. 344 (89%) of the 388 patients had one or more fractures in the ankle or foot. Calcaneus was the most commonly fractured bone, and the sensitivity of radiography in the detection of calcaneal fractures was 87%. The sensitivity of radiography in the detection of talar fractures was 78%, whereas it was only 25%-33% in the detection of midfoot fractures. A Lisfranc fracture-dislocation was not detected on primary radiography in 5 (24%) of 21 cases. The 3 main injury mechanisms were falling from a height (164 patients [48%]), a simple fall (68 patients [20%]), and a traffic accident (47 patients [14%]). In patients with injuries from high-energy polytrauma and in those with complex ankle and foot fractures, the sensitivity of radiography is only moderate to poor; in these cases, MDCT is recommended as the primary imaging technique. 3
49. Choi CH, Ogilvie-Harris DJ. Occult osteochondral fractures of the subtalar joint: a review of 10 patients. J Foot Ankle Surg. 41(1):40-3, 2002 Jan-Feb. Review/Other-Dx 10 patients To report a series of patients with occult injuries to the subtalar joint that occurred without dislocation. 9 osteochondral fractures involved the posterior facet. 7 patients had a stiff and painful subtalar joint, and an arthrodesis was performed. 3 patients presented with adequate subtalar joint motion and were treated with physiotherapy. Detection of osteochondral fractures of the subtalar joint is difficult. The "early warning" signs are massive swelling without definitive bone injury on radiographic examination, and a failure to regain subtalar motion after a period of immobilization. Confirmatory evidence is obtained from CT scans or MRI. Initially, aggressive physiotherapy should be considered. Arthrodesis should be used for patients who remain symptomatic. 4
50. Gonzalez FM, Morrison WB. Magnetic Resonance Imaging of Sports Injuries Involving the Ankle. [Review]. Top Magn Reson Imaging. 24(4):205-13, 2015 Aug. Review/Other-Dx N/A To discuss common injuries related to particular sporting activities. No results stated in abstract. 4
51. Martella I, Azzali E, Milanese G, et al. MRI in acute ligamentous injuries of the ankle. Acta Bio-Medica de l Ateneo Parmense. 87 Suppl 3:13-9, 2016 07 28. Review/Other-Dx N/A To analyse the magnetic resonance (MR) findings of both normal and pathological ankle's ligaments. No results stated in abstract. 4
52. Grosterlinden LG, Hartel M, Yamamura J, et al. Isolated syndesmotic injuries in acute ankle sprains: diagnostic significance of clinical examination and MRI. Knee Surg Sports Traumatol Arthrosc. 24(4):1180-6, 2016 Apr. Observational-Dx 100 patients To evaluate the incidence of syndesmotic injuries in acute ankle sprains using MRI, (2) to determine the accuracy of common clinical diagnostic tests, (3) to analyse their inter-rater reliability, and (4) to evaluate the role of clinical symptoms in the diagnosis of syndesmotic injuries. Ninety-six participants (57% male) met the inclusion criteria. MRI detected a ruptured anterior inferior tibiofibular ligament (AITFL) in 14 patients (15%); 9 partial tears and 5 complete tears were evident. Evidence of pain at rest was found to predict syndesmotic injuries most accurately (p = 0.039). The palpation test over the proximal fibula produced the highest inter-rater correlation (? = 0.65), but the lowest sensitivity for syndesmotic injuries of 8%. All other clinical tests demonstrated moderate to fair inter-rater reliabilities (? = 0.37-0.52). Low sensitivity values were found with all clinical tests (13.9-55.6%). 3
53. Longo UG, Loppini M, Romeo G, van Dijk CN, Maffulli N, Denaro V. Bone bruises associated with acute ankle ligament injury: do they need treatment? Knee Surg Sports Traumatol Arthrosc. 2013;21(6):1261-1268. Review/Other-Dx 9 studies To analyze the current knowledge, incidence, relevance, and need for treatment of bone bruises associated with acute ankle ligament injury. No randomized controlled trials or prospective cohort studies were found. Only case series were retrieved. A critical appraisal for validity and usefulness of the studies revealed that the best level of evidence on this topic is represented by retrospective comparative studies. Nine studies evaluating the management of bone bruises associated with acute ankle ligament injuries were found. 4
54. Roemer FW, Jomaah N, Niu J, et al. Ligamentous Injuries and the Risk of Associated Tissue Damage in Acute Ankle Sprains in Athletes: A Cross-sectional MRI Study. Am J Sports Med. 42(7):1549-57, 2014 Jul. Observational-Dx 261 ankle MRI scans To describe the injury pattern in athletes who were referred to MRI for the assessment of an acute ankle sprain and to assess the risk of associated traumatic tissue damage including lateral and syndesmotic ligament involvement. With regard to the injury pattern, there were 103 ankles (39.5%) with complete anterior talofibular ligament disruption and no syndesmotic injury, and 53 ankles (20.3%) had a syndesmotic injury with or without lateral ligament damage. Acute osteochondral lesions of the lateral talar dome were seen in 20 ankles (7.7%). The percentage of chronic lateral osteochondral lesions was 1.1%. The risk for talar bone contusions increased more than 3-fold for ankles with complete lateral ligament ruptures (adjusted odds ratio [aOR], 3.43; 95% CI, 1.72-6.85) but not for ankles with syndesmotic involvement. The risk for associated deltoid ligament injuries increased for ankles with complete lateral ligament injuries (aOR, 4.04; 95% CI, 1.99-8.22) compared with patients with no or only low-grade lateral ligament injuries. 3
55. Tamam C, Tamam MO, Yildirim D, Mulazimoglu M. Diagnostic value of single-photon emission computed tomography combined with computed tomography in relation to MRI on osteochondral lesions of the talus. Nucl Med Commun. 36(8):808-14, 2015 Aug. Observational-Dx 21 patients. To compare single photon emission computed tomography (SPECT) / computed tomography (CT) with magnetic resonance imaging (MRI) for image interpretation and treatment decision making in talar osteochondral lesions. A total of 25 lesions were identified. Seventeen lesions were located on the medial third of the talar dome, eight on the lateral third, and seven on the central third. Four patients revealed diffuse uptake on more than one zone on SPECT/CT. SPECT/CT identified two subchondral lesions, which were not visualized on MRI. 3
56. Kok AC, Terra MP, Muller S, et al. Feasibility of ultrasound imaging of osteochondral defects in the ankle: a clinical pilot study. Ultrasound Med Biol. 40(10):2530-6, 2014 Oct. Review/Other-Dx 18 patients To determine the feasibility of ultrasound for the visualization and grading of talar osteochondral defects (OCDs). Similarly to CT, ultrasound revealed typical morphologic OCD features, for example, cortex irregularities and loose fragments. Cartilage disruptions, Loomer grades IV (displaced fragment) and V (cyst with fibrous roof), were visible as well. 4
57. Hunt KJ, Githens M, Riley GM, Kim M, Gold GE. Foot and ankle injuries in sport: imaging correlation with arthroscopic and surgical findings. [Review]. Clin Sports Med. 32(3):525-57, 2013 Jul. Review/Other-Dx N/A To review imaging correlation with arthroscopic and surgical findings for foot and ankle injuries in sport. No results stated in abstract. 4
58. Leontaritis N, Hinojosa L, Panchbhavi VK. Arthroscopically detected intra-articular lesions associated with acute ankle fractures. J Bone Joint Surg Am. 2009;91(2):333-339. Review/Other-Dx 283 ankle fractures To determine if the severity of an acute ankle fracture is correlated with an increased number of arthroscopically detected intra-articular chondral lesions. Of the 283 patients, 84 (44 female and 40 male) met our inclusion criteria. Chondral lesions were found in 61patients (73%). Of 17 fractures graded as pronation-external rotation or supination-external rotation type I according to the Lauge-Hansen classification, 15 were associated with one or no chondral lesion and two, with two or more chondral lesions. Of 10 fractures graded as pronation-external rotation or supination-external rotation type II, 9 were associated with one or no chondral lesion and one, with two or more chondral lesions. Of 56 fractures graded as pronation-external rotation or supination-external rotation type IV, 27 were associated with one or no chondral lesion and 29, with two or more chondral lesions. Type-IV pronation-external rotation and supination-external rotation ankle fractures were more likely to be associated with two or more chondral lesions than type-I fractures (OR = 8.1, 95% CI, 1.7 to 38.6; P=0.0044) or type-II fractures (OR = 9.7, 95% CI, 1.1 to 81.5; P=0.0172). 4
59. Choi WJ, Choi GW, Kim JS, Lee JW. Prognostic significance of the containment and location of osteochondral lesions of the talus: independent adverse outcomes associated with uncontained lesions of the talar shoulder. Am J Sports Med. 41(1):126-33, 2013 Jan. Observational-Dx 399 patients To determine the relative prognostic significance of the containment (shoulder vs nonshoulder type) and location (medial vs lateral) of an osteochondral lesion of the talus (OLT). Patients with shoulder-type OLT had a substantially worse clinical outcome than did those with nonshoulder-type OLT, even after adjustment for OLT size (P < .05). However, there was no significant difference in clinical outcome between patients with medial OLT and those with lateral OLT, and the clinical failure rates of the 2 groups were similar (P > .05). A Cox proportional hazards regression model demonstrated that OLT containment, but not location, exerted an independent prognostic effect. 3
60. Darrow CJ, Collins CL, Yard EE, Comstock RD. Epidemiology of severe injuries among United States high school athletes: 2005-2007. Am J Sports Med. 2009;37(9):1798-1805. Review/Other-Dx 1378 severe injuries A descriptive epidemiology study on severe injury rates and patterns by gender and type of exposure. Participating certified athletic trainers reported 1,378 severe injuries during 3 550 141 athlete-exposures (0.39 severe injuries per 1,000 athletic exposures). Football had the highest severe injury rate (0.69), followed by wrestling (0.52), girls' basketball (0.34), and girls' soccer (0.33). The rate in all boys' sports (0.45) was higher than all girls' sports (0.26) (rate ratio, 1.74; 95% CI, 1.54-1.98; P<.001). However, among directly comparable sports (soccer, basketball, and baseball/softball), girls sustained a higher severe injury rate (0.29) than boys (0.23) (rate ratio, 1.28; 95% CI, 1.08-1.52; P=.006). More specifically, girls' basketball had a higher rate (0.34) than boys' basketball (0.24) (rate ratio, 1.43; 95% CI, 1.10-1.86; P=.009). Differences between boys' and girls' soccer and baseball/softball were not statistically significant. The severe injury rate was greater in competition (0.79) than practice (0.24) (rate ratio, 3.30; 95% CI, 2.97-3.67; P<.001). Nationally, high school athletes sustained an estimated 446 715 severe injuries from 2005-2007. The most commonly injured body sites were the knee (29.0%), ankle (12.3%), and shoulder (10.9%). The most common diagnoses were fractures (36.0%), complete ligament sprains (15.3%), and incomplete ligament sprains (14.3%). Of severe sports injuries, 0.3% resulted in medical disqualification for the athletes' career, and an additional 56.8% resulted in medical disqualification for the entire season. One in 4 (28.3%) severe injuries required surgery, with over half (53.9%) being knee surgeries. 4
61. Dhanaraj D, Chapman C. Osteochondral Lesions of the Talus Revisited Emerging Technologies. [Review]. Bull Hosp Jt Dis (2013). 73(2):134-40, 2015 Jun. Review/Other-Dx N/A To discuss opinions regarding the development of osteochondral lesions and also the approach to management, including the latest surgical modalities, such as osteochondral grafts and juvenile chondrocyte implantation No results stated in abstract. 4
62. Lopez-Ben R.. Imaging of the subtalar joint. [Review]. Foot Ankle Clin. 20(2):223-41, 2015 Jun. Review/Other-Dx N/A To review the anatomy and common anatomic variants as seen with different imaging techniques. No results stated in abstract. 4
63. McCollum GA, Calder JD, Longo UG, et al. Talus osteochondral bruises and defects: diagnosis and differentiation. Foot Ankle Clin. 2013;18(1):35-47. Review/Other-Dx N/A To review the available literature and concentrates on the diagnosis, prognosis, and management of posttraumatic ankle bone bruising and on differentiating the lesion from an OCD of the talus. Acute bone bruises of the talus after ankle injury are common. They need to be differentiated from OCDs because their management is different. Bone bruises have a benign course, with clinical resolution in 6 to 8 weeks, but MRI may show persistent edema for 6 to 12 months. The presence of a bone bruise should not delay rehabilitation unless symptoms persist or significant edema is close to the subchondral plate and do not cause ankle dysfunction. OCDs are essentially a fracture of the cartilage and underlying subchondral bone plate. They have a less predictable prognosis, and rehabilitation should aim at promoting healing of the fracture to avoid long-term symptoms, complications, and propagation of the lesion. A period of nonweight bearing, maintaining strength and range of motion, reduces the cyclical pressure load through the fissure and promotes healing. Surgery should be reserved for chronic symptomatic lesions (3 months after injury) or for those patients undergoing lateral ligament reconstruction in whom arthroscopic assessment is indicated. 4
64. Saxena A, Eakin C. Articular talar injuries in athletes: results of microfracture and autogenous bone graft. Am J Sports Med. 2007;35(10):1680-1687. Review/Other-Tx 26 microfracture procedures and 20 bone grafts to the talus To assess treatment options of talar osteochondral lesions. There were 26 microfracture procedures and 20 bone grafts to the talus. The AOFAS scores for both microfracture (preoperative, 54.6; postoperative, 94.4) and bone graft (preoperative, 46.1; postoperative, 93.4) patients improved significantly. The RTA for the entire group was 17.0 +/- 5.3 weeks; for those undergoing microfracture, RTA was 15.1 +/- 4.0 weeks; and for bone grafting, it was 19.6 +/- 5.9 weeks. The RTA for the bone graft group was significantly slower than that of the microfracture group. Anterolateral lesions had significantly faster RTA and higher postoperative scores compared with other lesion locations. Arthroscopically treated lesions had similar postoperative AOFAS scores to those who had arthrotomy and did not have significantly faster RTA. 44 (96%) "excellent/good" AOFAS scores were achieved overall for talar lesions, with the same percentage of return to sport. 4
65. Mandell JC, Khurana B, Smith SE. Stress fractures of the foot and ankle, part 1: biomechanics of bone and principles of imaging and treatment. [Review]. Skeletal Radiol. 46(8):1021-1029, 2017 Aug. Review/Other-Dx N/A To discuss the general principles of stress fractures of the foot and ankle. No results stated in abstract. 4
66. Crim J, Longenecker LG. MRI and surgical findings in deltoid ligament tears. AJR Am J Roentgenol. 204(1):W63-9, 2015 Jan. Observational-Dx 88 cases To determine the accuracy of new MRI criteria in detecting tears of the superficial deltoid ligament of the ankle, the accuracy of established criteria for detecting deep deltoid ligament tears, the most common location of super-ficial deltoid ligament tears, and the frequency of other injuries associated with deltoid tears. MRI findings of focal detachment of the superficial deltoid origin or detachment of the fascial sleeve of the medial malleolus yielded a sensitivity for superficial deltoid ligament tears of 83.3% (45/54) and specificity of 93.9% (31/33). Eight of nine prospectively missed tears were visible on retrospective review. All superficial deltoid tears involved the origin of the ligament from the medial malleolus, and six involved mid or distal bundles of the superficial deltoid as well. MRI findings of discontinuity or nonvisualization of discrete fibers yielded a sensitivity for deep deltoid ligament tears of 96.3% (26/27) and specificity of 97.9% (46/47). 3
67. Morris N, Lovell ME. Demographics of 3929 ankle injuries, seasonal variation in diagnosis and more fractures are diagnosed in winter. Injury. 44(7):998-1001, 2013 Jul. Review/Other-Dx 3,929 patients An audit was performed to look at the diagnostic or pick-up rate of ankle fractures. An automated x-ray system was looked at to see the number of x-rays taken and the diagnostic yield. Ankle x-rays of 3,929 patients over a 24-month period between 1 July 2009 and 31 June 2011; of which, 612 patients were found to have fractured their ankle giving a pick-up rate of 0.16. This is less than what might be expected with strict application of OAR. The pick-up rate fluctuated each month from an admirable 0.35 fractures per x-ray ordered in December 2009 to a lowly 0.06 fractures per x-ray in May 2010. The same pattern was noted for the other year. For both Decembers, the fewest number of x-rays were taken at 80 and 140, the most at 200 and 240 in May for both years. Less x-rays were taken in for all OAR months. For younger age groups, males dominated with the crossover to females dominating in the fifth decade. 4
68. Waterman BR, Belmont PJ, Jr., Cameron KL, Deberardino TM, Owens BD. Epidemiology of ankle sprain at the United States Military Academy. Am J Sports Med. 2010;38(4):797-803. Review/Other-Dx 614 cadets A longitudinal cohort study was performed to determine the effect of risk factors for ankle sprain at the United States Military Academy between 2005 and 2007. 614 cadets sustained new ankle sprains during 10,511 person-years at risk, resulting in overall incidence rates of 58.4 per 1,000 person-years. Women (96.4), compared with men (52.7), had a significantly increased rate ratio for ankle sprain of 1.83 (95% CI, 1.52-2.20). Men with ankle sprains had higher mean height, weight, and body mass index than uninjured men (P<.001). Men with ankle sprains had higher average scores in push-ups, sit-ups, and run time than uninjured men (P<.001). Ankle sprain occurred most commonly during athletics (64.1%). Ankle sprain IR did not significantly differ between intercollegiate and intramural athletic competition after controlling for athlete-exposure (increased rate ratio, 1.05; 95% CI, 0.81-1.37). The ankle sprain increased rate ratio of female compared with male intercollegiate athletes was 0.93 (95% CI, 0.67-1.32) per 1,000 person-years and 1.04 (95% CI, 0.74-1.47) per 1,000 athlete-exposures. The intercollegiate sports of men's rugby, women's cheerleading, and men's/women's basketball, soccer, and lacrosse had the highest ankle sprain incidence rates. 4
69. Nault ML, Gascon L, Hebert-Davies J, Leduc S, Laflamme GY, Kramer D. Modification of Distal Tibiofibular Relationship After a Mild Syndesmotic Injury. Foot ankle spec.. 10(2):133-138, 2017 Apr. Observational-Dx 114 ankle MRIs To show that a sprain or tear of 1 or more of the 3 syndesmotic ligaments will result in a significant change in the osseous anatomy relationship when comparing the injured and uninjured syndesmosis. Our secondary objective was to determine whether injuries to the syndesmosis as diagnosed on MRI could be found using static imaging. Fifty uninjured syndesmosis were compared to 64 injured syndesmoses. The majority of syndesmosis injuries concerned either an anterior inferior tibiofibular ligament sprain or tear. There was a significant difference in the anatomic position of the tibia and the fibula between injured and uninjured syndesmosis. 3
70. Bible JE, Sivasubramaniam PG, Jahangir AA, Evans JM, Mir HR. High-energy transsyndesmotic ankle fracture dislocation--the "Logsplitter" injury. J Orthop Trauma. 28(4):200-4, 2014 Apr. Observational-Dx 23 ankle fracture dislocations To describe and investigate the injury pattern and outcomes of high-energy transsyndesmotic ankle fracture dislocations, or "Logsplitter" injuries, in which the talus is axially wedged into the tibiofibular joint. Fracture characteristics included 52% open fractures (all medial) and syndesmotic widening of 30.7 ± 11.9 mm. The tibial plafond was involved in 11 (48%) of 23 injuries, with 5 (22%) Chaput, 5 (22%) posterior malleolar fragments, and 6 (26%) with articular impaction. A fibula fracture occurred in all but 1 patient, on average 64.2 ± 40.0 mm above the distal tip. All patients had fixation of their fibular and medial malleolar fractures, 21 of 23 patients had syndesmotic screws, and 8 of 23 had tibial plafond fixation. Anatomic alignment (within <= 2 mm) was obtained in 21 (87%) of 23 injuries. Mean follow-up was 20.6 ± 6.2 months. Sixteen (70%) of 23 patients had radiographic evidence of posttraumatic ankle arthritis. Dorsiflexion and plantarflexion at final follow-up were 6.9 ± 9.6 and 35.6 ± 12.1 degrees, respectively. Complications included a 17% infection and 17% nonunion rate. Average American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale score was 67.0 ± 26.8, whereas Short Musculoskeletal Function Assessment Dysfunction index was 32.9 ± 28.6 and Bother index 34.5 ± 29.5. 4
71. Boden KA, Weinberg DS, Vallier HA. Complications and Functional Outcomes After Pantalar Dislocation. Journal of Bone & Joint Surgery - American Volume. 99(8):666-675, 2017 Apr 19. Review/Other-Dx 19 patients To evaluate complications and outcomes following pantalar dislocation without talar fracture. The mean clinical follow-up was 45.1 months. Two patients had superficial wound-healing problems with prolonged drainage, which healed with dressing changes and oral antibiotics, and 1 patient developed cellulitis 4 months after injury, which resolved with intravenous antibiotics. No deep wound infections occurred. Fourteen (88%) of the 16 patients with a minimum of 11 months of radiographic follow-up developed osteonecrosis, 2 with collapse of the talar dome, and 7 (44%) developed arthrosis of =1 peritalar articulation. Outcome surveys were obtained for 11 (58%) of the 19 patients, at a mean of 5.2 years after injury. The mean MFA score was 30.3, and the mean FFI score was 25.3. Six of 10 survey respondents had returned to employment, but 88% (14 of 16) of the patients with radiographic and clinical follow-up reported at least mild pain and 75% (12 of 16) were taking analgesics. 4
72. Lee KM, Chung CY, Kwon SS, et al. Relationship between stress ankle radiographs and injured ligaments on MRI. Skeletal Radiol. 42(11):1537-42, 2013 Nov. Observational-Dx 229 patients To investigate the relationship between the injured lateral ankle ligaments on MRI and stress ankle radiographs. Gender (p?=?0.010), age (p?=?0.020), and anterior talofibular ligament (ATFL) injury (p?<?0.001) were the factors significantly affecting tibiotalar tilt angle. Posterior talofibular ligament (PTFL) injury (p?=?0.014) was found to be the only significant factor affecting the anterior translation on the anterior drawer radiographs. 3
73. Jiang KN, Schulz BM, Tsui YL, Gardner TR, Greisberg JK. Comparison of radiographic stress tests for syndesmotic instability of supination-external rotation ankle fractures: a cadaveric study. J Orthop Trauma. 28(6):e123-7, 2014 Jun. Observational-Dx 11 cadavers To examine external rotation (ER) and Cotton stress tests, in addition to radiographic parameters following sequential sectioning of the deltoid and syndesmotic ligaments in a cadaver model of supination-external rotation (SER) IV equivalent ankle fracture. External rotation stress test produced significant medial clear space widening when the deltoid ligaments were sectioned (P < 0.05). Lateral stress test produced no significant widening of the tibiofibular clear space until interosseous membranes were sectioned (P < 0.05). 4
74. Taweel NR, Raikin SM, Karanjia HN, Ahmad J. The proximal fibula should be examined in all patients with ankle injury: a case series of missed maisonneuve fractures. J Emerg Med. 2013;44(2):e251-255. Review/Other-Tx 5 patients A case study to show the ease of missing the proximal fibular fracture when the clinical examination is directed to the ankle region and to discuss the importance of palpating the proximal fibula and ordering appropriate radiographs. he Maisonneuve fracture injury pattern causes untoward consequences if not promptly recognized and treated. To avoid misdiagnosis, the proximal fibula should be examined in all patients with ankle injury. 4
75. Wiebking U, Pacha TO, Jagodzinski M. An accuracy evaluation of clinical, arthrometric, and stress-sonographic acute ankle instability examinations. Journal of Foot & Ankle Surgery. 21(1):42-8, 2015 Mar. Observational-Dx 30 patients To investigate three different measurement tools that can be used after a lateral ligament lesion of the ankle with injury of the anterior talofibular ligament to determine their diagnostic accuracy The ultrasound-assisted gadgetry according to Hoffmann, with a 3mm cut-off value, displayed a sensitivity of 0.27 and a specificity of 0.87. Using a 3.95mm cut-off value, the arthrometer displayed a sensitivity of 0.8 and a specificity of 0.4. The clinical investigation sensitivities and specificities were 0.93 and 0.67, respectively. 3
76. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
No of Rows: 76