Injury, Int. J. Care Injured 45 (2014) 583–585

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Ankle injury manipulation before or after X-ray – Does it influence success? G.R. Hastie *, H. Divecha, S. Javed, A. Zubairy Department of Trauma and Orthopaedic Surgery, East Lancashire Hospitals NHS Trust, Haslingden Road, Blackburn, Lancashire BB2 3HH, United Kingdom

A R T I C L E I N F O

A B S T R A C T

Article history: Accepted 9 October 2013

Many acute, deformed ankle injuries are manipulated in the Emergency Department (ED) before X-rays are taken to confirm the nature of the injury. This often occurs in the absence of neurovascular or skin compromise without consideration of other possible injuries such as talar, subtalar or calcaneal injuries. We believe that an inappropriate manipulation of an unknown injury pattern may place the patient at increased risk. A balance needs to be struck between making the correct diagnosis and preventing any further neurovascular or skin compromise. We prospectively reviewed 197 patients admitted to the Royal Blackburn Hospital with acute ankle injuries. Their ED notes were reviewed, specifically assessing whether a manipulation was performed; if so, was it performed before X-rays and the documented reasons. A total of 90 ankle fractures were manipulated and 31 of these were performed before X-ray. One manipulation was performed for vascular compromise, one for nerve symptoms, three for critical skin and 25 for undocumented reasons. 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. We conclude that performing ankle injury X-rays before an attempt at manipulation, in the absence of neurovascular deficit or critical skin, may constitute best practice as it provides a better assessment of fracture configuration, guides initial reduction and significantly lowers the risk of re-manipulation and the potential risks associated with sedation without delaying surgery. ß 2013 Elsevier Ltd. All rights reserved.

Keywords: Ankle fracture dislocation Manipulation

Introduction There is wide variety in the management of ankle fractures between different emergency departments (EDs). With an ageing population, the numbers of ankle fractures presenting to the ED will increase [1]. The aim in the management of these injuries should be to achieve an anatomical position of the ankle mortice and a stable, mobile and painless ankle joint [2]. Authors have advocated early manipulation of displaced ankle fractures even in the absence of critical skin or neurovascular damage to minimise the risk of skin breakdown [3] and to limit soft tissue damage [4]. Early manipulation is important as substantial soft tissue swelling can occur within hours of an injury and take weeks to resolve [5]. This is important as significant oedema can impede wound healing [6]; but, delaying surgery until after this has settled can adversely affect the surgical outcomes [7].

* Corresponding author. Tel.: +44 1254 263555. E-mail address: [email protected] (G.R. Hastie). 0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.10.016

There is no published evidence suggesting what is a reasonable time period to reduction in the absence of neurovascular or obvious skin compromise. Does a short delay, before manipulation to allow X-rays to be taken, negatively affect the outcome? We propose that performing 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. This is beneficial as it not only improves the patient experience but also reduces the risk of complications from repeated sedation for re-manipulations.

Method We prospectively identified 197 patients admitted with an ankle injury to the Orthopaedic Ward at our institution between November 2009 and July 2012. The medical records were reviewed to specifically assess whether or not a radiograph was obtained in the ED prior to attempting initial reduction of the injury. The final

G.R. Hastie et al. / Injury, Int. J. Care Injured 45 (2014) 583–585

584 Table 1 Comparison of demographics between groups.

n Median age (yrs) (range) Sex Female Male Side

Left Right

Open a b c

Before X-ray

After X-ray

31

59

p-value

Table 2 Comparison of time-points between groups; values are median (range); Kruskal– Wallis test.

Arrival to X-ray (h) Arrival to surgery (days) Length of stay (days)

a

43.6 (22.3–77.8)

48.9 (16.5–98.4)

0.298

14 17

37 22

0.11b

18 13

33 26

0.846b

2

1

0.272c

Kruskal–Wallis. Pearson Chi-square. Fisher exact.

management was recorded together with any delays of >48 h to surgery (with reasons for delays) and the total length of stay. Statistical analyses Data were stored in a Microsoft Excel 2010 spreadsheet and analyses performed using Analyse-it for Excel (ver. 2.26). 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. Relative risk (RR) ratios were determined and difference in proportions testing performed (Pearson’s chi-squared test, where expected table counts were >5; Fisher’s exact test where expected counts were 48 h), which could influence patient care and possibly length of stay. We do accept, however, that longer-term follow-up studies are required to assess whether functional outcomes differ, whether there is any difference in onset of degenerative changes and whether there are any differences in

the requirement for surgical intervention such as joint arthrodesis/ arthroplasty. We conclude that in modern EDs, patients presenting with a deformed ankle joint should have adequate X-rays performed expeditiously and before a ‘blind’ attempt at reduction unless there is neurovascular damage or critical skin. This is standard practice for other joints and our study confirms that this should be best practice for the ankle joint too, to minimise the need for a remanipulation and the associated risks. Conflict of interest statement The authors can confirm there are no conflicts of interest in the publication of this manuscript. References [1] Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures – an increasing problem? Acta Orthopaedica Scandinavica 1997;69(1):43–7. [2] Lesic A, Bumbasirevic M. Ankle fractures. Current Orthopaedics 2004;18:232– 44. [3] Watson JAS, Hollingdale JP. Early management of displaced ankle fractures. Injury 1992;23(2):87–8. [4] Deasy C, Murphy D, McMahon GC, Kelly IP. Ankle fractures: emergency department management. . .is there room for improvement? European Journal of Emergency Medicine 2005;12(5):216–9. [5] Chou LB, Lee DC. Current concept review: perioperative soft tissue management for foot and ankle fractures. Foot and Ankle International 2009;30(1):84–90. [6] Sxhaser KD, Vollmar B, Menger MD. In vivo analysis of microcirculation following closed soft-tissue injury. Journal of Orthopaedic Research 1999;17:678–85. [7] Fogal GR, Morrey BF. Delayed open reduction and fixation of ankle fractures. Clinical Orthopaedics 1993;215:187–95.

Ankle injury manipulation before or after X-ray--does it influence success?

Many acute, deformed ankle injuries are manipulated in the Emergency Department (ED) before X-rays are taken to confirm the nature of the injury. This...
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