Smith G F, Madlon-Kay D J, Hunt V
East Side Medical Center, St. Paul, MN 55106.
J Fam Pract. 1993 Oct;37(4):345-8.
The use of radiography in evaluating inversion ankle injuries remains high despite several studies suggesting that x-ray examination should be limited to patients meeting certain clinical criteria. These studies were all done in emergency departments. The present study examined detection of ankle fractures by clinical evaluation alone in private family practice offices.
Twelve physicians in three family practice offices participated. Check-off forms were developed to record clinical data. The physicians all attended a session to standardize terminology. The physicians then evaluated 94 consecutive patients with inversion ankle injuries.
Eight fractures were detected by radiography, five of which had not been suspected on clinical examination (5.9% false-negative rate). Only one fracture required treatment different from that for a sprain. Tenderness on the dorsum of the foot, impaired weight-bearing ability, recentness of injury (less than 12 hours earlier), and presence of additional injuries were significantly associated with a fracture. Unlike several previous studies, swelling was not associated with fractures. If radiography had been limited to patients presenting with inability to bear weight fully or tenderness on the dorsum of the foot, none of the fractures would have been missed, and the use of radiography would have been reduced from 90% to 61%.
The fracture rate in these family practice offices is lower than that reported in most emergency department studies. It is important that family physicians order radiographs judiciously rather than routinely for patients with inversion ankle injuries. The clinical criteria reported here are likely to reduce unnecessary ordering of radiographs and are compatible with recently published, prospectively validated rules for acute ankle injury in an emergency department setting.
尽管多项研究表明X线检查应仅限于符合特定临床标准的患者，但X线摄影在评估踝关节内翻损伤中的应用仍然广泛。这些研究均在急诊科进行。本研究在私人家庭诊所中单独通过临床评估来检测踝关节骨折。
来自三个家庭诊所的12名医生参与了研究。设计了检查表来记录临床数据。所有医生参加了一次会议以规范术语。然后，这些医生对94例连续的踝关节内翻损伤患者进行了评估。
X线摄影检测出8例骨折，其中5例在临床检查中未被怀疑（假阴性率为5.9%）。只有1例骨折需要与扭伤不同的治疗。足背压痛、负重能力受损、损伤时间短（少于12小时）以及存在其他损伤与骨折显著相关。与之前的几项研究不同，肿胀与骨折无关。如果X线摄影仅限于那些完全无法负重或足背压痛的患者，那么所有骨折都不会被漏诊，X线摄影的使用率将从90%降至61%。
这些家庭诊所的骨折发生率低于大多数急诊科研究报告的发生率。对于踝关节内翻损伤患者，家庭医生明智地而非常规地开具X线检查单非常重要。此处报告的临床标准可能会减少不必要的X线检查单开具，并且与最近发表的、在急诊科环境中经过前瞻性验证的急性踝关节损伤规则相符。
