Dr. Kathy Boutis and colleagues conducted a study to see if hospitals could cut down on the number of children who receive radiographs on their ankles for minor injuries. Dr. Boutis believed many children were receiving radiographs for what she termed “low-risk” ankle injuries. She hoped that through new procedural rules and a streamlined emergency department system, a large portion of children could have their ankle injuries diagnosed without the use of an X-ray.

The Study

Dr. Boutis recruited six hospitals to participate in the study. Three of the hospitals received new procedural guidelines while the other three hospitals acted as a control group. The hospitals that undertook the new rules treated 1055 children with ankle injuries during the study, while the control hospitals treated 1,096 children.

The hospitals with the new guidelines implemented a three-phase system that included:

• An initial phase where baseline data was collected;
• A second phase that included intervention; and
• A final phase that used a decision support system to determine treatment protocols.

The second phase was arguably the most important phase for medical professionals, as it was during this stage that they underwent training and received guidelines of the “Low Risk Ankle Rule”.

The Low Risk Ankle Rule said that if a child suffered an ankle injury that had a low risk examination, radiography could be avoided. Children were determined to have a low risk examination if tenderness and swelling were isolated to the distal fibula and/or adjacent lateral ligaments distal to the tibial anterior joint line.

After a physician assessed a child’s injury, they would input their findings into a computerized decision support system. Based on their findings in regards to appearance, symptoms and other factors, the system would automatically determine the risk associated with the ankle injury and if the Low Risk Ankle Rule should be applied.

The Results

According to researchers, during the intervention stage physicians reduced the use of radiography by 22 percent compared to the control group without any significant differences in patient satisfaction. They also concluded:

• The Low Risk Ankle Rule could have been used in 430 of 628 cases in the second and third phases, and they followed the rule recommendations in 350 cases.
• The two main reasons why the Low Risk Ankle Rule wasn’t followed in the cases that qualified were because physicians feared missing a significant fracture, and because the child’s family preferred an X-ray.
• Researchers believed had all physicians completely complied with the rule, 49.5 percent of X-ray procedures could have been avoided.

While similar studies will certainly follow, the researchers were pleased with their findings.

“The ankle rule has potential broad applicability to emergency departments throughout most of the developed world, and widespread implementation of this rule could safely lead to reduction of unnecessary radiography in this radiosensitive population and a more efficient use of health care resources,” researchers concluded.

Related source: Medscape

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TEREM Emergency Medical Centers operates five urgent care facilities and consults over 200,000 patients a year, including 10,000 fractures and 30,000 nonfracture injuries.  The medical center has round-the-clock computerized radiology, but they wanted to implement a system that would allow their orthopedists to provide consultations without getting on a computer or coming into the medical center.  Although they wanted to test smartphone technology, they did not want a patient to be misdiagnosed because the consultants were viewing the images on a small screen.

For their study, 41 sample images were taken from previous consultations.  The sample images featured everything from major fractures to minor conditions.  The images were sent to the orthopedists to be examined their smartphone.

In all 41 cases, each condition was successfully diagnosed by consultants using their smartphone.  To confirm their findings, each image was then reviewed using the medical center’s computerized imaging techniques.

Since the successful study, the TEREM medical center has reviewed an additional 312 images through smartphone technology.  As was the case with the study, all images were later confirmed using the center’s computerized imaging.  No clinically significant fracture has been missed in any of the 312 cases reviewed by mobile telephone.

The TEREM medical center has also found that their hospital referral rate has dropped significantly since the inception of smartphone consultation technology.  They reported a 50% drop in referrals from their clinics to hospitals because remote consultants were often able to provide medical advice to local clinics, which meant that patients could be treated without needing to visit an emergency room.  The medical center also reported increased comfort among their clinic physicians because they have greater access to specialized consultation through smartphone technology.

Dr. Silverman comments

I believe this was a great study, and I am pleased that the findings proved to be so successful.

In my line of work, there have been times where I have been asked to provide a consultation using only telephone conversation and limited radiology images.  Sometimes the images are sent through email, but I have also reviewed many images using only a smartphone.  I have been able to easily review radiographs and select MRI images through both the Android and iPhone platform.

I remember one specific incident where I reviewed a friend’s X-rays on my smartphone while I was on a plane.  He had fallen on while on vacation in Hawaii, and I was able to help him plan his care for the rest of the trip.

The prospect of smartphone imaging is exciting, but the finding that revealed a 50% drop in hospital referrals is also crucial.  Minor orthopedic injuries are an extremely common reason for emergency room referrals, which can be time consuming and put an extra burden on ER doctors.  Redirecting non-emergent problems to a clinic setting will save much needed time and money.  I look forward to this seeing this research applied in the United States.

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Luckily for Roethlisberger, the sprain has been classified as grade 2, not 3. There are 3 grades of high ankle sprains, 3 being the most severe.

Roethlisberger is wearing a walking boot and getting rest before the Steelers’ next game against the 49ers.

Players who sustain high ankle sprains are usually not able to return to play for 2-3 weeks. First time high ankle sprains are confusing for players who are used to bouncing back quickly from more commonplace ankle sprains. They get frustrated, return early and become re-injured.  This is Roethlisberger’s first high ankle sprain.

“I’ve never had a high-ankle sprain before, so I don’t know what to expect,” he said after the game. “But it feels like my ankle is about to explode. I’m ready to get off of it.”

In general, high ankle sprains are more severe than the typical “rolled” ankle sprain. Grade 1 sprains recover within 2-3 weeks.  More severe injuries and non-surgically treated ankles need a 5-6 weeks recovery.

“As Roethlisberger has clearly demonstrated an almost superhuman pain tolerance, a standing ankle x-ray can be obtained and compared to his uninjured ankle,” says Orthopedic Specialist, Lance Silverman. “Simply relying on an MRI will not show whether or not the ankle is stable.  If widening occurs, surgery should be strongly considered or the risk increases for re-injury and the development of chronic ankle problems.”

Related Sources:

SportingNews.com

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