How to Diagnose an Ankle Fracture - Ottawa ankle rules - Dr Gill

[Music] hello and welcome back to the channel you've joined myself Dr James Gill on a beach admittedly not one I think I'd like to be running on you see the thing is I've been seeing an awful lot of injured ankles at the moment and that made me think that perhaps there's a good idea to do a video looking at ankle injuries and how I can determine what we're going to do with them you see I do see a lot of ankles both as an expedition medic and a GP and given that people are forever rolling and tripping and turning their ankles I think it seems like a badly designed joint but the thing is when you've got that injury you know some patients clearly need an x-ray and some don't the question is how can we differentiate that thankfully there's a tool the auto ankle criteria that are going to give me a clear answer about what to do and frankly I think it's something that anyone who either owns ankles or does a lot of sports or adventuring should at least be familiar with hence this video so with that in mind let's look at the Ottawa ankor criteria prior to the development of these rules in 1992 anyone who basically attended the A&E Department with an injury would be given an x-ray to be on the safe side however only 15% of the people who had an x-ray actually were found to have a fracture and that's a lot of people having x-rays that don't need them now that doesn't sound too problematic Until you realize that's a lot of people waiting many extra hours and the waiting room isn't really the best place to be also x-rays aren't free either so given that 85% of these previously performed x-rays were negative that's not only a waste of resource time but also a large amount of unnecessary radiation to patients hence the auto our ankle rules would develop to try and reduce this level of unnecessary radiation excess cost but also frankly to reduce those waiting times and here's why everyone should at least have a familiarity with the auto ankle rules they give an ancillary benefit that out in the field they give us a very reliable tool as to whether or not someone really needs to go to hospital for an x-ray or not but simply the auto team worked backwards they took the 15% of the patients who did have fractures to their ankles on X-rays and compared their clinical examination findings against the remaining 85% of patients who had X-rays but were found not to have fractures from this data they were able to work out an effective set of clinical criteria to indicate who does and does not need an ankle x-ray after an ankle injury when it comes to being out in the wild or frankly just on a sporting pitch the power of the auto ankle CR criteria becomes even more valuable if a patient has merely strain their ankle then that's much less likely to put to the end of their Adventure or frankly the end of their season when you compare it to a fracture so being able to reliably make the call of I think we just need painkillers and strapping versus I'm so sorry we do need to get you to the hospital this is particularly key especially if it transpires that that hospital could be a helicopter right away so we've established that the UT ankle rules are useful but how do we use them to determine who needs an ankle strap and who needs a zap of radiation the first step of the Ottawa ankle criteria or rules is actually a really simple question and honestly it's one that's incredibly powerful can the patient weight bear immediately after the injury the followup to that is can they also weight bear for at least four steps during their evaluation the implication here is that even though that eval Val ation is probably going to be slightly delayed in time after the injury that shouldn't have a huge impact now speaking of someone who's broken plenty of Bones and has severely strained my ankles in the past this kind of makes a lot of sense when you've broken a bone it's broken and if we're talking about your ankle it's highly unlikely you're going to be able to walk on a fractured ankle even if after a brief rest however this is just the first point we we also need to examine the ankle and that's one thing that AI can't replace yet that ability for the clinician to poke and prod the patient so we want to examine specific locations on the ankle for focal tenderness and that provides probably the most powerful discriminating point of the auto Anor rules to start off we want to look at potential fractures in four bones two in the ankle two in the foot so we're going to assess the tibia and the fibula and we're going to assess the fifth metat tassle and the navicular bone of the foot starting on the outside of the ankle in the malola zone we're looking to see if there's bony tenderness on the posterior edge of the distal fibula going up the leg about 6 cm up from the ankle then coming back down is there focal bony tenderness at the tip of the lateral malleolus in the Ottawa anchor rules this is going to be labeled as point a we then want to look for similar tenderness on the opposite side of the ankle checking the tibia initially so we want to palpate in a similar way to that which we did on the fibula and we're looking to see if there's tenderness on the posterior six cm of the tibia up the inside of the ankle then we're again going to look for tenderness at the tip of the bone pressing over the medial malleolus which will label as point B having cleared both of the large bones of the ankle we then need to move down the foot specifically to the mid Zone as depending on the mechanism in which the ankle was injured a rolled ankle can actually result in a fracture to Bones within the feet not just the ankle itself so if we follow the same approach that we did before we're going to start off on the outside of the foot and then move to the inside we're going to look for pain at the base of the fifth metat tarel so the base of the bones that connect to the fifth toe which is labeled Point C then Crossing to the inside of the foot we're going to look for pain to the navicular bone labeled Point D so basically we're asking can they walk and does it hurt if we poke them at points a through to D although you don't need a full house to get the X-ray if there's inability to weight bear immediately after the injury and also you can't take those four steps when we come to have a look at you it's off to x-ray you go so can walk but ankle pain in the medium malleolus zone so that's a point tenderness at Point a the lateral malleolus or point tenderness at B the medium molis again off X-ray let's assume we can walk but foot pain in the mid zone so pain with palpation at Point C that being the base of the fifth metat tarel or Point D the navicular bone again you've won that x-ray now this does seem to be a bit of a wide criteria so how good are these rules at actually helping us work out who's fractured a bone and who hasn't honestly they're shockingly good the Ottawa ankle rules have a 97.6% Sensitivity I the ability to detect a true negative thus if somebody doesn't fit these rules we can be 97.8% certain they do not need an x-ray to be honest I'd take those odds as opposed to having to go off to the hospital and leave my adventure however they're not perfect being less robust at detecting the fracture which is a bit of a shame the uto rules have a specificity of 31.5% that's the ability to detect a true positive if somebody does fit these rules and that patient will turn out to have a fracture in about onethird of cases now those numbers don't really sound great in terms of diagnosing a fracture but flip it around when people have injured themselves when you really break it down they want to know particularly one on Expedition or on the sports pitch is am I okay the auto rules allow us to basically say you probably are okay or at least we don't need to take you out and get you checked from a fracture perspective not saying you don't have a sprain and that's why these rules are so important for Expedition medicine Ane teams and frankly people at home which is why I've done this video hopefully the next time either yourself a friend or a patient injures their ankle you'll be able to be in a much much better place to say you can walk on it it doesn't hurt over there on the tiia doesn't hurt on the fibula there's no pain on the fifth matter tassel nor over the niic bone so it's unlikely that you've broken your ankle hope that's been a helpful Expedition medicine Sports generall life video for you um if you've got any questions put them in the comments down below and if I could ask a small favor if you subscribe to the channel you get notifications on the next one take care we'll see you in the next one Jerry [Music]