Ankle injury manipulation before or after X-ray–Does it...
Transcript of Ankle injury manipulation before or after X-ray–Does it...
Accepted Manuscript
Title: Ankle injury manipulation before or after X-ray–Does itinfluence success?
Author: G.R. Hastie H. Divecha S. Javed A. Zubairy
PII: S0020-1383(13)00480-4DOI: http://dx.doi.org/doi:10.1016/j.injury.2013.10.016Reference: JINJ 5532
To appear in: Injury, Int. J. Care Injured
Received date: 22-9-2013Accepted date: 9-10-2013
Please cite this article as: Hastie GR, H D, Javed S, Zubairy A, Ankle injurymanipulation before or after X-rayndashDoes it influence success?, Injury (2013),http://dx.doi.org/10.1016/j.injury.2013.10.016
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Ankle injury manipulation before or after X-ray – Does it influence success?
Hastie GR, Core Orthopaedic Trainee1
Divecha H, Speciality Registrar in Trauma and Orthopaedic Surgery1
Javed S, Core Orthopaedic Trainee1
Zubairy A, Consultant Orthopaedic Surgeon1
Department of Trauma and Orthopaedic Surgery
East Lancashire Hospitals NHS Trust
Haslingden Road
Blackburn
Lancashire
BB2 3HH
Tel: + 44 1254 263555
Fax:
Corresponding Author:
Mr Graham Hastie ([email protected])
Keywords: ankle fracture dislocation; manipulation
*Manuscript title page (Incl title, ALL authors & affiliations and corr. author contact info. NOT manuscript itself)
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Ankle injury manipulation before or after X-ray – Does it influence success?
Abstract
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 a 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 Royal Blackburn Hospital with acute ankle
injuries. Their ED notes were reviewed, specifically assessing if a manipulation was performed, if so
was it before X-rays and the documented reasons. Ninety ankle fractures were manipulated and 31
of these were performed before X-ray. One manipulation was performed for vascular compromise, 1
for nerve symptoms, 3 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-square test: p=0.03; RR = 2.72: 95%
CI 1.15 - 6.44). Delay to surgery and need for ORIF were not statistically different.
*Blinded Manuscript (Incl title, abstract, keywords, text, references. NOT tables or figures)
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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.
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Introduction
There is wide variety in the management of ankle fractures between different Emergency
Departments (ED). With an ageing population the numbers of ankle fractures presenting to the ED
will increase1. The aim in management of these injuries should be to achieve an anatomical position
of the ankle mortice and a stable, mobile and painless ankle joint2. 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 breakdown3 and to limit soft tissue damage4. Early manipulation
is important as substantial soft tissue swelling can occur within hours of an injury and take weeks to
resolve5. This is important as significant oedema can impede wound healing6, but delaying surgery
until after this has settled can adversely affect the surgical outcomes7.
There is no published evidence suggesting what a reasonable time period to reduction is, 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 not only beneficial as it improves
the patient experience but reduces the risk of complications from repeated sedation for re-
manipulations.
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Method
We prospectively identified 197 patients admitted with an ankle injury to the Orthopaedic Ward at our institution between Nov
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 management was recorded together with any delays
more than 48hrs to surgery (with reasons for delays) and the total length of stay.
Statistical analyses
Data was 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 ratios were determined and difference in proportions testing performed (Pearson’s Chi-square
test where expected table counts were >5, Fisher’s exact test where expected counts were <5).
Statistical significance was set at p<0.05.
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Results
Out of 197 ankle injuries, 90 were manipulated in the ED. Thirty one were manipulated before and 59
after obtaining X-rays. Table 1 summarises the demographic characteristics of these two groups,
showing no significant differences.
Table 2 summarises a comparison of certain time-points from admission through to discharge. No
significant differences were noted between the groups. Interestingly, the median time to X-ray was
not significantly different in the group who were manipulated after obtaining X-rays.
The outcomes of these 90 ankle manipulations with respect to requiring remanipulation, definitive
treatment and delay to ORIF ≥48hrs for swelling are summarised in Table 3.
A significant association was found between remanipulation and whether the first manipulation was
performed before/ after X-rays. A remanipulation was 2.7 times more likely to be required if the
initial manipulation was performed before compared to after obtaining radiographs.
When assessing who performed the manipulation, all except 9 were performed by or under
supervision of ED middle grades or consultants. The other 9 were performed by the orthopaedic
registrar, 3 before x-rays and 6 after. None of the ankles manipulated by the orthopaedic team
required a remanipulation. Table 4 repeats the analysis in Table 3, excluding the 9 ankles reduced by
the orthopaedic team. The relative risk ratio remains essentially unchanged and statistically
significant (RR = 2.70; p = 0.038; 95% CI: 1.16 – 6.33).
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The documented reasons for performing a manipulation in the ED before obtaining X-rays are
summarised in Error! Reference source not found.. The majority had no obvious reason documented
for requiring an emergency reduction. The documented reasons for delay to ORIF of ≥ 48hrs are
summarised in Error! Reference source not found..
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Discussion
The reasons given previously for manipulating deformed ankles without neurovascular injury or
critical skin before x-ray are based on a belief that a delay in reduction will increase the risk of skin
breakdown, soft tissue damage and swelling leading to delays to surgery. This is routine practice in
many EDs regarding deformed ankle injuries, but the same concern is often not given to other joint
dislocations. Our prospective study has shown that there is a significant risk (2.72 times) of requiring
a re-manipulation if the first manipulation is performed before an X-ray with no delays in time to
surgery regardless of who was performing the manipulation (dropping to 2.7 times when excluding
cases initially reduced by the orthopaedic team). There was no difference in final treatment (need for
ORIF) and no complications arising from waiting for an initial X-ray. Additionally we found that there
was no difference in time to X-ray between the two groups, nor any difference in overall length of
stay.
We hypothesise the reason for reduction in the number of re-manipulations, in the group who had
an X-ray before their first manipulation, is because practitioners have a better idea of the fracture-
dislocation configuration which helps guide the reduction. There were two subtalar dislocations that
had failed attempts at reduction in the ED and required formal treatment under general anaesthesia.
If X-rays had been performed first, these failed attempts along with the risks of sedation and patient
discomfort could have been avoided. A limitation of our study is the lack of comparison of final
functional outcomes between the groups. Whilst this would have been useful, our focus was on
differences in immediate outcomes (remanipulation, need for ORIF and delay to surgery >48hrs),
which could influence patient care and possibly length of stay. We do accept however that longer
term follow-up studies are required to assess if functional outcomes differ, whether there is any
difference in onset of degenerative changes and if there are any differences in requirement for
surgical intervention such as joint arthrodesis/ arthroplasty.
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We conclude that in modern Emergency Departments, 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.
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References
1. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures – an increasing problem? Acta
Orthop Scand 1997;69(1):43-47.
2. Lesic A, Bumbasirevic M. Ankle Fractures. Current Orthopaedics 2004; 18:232-244.
3. Watson JAS, Hollingdale JP. Early management of displaced ankle fractures. Injury 1992; 23
(2):87-88.
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):216-219.
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; 17:678-685.
7. Fogal GR, Morrey BF. Delayed open reduction and fixation of ankle fractures. Clin. Orthop 1993;
215:187-195.
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Ankle injury manipulation before or after X-ray – Does it influence success?
Before X-Ray After X-Ray p-value
n 31 59 Median age (yrs) (range) 43.6 (22.3 – 77.8) 48.9 (16.5 – 98.4) 0.298 a
Sex Female 14 37
0.11 b
Male 17 22
Side Left 18 33
0.846 b
Right 13 26
Open 2 1 0.272 c
Table 1: Comparison of demographics between groups (a – Kruskal-Wallis; b – Pearson Chi-square; c – Fisher exact)
Table
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Before X-Ray After X-Ray p-value
Arrival to X-ray (hrs) 1.17 (0 – 4.5) 0.95 (0 – 3.3) 0.136
Arrival to Surgery (days) 1.0 (0 – 32) 1.0 (0 – 8) 0.419
Length of stay (days) 4.0 (0 – 47) 4.0 (0 – 45) 0.935
Table 2: Comparison of time-points between groups; values are median (range); Kruskal-Wallis test
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First Manipulation Performed p-value
Relative risk
ratio 95% CI
Before X-Ray After X-Ray
Remanipulation No 21 52
0.039 a 2.72 1.15 - 6.44 Yes 10 7
Definitive
Treatment
Cons. 3 12 0.197 a 1.13 0.95 - 1.35
ORIF 28 47
Delay to ORIF
≥48hrs for swelling
No 26 54 0.881 b 1.33 0.41 - 4.37
Yes 4 6
Table 3: Comparison of outcomes (a – Pearson Chi-square with Yates’ continuity correction; b – Fisher Exact)
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First Manipulation Performed p-value
Relative risk
ratio 95% CI
Before X-Ray After X-Ray
Remanipulation No 18 46
0.038 a 2.70 1.16 - 6.33 Yes 10 7
Table 4: Comparison of remanipulations excluding cases initially manipulated by orthopaedic team (a – Pearson Chi-square with Yates’ continuity correction)
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Ankle injury manipulation before or after X-ray – Does it influence success?
Figure 1: Reasons for manipulation before obtaining radiographs
1 1
4
26
0
5
10
15
20
25
30
Vascular Neurological Critical Skin No reason
Figure
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Figure 2: Reasons for delay to ORIF ≥ 48hrs
1 2
4
8
0
3
6
15
0
2
4
6
8
10
12
14
16
Awaiting CT scan Trauma Load Swelling No reason
Before XR
After XR
First Manip
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Ankle injury manipulation before or after X-ray – Does it influence success? Conflict of Interest Statement The authors can confirm there are no conflicts of interest in the publication of this manuscript.
*Conflict of Interest Statement