Implementation of the Ottawa ankle rules

Acute ankle sprain in athletes: Clinical aspects and algorithmic approach

Acute ankle sprain is the most common lower limb injury in athletes and accounts for 16%-40% of all sports-related injuries. It is especially common in basketball, American football, and soccer. The majority of sprains affect the lateral ligaments, particularly the anterior talofibular ligament. Despite its high prevalence, a high proportion of patients experience persistent residual symptoms and injury recurrence. A detailed history and proper physical examination are diagnostic cornerstones. Imaging is not indicated for the majority of ankle sprain cases and should be requested according to the Ottawa ankle rules. Several interventions have been recommended in the management of acute ankle sprains including rest, ice, compression, and elevation, analgesic and anti-inflammatory medications, bracing and immobilization, early weight-bearing and walking aids, foot orthoses, manual therapy, exercise therapy, electrophysical modalities and surgery (only in selected refractory cases). Among these interventions, exercise and bracing have been recommended with a higher level of evidence and should be incorporated in the rehabilitation process. An exercise program should be comprehensive and progressive including the range of motion, stretching, strengthening, neuromuscular, proprioceptive, and sport-specific exercises. Decision-making regarding return to the sport in athletes may be challenging and a sports physician should determine this based on the self-reported variables, manual tests for stability, and functional performance testing. There are some common myths and mistakes in the management of ankle sprains, which all clinicians should be aware of and avoid. These include excessive imaging, unwarranted non-weight-bearing, unjustified immobilization, delay in functional movements, and inadequate rehabilitation. The application of an evidence-based algorithmic approach considering the individual characteristics is helpful and should be recommended.

Anti-inflammatory effect of Resolvin D1 on LPS-treated MG-63 cells

Inflammation reaction plays an important role in the pathogenesis of ankle fracture. The aim of the present study was to investigate the effect of RvD1 on the inflammatory response and underlying molecular mechanisms in MG-63 cells. Reverse transcription-quantitative polymerase chain reaction (RT-qPCR) and ELISA were used to determine the mRNA and protein expression of cytokines extracted from peripheral blood in children with or without ankle fracture, respectively. MG-63 cells were pre-treated with/without RvD1 and stimulated with 1 µg/ml LPS. The cell viability was detected by MTT assay. The production of cytokines from MG-63 cells was assessed by RT-qPCR and western blot, respectively. The expression of p-p38, NF-κB (p50) and cyclooxygenase-2 (COX-2) mRNA and protein were detected by western blot and/or RT-qPCR. The levels of NLRP3, associated recruitment domain (ASC), cleaved caspase1, caspase-1 were measured by RT-qPCR and/or western blot. The levels of interleukin (IL)-1β, IL-6 and tumor necrosis factor (TNF-α) mRNA and protein were up-regulated in children with ankle fracture compared with healthy children. RvD1 treatment did not induce cytotoxicity in MG-63 cells, but it can inhibit LPS induced MG-63 cell proliferation inhibition. RvD1 was able to dose-dependently reverse LPS induced up-regulation of TNF-α, IL-1β, IL-6 mRNA and protein expression. Furthermore, the LPS induced up-regulation of p-p38, NF-κB (p50), and NLRP3, ASC, cleaved caspase-1/caspase-1, and COX-2 was dose-dependently reversed by RvD1. In conclusion, The present study demonstrated that RvD1 inhibited inflammation though inhibiting MAPKp38/NF-κB pathway and NLRP3 inflammasome expression in MG-63 cells, indicating that it may be an effective drug for the treatment of ankle fracture.

N-methyl pyrrolidone promotes ankle fracture healing by inhibiting inflammation via suppression of the mitogen-activated protein kinase signaling pathway

N-methyl pyrrolidone (NMP), a small bioactive molecule, has the potential to stimulate bone formation and inhibit osteoclast differentiation. The aim of the present study was to investigate the effect of NMP on the inflammatory response and underlying molecular mechanisms in MG-63 cells. The mRNA and protein expression of cytokines from peripheral blood in children with or without ankle fracture were determined by reverse transcription-quantitative polymerase chain reaction (RT-qPCR) and ELISA, respectively. MG-63 cells were pre-treated with/without NMP and stimulated with 1 µM bradykinin (BK). The production of cytokines from MG-63 cells was assessed by western blotting and RT-qPCR. The expression of inducible nitric oxide synthase (iNOS) and cyclooxygenase-2 (COX-2) mRNA and protein were measured using western blotting and/or RT-qPCR. Western blotting was used to examine the activation level of mitogen activated protein kinase. Compared with healthy children, levels of tumor necrosis factor (TNF-α), interleukin (IL)-1β and IL-6 mRNA and protein were upregulated in children with ankle fracture. NMP treatment did not induce cytotoxicity in MG-63 cells. The BK-induced upregulation of TNF-α, IL-1β, IL-6, iNOS and COX-2 mRNA and protein was reversed in a dose-dependent manner by NMP. Furthermore, NMP downregulated the activation of c-Jun NH2-terminal kinase and p38 pathways, but not the extracellular signal-related kinase pathway. Therefore, the results of the current study demonstrate that NMP inhibits inflammation dependent on the mitogen-activated protein kinase pathway in MG-63 cells, indicating that it may be beneficial in the healing of fractures.

Risk prediction models for mortality in community-acquired pneumonia: a systematic review

BACKGROUND

Several models have been developed to predict the risk of mortality in community-acquired pneumonia (CAP). This study aims to systematically identify and evaluate the performance of published risk prediction models for CAP.

METHODS

We searched MEDLINE, EMBASE, and Cochrane library in November 2011 for initial derivation and validation studies for models which predict pneumonia mortality. We aimed to present the comparative usefulness of their mortality prediction.

RESULTS

We identified 20 different published risk prediction models for mortality in CAP. Four models relied on clinical variables that could be assessed in community settings, with the two validated models BTS1 and CRB-65 showing fairly similar balanced accuracy levels (0.77 and 0.72, resp.), while CRB-65 had AUROC of 0.78. Nine models required laboratory tests in addition to clinical variables, and the best performance levels amongst the validated models were those of CURB and CURB-65 (balanced accuracy 0.73 and 0.71, resp.), with CURB-65 having an AUROC of 0.79. The PSI (AUROC 0.82) was the only validated model with good discriminative ability among the four that relied on clinical, laboratorial, and radiological variables.

CONCLUSIONS

There is no convincing evidence that other risk prediction models improve upon the well-established CURB-65 and PSI models.

Utilization of radiographs for the diagnosis of ankle fractures in Kingston, Ontario, Canada

OBJECTIVES

This study assessed the utilization and clinical yield of radiographs ordered to assist in the diagnosis of acute ankle injuries presenting to two emergency departments (EDs) in Kingston, Ontario, Canada, over a 7-year period.

METHODS

A large case series was assembled. Records of ankle injuries from the Kingston sites of the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) were linked to hospital discharge records containing procedure codes. Utilization of radiographs and the clinical yield of these assessments were analyzed over time.

RESULTS

Following exclusions, 7,706 acute ankle injuries were identified for analysis. Utilization of radiography increased modestly over time, to a high of 70.3% (95% confidence interval [CI] = 67.3% to 72.9%) in 2007. The percentage of cases positive for fracture remained consistent (18.3% to 21.9% annually).

CONCLUSIONS

Explanations for the observed increase in utilization of radiographs remain uncertain. Increased use of clinical decision tools such as the Ottawa Ankle Rules (OAR) appear to be required to reduce procedure costs within the ED and to limit patient exposure to radiography.

Should a head-injured child receive a head CT scan? A systematic review of clinical prediction rules

CONTEXT

Given radiation- and sedation-associated risks, there is uncertainty about which children with head trauma should receive cranial computed tomography (CT) scanning. A high-quality and high-performing clinical prediction rule may reduce this uncertainty.

OBJECTIVE

To systematically review the quality and performance of published clinical prediction rules for intracranial injury in children with head injury.

METHODS

Medline and Embase were searched in December 2008. Studies were selected if they included clinical prediction rules involving children aged 0 to 18 years with a history of head injury. Prediction-rule quality was assessed by using 14 previously published items. Prediction-rule performance was evaluated by rule sensitivity and the predicted frequency of CT scanning if the rule was used.

RESULTS

A total of 3357 titles and abstracts were assessed, and 8 clinical prediction rules were identified. For all studies, the rule derivations were reported; no study validated a rule in a separate population or assessed its impact in actual practice. The rules differed considerably in population, predictors, outcomes, methodologic quality, and performance. Five of the rules were applicable to children of all ages and severities of trauma. Two of these were high quality (>or=11 of 14 quality items) and had high performance (lower confidence limits for sensitivity >0.95 and required <or=56% to undergo CT). Four of the 8 rules were applicable to children with minor head injury (Glasgow coma score >or=13). One of these had high quality (11 of 14 quality items) and high performance (lower confidence limit for sensitivity = 0.94 and required 13% to undergo CT). Four of the 8 rules were applicable to young children, but none exhibited adequate quality or performance.

CONCLUSIONS

Eight clinical prediction-rule derivation studies were identified. They varied considerably in population, methodologic quality, and performance. Future efforts should be directed toward validating rules with high quality and performance in other populations and deriving a high-quality, high-performance rule for young children.

Impact of clinical decision rules on clinical care of traumatic injuries to the foot and ankle, knee, cervical spine, and head

INTRODUCTION

Traumatic injuries to the ankle/foot, knee, cervical spine, and head are very commonly seen in emergency and accident departments around the world. There has been much interest in the development of clinical decision rules to help guide the investigations of these patients in a standardised and cost-effective manner.

METHODS

In this article we reviewed the impact of the Ottawa ankle rules, Ottawa knee rules, Canadian C-spine rule and the Canadian CT head rule.

RESULTS

The studies conducted have confirmed that the use of well developed clinical decision rules results in less radiography, less time spent in the emergency department and does not decrease patient satisfaction or result in misdiagnosis.

CONCLUSIONS

Emergency physicians around the world should adopt the use of clinical decision rules for ankle/foot, knee, cervical spine and minor head injuries. With relatively simple implementation strategies, care can be standardized and costs reduced while providing excellent clinical care.

Print format and sender recognition were related to survey completion rate

OBJECTIVE

To assess whether print format (single-sided vs. double) and sender recognition (known vs. unknown) affect response and completion rates among physician survey respondents.

STUDY DESIGN AND SETTING

Postal survey of 399 members of the Canadian Association of Emergency Physicians; 2 x 2 factorial design.

RESULTS

Response rate was 69.4%. Single-sided printing yielded 7.4% (odds ratio OR = 1.41; 95% confidence interval CI = 0.90-2.20; P = 0.13), and a known sender yielded a 6.3% greater response rate (OR = 0.73; 95% CI = 0.47-1.14; P = 0.16). Overall item completion was 98.2%; items missed per respondent ranged from 1 to 14 out of 50. Print format and sender recognition interacted in predicting completion rate (OR = 13.33; 95% CI = 3.10-57.4; P = 0.001); completion was higher for double-sided printing with an unknown sender, and for single-sided printing with a known sender. Completion was also lower when response came after later mailouts (chi2(2) = 10.13; P = 0.006).

CONCLUSIONS

Print format and sender recognition both yielded 6%-7% (nonsignificant) response rate differences. Survey completion rate varied even when overall item completion was high. Completion rate was useful for identifying subgroups likely to provide incomplete data (i.e., late responders), and may provide important information for subsequent surveys. Combining factors that on their own improve survey response may have unexpected consequences.

Orthopedic trauma: office management of major joint injury

Orthopedic injuries are common reasons for visits to primary care physicians. Careful history and physical examination with intelligent use of imaging technology will arrive at the correct diagnosis in most patients. Many conditions may be definitively managed by the office internist. Others maybe initially stabilized and referred to orthopedic surgeons for definitive care. Nondisplaced fractures, tendon injuries, sprains, and overuse syndromes are entities within the purview of the primary care physician. Familiarity and confidence with diagnosis and management of these conditions in the office is optimal for the care of the adult patient.

Development of radiology prediction models using feature analysis

RATIONALE AND OBJECTIVES

This article provides an introduction to prediction models and their application in diagnostic imaging research. Prediction models capitalize on the different degrees of association among variables to make a prediction of a health state, formulate a rule, or quantify individual contributions of various predictor variables. The purpose of this article is to elucidate the rationale, implication, and interpretation of prediction models using imaging features.

MATERIALS AND METHODS

The techniques and challenges of developing, testing, and implementing prediction models are described. Prediction model development methods are similar to data-mining techniques.

RESULTS

Learning objectives are to review prediction rule (model) methods, learn how prediction models may be applied to feature analysis, and understand the challenges of developing, testing, and implementing prediction models.

Validation of the Ottawa Ankle Rules in Australia

OBJECTIVE

This study was a prospective validation of the Ottawa Ankle Rules (OAR) in Australia following appropriate education in the use of the rules.

METHODS

The OAR were applied to consecutive patients 18 years and over presenting with acute ankle and foot injuries to the ED of an urban teaching hospital.

RESULTS

Three hundred and thirty-three patients had 366 injuries. There were 43 fractures in 265 ankle injuries and 14 fractures in 101 foot injuries. Sensitivity was 100% for ankle (95% confidence interval (CI): 92-100) and midfoot fractures (95% CI: 77-100). Specificity was 15.8% (95% CI: 11-21) for ankle fractures and 20.7% (95% CI: 13-31) for midfoot fractures.

CONCLUSION

The OAR had a sensitivity of 100% for ankle and midfoot fractures when used by both junior and senior physicians.

Evaluation of the Ottawa ankle rules in children

OBJECTIVE

The Ottawa Ankle Rules (OAR) are criteria for predicting ankle fractures in adults allowing for insignificant fractures, defined as small avulsion fractures. Because the clinical significance of avulsion fractures and Salter-Harris type I fractures in children is unclear, we sought to prospectively evaluate the use of the OAR in children and to determine whether different criteria should be used for predicting ankle fractures in children.

METHODS

In this prospective study, patients younger than 18 years presenting to a pediatric emergency department (ED) with an acute nonpenetrating ankle injury were eligible for study participation. Information on 22 clinical variables was recorded on a standardized data sheet. The OAR were included but not specifically identified on the data sheets. A standard ankle radiographic series was obtained on all subjects. All fractures were considered to be significant. Follow-up phone calls were performed to assess final diagnosis and outcome. Sensitivity and specificity of OAR and other potential criteria for predicting ankle fractures in children were calculated.

RESULTS

A total of 195 patients with ankle injuries were evaluated. The mean age of patients was 12.6 years. Forty fractures (21%) were identified. The sensitivity of OAR was 83% (95% CI, 65-94%), specificity was 50% (95% CI, 41-59%), positive predictive value was 28%, and negative predictive value was 93%. Three independent factors were significantly associated with ankle fractures: inability to walk immediately after the event, inability to bear weight for four steps in the ED, and tender deltoid ligament. If one or more of these factors were present, sensitivity for predicting ankle fractures was 93% (95% CI, 78-99%), specificity was 27% (95% CI, 20-36%), positive predictive value was 23%, and negative predictive value was 95%.

CONCLUSION

The OAR cannot be applied to children with the same sensitivity as adults.

Comparison of search strategies and quality of medical information of the Internet: a study relating to ankle sprain

OBJECTIVES

to evaluate the quality of web sites on ankle sprain diagnosis and treatment and to assess the impact of Internet search expertise on quality of retrieved information.

METHOD

two internet search strategies were conducted - one developed by an experienced information officer (expert's search) and the other based on the search terms used by orthopaedic medical staff (doctors' search).

RESULTS

the expert's search revealed 32 web sites, of which nine were relevant, whereas the doctors' search revealed 61 web sites of which 27 were relevant. Of the relevant web sites in the expert's search, one complied with all quality criteria, whereas none of the web sites in the doctors' search complied with all criteria (11 vs. 0%, P=0.25). The web sites identified by expert's search had higher credibility (median scores 70 vs. 44, P=0.01) and accuracy of content (median scores 50 vs. 35, P=0.24).

CONCLUSION

the quality of medical information on the internet is generally poor and information experts can capture higher quality web sites compared with doctors.

Triage nurse application of the Ottawa knee rule

OBJECTIVE

To determine interobserver agreement between triage registered nurses (RNs) and emergency physicians (EPs) regarding indication for knee radiographs by applying the Ottawa knee rule (OKR) and individual components of the rule.

METHODS

This was a prospective, observational study in a suburban, teaching emergency department. The study enrolled a convenience sample of patients aged >17 years with traumatic knee injuries less than one week old. Patients with prior knee surgery or distracting conditions were excluded. Before study initiation, the RNs and EPs were in-serviced in the OKR. Nurses and EPs independently examined each patient for OKR criteria, blinded to the other's assessment. Knee radiographs were ordered at the discretion of the EP and were interpreted by board-certified radiologists. All patients received follow-up with a structured telephone interview to identify any undetected fractures. Kappa was calculated for each component and the overall application of the OKR to assess interobserver agreement.

RESULTS

Ninety-six patients were enrolled. The mean age was 39.6 +/- 18.7 years; 50% were male. Eight patients (8%) had knee fractures. Interobserver agreements between the RNs and EPs for individual components of the OKR were: age > or =55 years (kappa = 0.97); inability to weight bear (kappa = 0.51); inability to bend knee to 90 degrees (kappa = 0.52); fibular head tenderness (kappa = 0.45); and isolated patellar tenderness (kappa = 0.40). The EPs and RNs agreed with OKR criteria for x-ray 71% of the time (kappa = 0.41).

CONCLUSIONS

The only criterion that resulted in almost perfect agreement between the RNs and EPs was patient age; agreement for the other four criteria and the overall decision to order x-rays was moderate.

Sports-specific concerns in the young athlete: basketball

Basketball is played by millions of athletes throughout the world and is the most popular team sport in American high schools. Basketball is the leading cause of sports-related injury in the United States. Acute basketball injuries most often involve the extremities, especially the hands, wrists, ankles, and knees. This article reviews the history, epidemiology, and common injury patterns that occur in this sport. We include several case reports to emphasize diagnostic dilemmas frequently encountered by emergency physicians.

Evaluation of the physician's ability to recognize the presence or absence of anemia, fever, and jaundice

OBJECTIVE

The evaluation of the patient through a comprehensive history and physical examination is considered the cornerstone of medical diagnosis, but many studies suggest that physicians have inadequate physical examination skills. It is unknown whether these skills are reliable and whether they can be adequately acquired through training. The objective of this study was to evaluate the ability of the clinician to detect the presence and discriminate the extent of clinical anemia, fever, and jaundice in an ED or hospitalized patient.

METHODS

This was a prospective observational study of a convenience sample of patients presenting to the ED or admitted to the hospital who had a rectal temperature measurement within 30 minutes prior to the observation, serum hematocrit measurement on the day of observation, or serum bilirubin measurement one day prior to the day of observation. Observers' (emergency medicine attending physicians', resident physicians', and rotating medical students') estimated serum hematocrit, rectal temperature, and serum bilirubin values were obtained after each observation. Sensitivity, specificity, positive predictive value, negative predictive value, and mean absolute difference between actual and estimated values were calculated for each observer.

RESULTS

The physicians detected the presence or absence of anemia, fever, and jaundice in patients with sensitivities and specificities of approximately 70%. Their predictions varied from the measured value on average by 6.0 +/- 4.6% for serum hematocrit, 1.3 + 1.1 degrees F for rectal temperature, and 3.4 +/- 5.3 mg/dL for serum bilirubin. Observer accuracy decreased when evaluating patients with high and low measured values.

CONCLUSIONS

The ability to correctly perform and interpret the physical examination appears to be independent of the observer level of training, patient ethnicity, or patient gender. The examination for pallor, warmth, and jaundice is unreliable in predicting the corresponding laboratory or electronic measurement. Certain anemic, febrile, or jaundiced patients may not be reliably detected solely by a focused physical examination.

Critical appraisal of papers describing triage systems

This article seeks to provide readers with a framework to enable them to assess the quality of the published description or evaluation of a triage system. Similarities between the triage process and the process of diagnosis and the nature of clinical decision rules are noted. Criteria that triage evaluations should meet are recommended, based on methodology suggested from evidence-based medicine, the development of clinical decision rules, and evaluation of diagnostic tests.

Validation of the Ottawa Ankle Rules in children with ankle injuries

OBJECTIVES

The Ottawa Ankle Rules (OAR) have been found to be 100% sensitive in adult patients with ankle injuries, and application of the OAR has resulted in a 28% reduction in the number of x-rays ordered. The objectives of this study were to determine the sensitivity and specificity of the OAR in children and to determine the potential change in x-ray utilization.

METHODS

Children, aged 2-16 years, presenting to the EDs of two children's hospitals, with an ankle injury in the previous 48 hours, were enrolled. All patients were assessed by either staff physicians or fellows. X-rays were ordered according to standard clinical practice. Prior to reviewing x-rays, the physical examination was recorded on a standardized form. Positive outcomes (clinically significant) were defined as fractures with fragments > or =3 mm. Patients not x-rayed and asymptomatic at five to seven days postinjury were considered to have no significant fracture.

RESULTS

Six hundred seventy patients were enrolled. The OAR were 100% sensitive (95% CI = 95% to 100%) for significant ankle fractures, with a specificity of 24% (95% CI = 20% to 28%). The OAR were 100% sensitive (95% CI = 82% to 100%) for the midfoot, with a specificity of 36% (95% CI = 29% to 43%). If the OAR had been followed, there would have been a reduction of ankle x-rays by 16% and foot x-rays by 29% without missing any clinically significant fracture. However, analysis of the two hospitals showed that if the rules had been applied, one would have a reduction in x-rays, while the other center would have an increase.

CONCLUSIONS

This study demonstrates the OAR to be sensitive for detecting clinically significant (> or =3 mm) ankle and midfoot fractures in children. The application of these rules may reduce the number of x-rays ordered. A further study is required to determine the effect of using the OAR in clinical practice.

Comparison of the results of short-term rigid and semi-rigid cast immobilization for the treatment of grade 3 inversion injuries of the ankle

In this prospective, randomized study, short-term immobilization with semi-rigid (Soft Cast) and rigid (Scotchcast Plus) synthetic cast materials were compared for the functional treatment of acute grade 3 lateral ligament injuries of the ankle. Degree of ligament injury was assessed by clinical criteria. Duration of immobilization was 2 weeks for both groups and home physiotherapy was started thereafter. Fifty-seven patients completed the study and both materials were found to be equally effective in providing a stable ankle at the end of 6 weeks follow-up. Soft Cast group had better range of motion and could walk better at 2 weeks, but these differences diminished at 6 weeks. With the Soft Cast, patient satisfaction was higher, need for a support for walking was less and return to work was earlier. When combined with the reduced cost of application, Soft Cast is the material of choice for the initial short-term immobilization for the functional treatment of acute ankle ligament injuries.

Clinical guidelines and the fate of medical autonomy in Ontario

Conceptually, clinical guidelines and professional autonomy have a paradoxical relationship. Despite being the quintessence of medical knowledge at the corporate level, guidelines diminish the clinical autonomy of individual practitioners, and therefore threaten medicine's justification for its autonomy. Theorists have argued that professional autonomy will be retained through elite dominance of practitioners, while comparative research suggests that economic autonomy can be traded off to retain clinical autonomy. Under government pressure to regulate the growth of Ontario physicians' fee-for-service public expenditure, the profession's representative organization, the Ontario Medical Association (OMA), promoted voluntary clinical guidelines, hoping to both constrain costs and preserve professional control over the content of medical care. The OMA collaborated with the Ministry of Health in developing guidelines and establishing a provincial centre for health service research. Ontario's practitioners disregarded the OMA's exhortations to implement clinical guidelines, suggesting that in the absence of external constraints, practitioners can subvert elite dominance. However, practitioners' unchecked clinical and economic autonomy, combined with evidence of wide provincial variations in medical care, served to legitimize the government's increasingly unilateral control over the schedule of insured medical services, and, in 1993, their imposition of a global cap on physicians' fee-for-service income pool. When analysed in the context of ongoing Ministry-OMA relations, the failure of the OMA's guidelines strategy to constrain medical service costs has expedited an overall decline in medical autonomy in Ontario. The emergence and course of Ontario's clinical guidelines movement is consistent with the view that medical autonomy is contingent upon broad class forces, and the conceptualization of professional organizations as instruments for mediated occupational control.

The role of decision analysis in informed consent: choosing between intuition and systematicity

An important goal of informed consent is to present information to patients so that they can decide which medical option is best for them, according to their values. Research in cognitive psychology has shown that people are rapidly overwhelmed by having to consider more than a few options in making choices. Decision analysis provides a quantifiable way to assess patients' values, and it eliminates the burden of integrating these values with probabilistic information. In this paper we evaluate the relative importance of intuition and systematicity in informed consent. We point out that there is no gold standard for optimal decision making in decisions that hinge on patient values. We also point out that in some such situations it is too early to assume that the benefits of systematicity outweigh the benefits of intuition. Research is needed to address the question of which situations favor the use of intuitive approaches of decision making and which call for a more systematic approach.

The impact of ankle radiographs on the diagnosis and management of acute ankle injuries

RATIONALE AND OBJECTIVES

We assessed the impact of ankle radiographs on referring physicians' diagnoses and treatment of acute ankle injuries.

METHODS

Twenty emergency department physicians prospectively completed questionnaires before and after radiography on 101 patients with acute trauma receiving ankle radiographs. The questionnaires asked physicians to estimate the probability (0-100%) of their most likely diagnosis before and after receiving the radiographic information. We also asked their anticipated and final treatment plans. We calculated the mean gain in diagnostic confidence percentage and the proportion of patients with changed initial diagnoses or anticipated management.

RESULTS

The mean gain in diagnostic certainty from ankle radiographs was 34% (95% confidence interval [CI] = 28-40%). Ankle radiographs changed physicians' initial diagnoses in 37% (95% CI = 28-47%) of the patients. Immediate clinical management changed in 30% (95% CI = 22-40%) of the patients.

CONCLUSION

Plain ankle radiographs have considerable impact on referring physicians' diagnoses and treatment of acute ankle trauma.