Clinical Study On X-Ray Examination During Acute Ankle Injuries

Background1. Acute ankle injuries are common and frequently occurring musculoskeletal illness. Ankle joint is a bearing weight joint which both stable and flexible. The major bearing weight function of ankle is mainly based on the rotation of plantar flexion and dorsiflexion along the medial-lateral Cartesian axis. The ankle bears whole boby weight when people stand, and even5times when walk;the joint surface areas smaller than that of hip and knee. The ankle is the hub which connects the body and ground to convert vertical load to flat. we can stand、walk、 run and perform other daily activities thanks for the normal function of ankle. Being of frequently used during daily life’s makes the ankle to be one of the most easily injured joints.At present, there is no study of epidemiology and clinical epidemiology of population about acute ankle injuries in our country. It is reported that the overall sprain incidence was7.00/1000person-years in Denmark. During the USA general population, the incidence rate is2.15per1000person-years.the overall IR is58.4per1000person-years in the athletic populations, and34.95/1000person years among active-duty members of the US armed services. A history of ankle injuries in the previous2years increased ankle injuries rates by93%to160%and also was the major reason (15.6%) for chronic musculoskeletal ankle disorders which can limit or change patient’s physical activity. The ankle is fractured more often in young men and older women. There has been a significant increase in the incidence and severity of ankle fractures in the elderly population in the last few decades. Ankle fractures accounts for3.9%of whole body fracture,9%of all fractures in adults. Ankle fractures occurred with an overall incidence of187per100000person-years in Minnesota, while107fractures per10(5) person-years. Below the age of50,fractures were commonest in men, aged at45±19,After this age, female became predominant, aged at58±18years.Acute ankle injuries treated incorrectly will affect the rehabilitation, even reoccur frequently or traumatic arthritis. A history of ankle injury is known to be associated with an increased risk of future injuries, also as a risk factor for new injuries among u-16players, can increased ankle injuries rates by93%to160%.Ankle injury reoccur was highly associated with previous treatment. Earlier treatment could minimize secondary joint damage.Doctor should pay attention to ankle injuries early diagnosis and treatment.Early diagnosis, especially right diagnosis is a critical factor for prognosis. Shooting X-ray film is routine for the diagnosis of trauma. Doctors may ask more than95%of patients (even those who had no needs) with ankle injuries to do radiographic examinations. Outcome show ankle fractures about15%.Overuse of X-Ray not only violate the rules of medical imaging but also waste the limited medical resources, what’s more increased the X-Ray exposure.Luckly, the scholar Stiell had developed clinical decision rules for the use of radiography in acute ankle injuries. According to literatures the rule of high value in clinical practices, for better use the rule in china where it is difficult and expensive for patients to see the doctor, this research try to verify the usefulness of the rule.2. X-Ray examinations play a critical role in the diagnosis and follow-up of trauma. For get much more information from X-Ray images; we need to analysis the anatomy relationship. During clinical practices, we often met the diagnosis as "medial gap seems widened", this judgment (entirely subjective judgment) rely on visual of the clinician, it is difficult to make accurate judgements.Literatures have reported the measurement of images anatomy parameter, but the result inconsistent, and no report about distance between the medial-lateral malleolar tip and the medial gap on a horizontal line based on medial malleolar tip. Reconstruction anatomically, especially the normal length of fibular and position of talus has become a consensus at present. To measure the position parameter as a supplement seems of high value in illustrating the importance of X-Ray images.Objective1. To examine the usefulness of the Ottawa ankle rule in deciding those patients presenting with acute ankle injuries who need to further take X-Ray examination.2. To measure the position parameters in X-Ray images of normal adult ankles on PACS workstation as a supplement of literatures, provide data for get much more information from X-Ray images; illustrate the critical role of X-Ray in acute ankle injuries.Methods1Methods of Clinical research1.1Source of patient:From May,2011to April,2012, a total of185cases of adult patients who presenting with acute ankle injuries coming to see doctors in Guangzhou Orthopedics Trauma Hospital were collected.1.2Diagnostic criteria(1) A history of acute ankle injuries.(2)there are pain、local swelling、bruising and limp of the ankle.(3)local obvious tenderness, version/inversion makes much more pain of medial/lateral malleolus.(4) Be certain of no ligaments completely rupture.1.3Inclusion criteria patients with inclusion criteria (five are available)(1)meet the above diagnostic criterias.(2)Aged18years or above.(3)the time between injuries and in clinic lasted no more than48hours.(4) have not been in any clinics.(5) sign in the ICF(informed consent forms) voluntary.1.4Exclusion criteria patient with exclusion criteria (any one)(1)the patient who go to see doctor later than48hours since injuries.(2)the injured ankle have been examined by doctor(s) or X-Ray.(3) Combined with unconsciousness and other serious underlying diseases.(4) Pregnancy women or ready for fertilize in six months.(5) Patient who have not signed the ICF or refuse the doctor(s) professional advices.1.5clinical judgmentsThis is a single-blinded、prospective cohort study. All the eligible patients were examined by two independent doctors according the OAR. Then the patient was order X-Ray in spite of the judgment conclusion as gold standard. Debates were solved by third party. All the participants were followed-up for at least two weeks.1.6collections of imagesAll the injured ankles were fixed in the same self-made stent, then taken anterior-posterior(AP)、lateral(LAT) views by the same500MA TOSHIBA X-Ray machine under the condition of60kv、6MAS、90cm of the projection distance. Images were sent to PAC Station TM3.0, judged by doctor.2Methods of parameters measurementAnterior-posterior images of the40participants who’s ankle no fracture report according to X-Ray、no positive physical examinations were loaded to PACS.A soft-reading method on PACS was employed to measure the parameters. Measurement methods:According to literature, a straight line X paralleled to the superior talar joint line based on the medial malleolus tip was made, the line intersect with medial malleolus、 talus、fibular at the points of A, B、C、D、E. Line Y intersect with lateral malleolus of M perpendicular to the X at the point of N.Dl:the vertical distantance(MN) of bi-malleolus tips;Gl:the medial clear space(AB)distance;D2:the horizontal distance (AE)of medial tip to lateral cortical bone of fibular.T1:the width of fibular (DE)at the line of X.3Statistical methodsWith the application of SPSS13.0Statistical Package for data processing. The enumeration data from clinical research were processed by2X2table’s chi-square test, and calculate ratios; All measurements are recorded as Mean±Standard Deviation. Histograms and Q-Q plots were used to test data normality. Using "men or women","left or right" as the grouping variable, the measurement data were statistically tested with the independent sample t tests. The differences between the two groups were checked whether they were statistically significant. P<0.05, the differences were statistically significant.Result1. Clinical researchThe sensitivity、specificity、positive likelihood ratio、negative likelihood ratio、 positive predictive value、negative predictive value、accuracy of Ottawa ankle rules on deciding ankle injured patients who need to further undergo X-Ray was100%、48.75%、1.96、、0.51、23.36%、100%、55.68%.The positive predictive value of the rule was significant higher than all patients take X-Ray positive value. Can safely reduce the unnecessary radiography by42.2%.2. Measurements of X-Ray In the40images of ankle, D1:the vertical distantance(MN) of bi-malleolus tips were(12.00±3.56)mm;Gl:the medial clear space(AB)distance were(4.79±0.85)mm;D2:the horizontal distance (AE)of medial tip to lateral cortical bone of fibular were (56.86±4.50)mm.T1:the width of fibular (DE)at the line of X were(16.69±2.98)mm.The distribution of the measurement data was almost normality, the95%confidence interval of D1、G1were (10.86～13.14) mm,(4.52～5.06) mm,The95%CI of D2. Tlwere (55.42～58.30) mm.(15.73～17.64) mm.The D1、D2、T1of left was smaller than the right’s, and the D2of female was smaller than male by statistical analysis.Conclusion1. The Ottawa ankle rule was of high safety and efficiency in deciding whether an X-Ray was necessary for an injured ankle.2. The measurements of parameters can provide data for get much more diagnostic information from X-Ray.