Ankle injury manipulation before or after X-ray–Does it ...fedral.com.au/wp-content/uploads/2013/11/Ankle-dislocn-xray.pdf · Many acute, deformed ankle injuries are manipulated

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

This is a PDF file of an unedited manuscript that has been accepted for publication.As a service to our customers we are providing this early version of the manuscript.The manuscript will undergo copyediting, typesetting, and review of the resulting proofbefore it is published in its final form. Please note that during the production processerrors may be discovered which could affect the content, and all legal disclaimers thatapply to the journal pertain.

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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