The injured ankle and foot

Diagnostic dilemma

Injuries to the ankle and mid-foot are commonly seen in primary care and hospital emergency departments. Only 15% of these are fractures,1 and the diagnostic dilemma for the clinician is thus to identify patients with such fractures, as these require plaster immobilisation or referral to an orthopaedic specialist. Most other injuries are treated for ligamentous stretch or disruption with dynamic stabilisation, rest, and physical therapy.

In the past, the decision making process for ankle and mid-foot injuries involved subjective elements of the history and physical examination, followed almost always by an x ray, a process that is potentially harmful and wasteful. Historical clues included asking patients whether they heard a pop at the time of injury and were able to walk after the injury. Examination findings suggesting fracture were the presence of swelling, ecchymoses, stability when the ankle or mid-foot was moved, and ability to dorsiflex or plantar flex against resistance. However, such clinical findings were found to be unreliable, with poor inter-rater reliability.2

Thus clinicians need a more accurate method to identify high risk …