Session IV Scientific Basis for Fracture Care

The Ankle Radiographic Series: Discard the AP

Lawrence S. Deutsch, MD, Ira D. Gelb, MD, Francisco Noda, MD

Cooper Hospital / UMC, Camden, NJ

Introduction: Ankle fractures are extremely common and management is often dictated by radiographic assessment. Currently, the standard radiographic views for ankle trauma are the AP, lateral and mortise. The authors hypothesize that the lateral and mortise views alone are sufficient for diagnosis and treatment of ankle fractures.

Methods: One hundred sets of films were selected randomly from a computer generated list for ankle fractures treated at our institutions. Only series containing adequate AP, lateral and mortise views in skeletally mature patients were included. The films were reviewed independently by two orthopaedic surgeons and were evaluated for diagnosis and operative vs. non-operative treatment plan. Each physician reviewed the films once with the mortise and lateral views and a second time with all three views. Management was based upon currently accepted radiographic criteria for operative intervention.

Results: Each physician arrived at the same diagnosis and treatment plan for the two view Vs three view series in 99 out of 100 cases. No fractures seen on the three view series were missed on the two view series although certain fractures were more obvious on the AP than the mortise view. Physician A changed his diagnosis from isolated lateral malleolus fracture to lateral malleolus fracture and associated medial ligament rupture and his treatment plan from non-operative to operative in one patient. Physician B had the same change in a different patient.

Discussion and Conclusion: In the current cost conscious health care environment, there is a need to eliminate unnecessary tests. In this study, the lateral and mortise views alone provided sufficient information for diagnosis and treatment in 99% of the ankle fractures as compared to the traditional three view series. The two changes in treatment plan were secondary to medial ligamentous injury that would have been discovered on physical examination. At our institutions, the average cost of a two view series is $20 less than a three view series. Based on 1980 statistics, we estimate 3.6 million ankle series are performed annually in the United States projecting an estimated savings of an astounding 77 million dollars by eliminating a single view in each series. Thus, we recommend that, for routine ankle trauma, the standard three view ankle be replaced by the mortise and lateral views alone. The exception to this may be to further evaluate a lateral malleolus fracture with medial tenderness when non-operative treatment is considered.