Pediatric emergency medicine trisk 0812 0812
Bạn đang xem bản rút gọn của tài liệu. Xem và tải ngay bản đầy đủ của tài liệu tại đây (70.94 KB, 1 trang )
Radiographic Imaging
The Ottawa Ankle Rules (OARs) are used to predict radiographically evident
ankle fractures in adults. The OAR maintain that ankle radiographs are required
only if the patient has pain near the malleoli and one or both of the following: (i)
Inability to bear weight immediately following the injury and in the emergency
department (four steps) and (ii) bone tenderness at the posterior edge or tip of
either malleolus. These rules are 100% sensitive in detecting clinically significant
fractures in adults; pediatric studies caution the use of OARs to predict ankle
fractures in children less than 6 years of age but in older children OARs are
98.5% sensitive and reduce ankle radiography by 24.8%. The Low Risk Ankle
Rule (LRAR) states that radiography may not be indicated to exclude a high-risk
ankle injury (fracture of the foot, distal tibia and fibula proximal to the distal
physis, tibiofibular syndesmosis injury, and ankle dislocations) if tenderness and
swelling is isolated to the distal fibula and/or adjacent lateral ligaments distal to
the tibial anterior joint line. Low-risk ankle injuries include lateral ankle sprains,
nondisplaced S-H type I and II fractures of the distal fibula, and avulsion
fractures of the distal fibula and lateral talus. One study found the LRAR to be
100% sensitive in children of ages 3 to 16 and reduced ankle radiography by
20%.
Radiographic evaluation of the ankle should include at least three views: AP,
lateral, and mortise. If tenderness of the proximal fibula is noted, full-length
views of the fibula are essential. Tenderness at the base of the 5th metatarsal or
midfoot mandates visualization of this area with AP, lateral, and oblique
radiographs of the foot. If radiographic findings are questionable, consider
obtaining comparison views of the noninjured ankle.
Note areas of soft tissue swelling. This may be the only clue to an S-H type I
fracture of the distal fibula. Stress radiographs to evaluate growth plate injuries
are rarely necessary and may cause further damage. Ultrasound may be a useful
adjunct in identifying radiographic occult ankle fractures.
CT scan of the ankle is often necessary to fully evaluate fracture into the joint
space, including triplane, juvenile Tillaux, and S-H type IV fractures. Magnetic
resonance imaging (MRI) of ankle injuries is rarely performed during acute
evaluation but may be useful in evaluating patients in whom one has a high
clinical suspicion of injury despite normal radiographs. MRI may also delineate
suspected tendon and ligament injuries in selected circumstances.
Approach
