Painful Ankles...to X-Ray or NOT?

Image: http://www.bmj.com/content/326/7386/417

This month I am talking a bit about bone fractures and x-rays. As we try to "do no harm" in medicine, leading physician groups have been taking a closer look at procedures that have become automatic, and determine whether or not they are medically necessary- do they IMPROVE outcomes? One such procedure involves imaging ankle injuries. Both clinicians and patients often expect that a painful joint needs an x-ray as part of a thorough evaluation. When SHOULD we order an x-ray for a painful ankle? Current evidence suggests the answer to that question- at least for adults- lies in the "Ottawa Rules", a guideline to help clinicians decide whether or not a fracture is truly likely, and therefore, whether or not to order an x-ray.

First, questions for the patient:
When the injury happened- could you bear weight immediately? 
Could you bear weight when you reached the medical facility? 
                     If the answer to both of these is YES- you could definitely bear weight and walk on the ankle- it is less likely to be fractured.

Then, questions for the doctor as she examines your ankle: 
Is there pain at the bottom, back edge of your ankle bones, both on the inside and the outside? (in medical terms, the distal 6 cm, posterior edge or tip of the lateral or medial malleolus).
Is there tenderness at two different spots on your foot (the navicular and 5th metatarsal bones)? 

The majority of ankle injuries are sprains, not fractures, which involves the ligaments attaching the bones to each other- not the bones themselves. As such, x-rays will not "show" ankle sprains- they are diagnosed by clinical exam. Ankle sprains can be very serious injuries that require splinting or even casting, but they do NOT necessarily require imaging with x-rays.

BOTTOM LINE: Not all ankle injuries need to be x-rayed; an open conversation with your physician about utilizing the Ottawa Rules may save you some unnecessary radiation and expense. 

Do I Need An X-Ray?

Image: B. Rushing

When you hurt your back (or ankle, or wrist) and head to the doctor, should you expect an x-ray? In my last post, I mentioned that the only way to be certain whether or not a bone is broken is with imaging, and that is true. However, not every painful joint NEEDS to be x-rayed. I find that many patients are surprised or disappointed if I do not insist on an x-ray for an acute injury, but they are simply not always necessary, and radiation is not without harm.

XRAYS look at bones. They do not "see" cartilage, muscles, tendons or ligaments, though sometimes distance between bones suggests lack of cartilage. The vast majority of injuries that send patients to their doctors are not from broken bones, but strains and sprains and spasms of muscles and supporting tissue.  (As a quick aside,  a SPRAIN happens to ligaments, the tissue that attaches bone to bone. A STRAIN occurs in muscles or tendons (tissue connecting muscles to bones.)

As we try to limit both unnecessary radiation and expense, the world of medicine is taking a closer look at when interventions such as taking x-rays are really needed to improve patient outcomes. Medical centers are developing guidelines for different injuries that help physicians determine when an xray is truly needed, such as the Ottowa rules for ankle injuries. Stay tuned for more on those rules in my next post.)

RICE: Rest, Ice, Compression and Elevation (plus a bit of pain-reliever/anti-inflammatory medicine such as ibuprofen) go a long way towards treating injuries. Your doctor can show you the best way to compression wrap an extremity, plus possibly prescribe muscle relaxants or stronger anti-inflammatory medicine. Perhaps most importantly, your doctor may prescribe PHYSICAL THERAPY- where you will learn strengthening, flexibility and stability for your injury to fully rehab.

BOTTOM LINE: XRAYS are helpful diagnostic tools for bone injury, but don't assume your treatment of an injury isn't complete without one!

Spring Break: Alcohol 411

Spring Break is nearly here, and students everywhere are gearing up for a week-long party. Alcohol is often a large part of these festivities, so I think this is a great time to review some facts about alcohol dangers. In recent years, studies show that about a third of college students admit to binge drinking (consuming 5 or more drinks in a row.) The good news is that this number is down over 15% from over the last two decades, and actually, drinking trends in ALL categories are decreasing- whether the measurement is annual consumption, monthly, weekly or number of binging episodes. A great website to educate yourself (or your favorite college student) is  http://www.b4udrink.org/statistics - complete with a virtual bar where you can enter in your gender, age and weight, and then "pour" yourself drinks and watch your blood alcohol levels rise...

Another wonderfully informative program/website is Aware Awake Alive. Check out their table with drinks/blood alcohol concentrations, and SHARE THIS WITH YOUR FRIENDS. Ultimately, know that if you have a THIRD drink, you are most likely legally drunk. AND, please note, this is a third drink measured by the book (not a "college pour" of alcohol into a plastic red cup- those cups hold several servings in just one glass). The biggest mistake friends make is leaving their intoxicated friends alone to "sleep it off".  If someone has "passed out," they NEED supervision. The alcohol level in their bloodstream will continue to rise, which can cause them to either vomit (and potentially choke, because their gag reflex is dulled by the alcohol) or to stop breathing. If their breathing is less than 8 breaths/minute, CALL 911 immediately.

Pain killers often find their way to spring break as well, whether that is courtesy of a knee injury skiing, or simply part of someone's personal medicine cabinet. Please take note: Pain Killers (narcotics- think codeine or vicodin) + ALCOHOL= DEATH. This combination accounts for far too many accidental suicides per year- don't do it.

BOTTOM LINE: Enjoy spring break, but if your festivities include alcohol, make sure you know your limit AND know exactly what to do if one of your friends drinks too much.