title: [Fewer x-rays while maintaining quality of clinical care using clinical protocols for physical diagnosis of ankle injuries].
abstract: OBJECTIVE
  To determine whether it is possible to decrease the number of X-rays in acute ankle injury while keeping the health care constant, using a scoring system.
  
  
  METHODS
  Prospective.
  
  
  METHODS
  Patients presenting in the emergency department of the University Hospital Utrecht (AZU), the Netherlands, over a one-year period of time with acute ankle injuries were subjected to a thorough physical examination based on a scoring system developed at Leiden University Hospital. The score was calculated and X-ray examination was indicated when this score was > or = 8 points. Radiological investigation or telephone interviews six weeks after injury achieved verification of the clinically relevant ankle fractures. Specificity and sensitivity were calculated from every possible cut-off point and drawn in a 'receiver operating characteristics' (ROC) curve.
  
  
  RESULTS
  Of the 514 patients included 81 patients had a score of 8 or higher and 24 of them had a clinically relevant fracture. In 34 patients an ankle X-ray was made although their score was < 8 points. The positive and negative predictive values of the system were 30% (95% confidence interval (95% CI): 20-41) and 99% (95% CI: 97-100) respectively. The score yielded an area under the ROC curve of 91% (95% CI: 84-98). A cut-off point of 8 led to a reduction of X-rays by 60% (using the 'Ottawa ankle rules' the decrease in this population would have been 28%). On the other hand, 5 clinically relevant fractures were missed.
  
  
  CONCLUSIONS
  Radiological examination in patients wit acute ankle complaints was reduced while health care remained almost constant. In the AZU, a decision was made for a major reduction in X-rays while accepting that some fractures would be missed.
authors.affiliation: Bosch Medicentrum, afd. Chirurgie, NL's-Hertogenbosch.
authors.forename: Y E
authors.initials: YE
authors.lastname: van Riet
authors.forename: Y T
authors.initials: YT
authors.lastname: van der Schouw
authors.forename: C
authors.initials: C
authors.lastname: van der Werken
mesh_terms: D000328:Adult; D016512:Ankle Injuries / Q000175:diagnosis* / Q000000981:diagnostic imaging; D016001:Confidence Intervals; D003937:Diagnosis, Differential; D005500:Follow-Up Studies; D050723:Fractures, Bone / Q000175:diagnosis / Q000000981:diagnostic imaging; D006801:Humans; D009426:Netherlands; D010808:Physical Examination / Q000379:methods*; D011446:Prospective Studies; D012372:ROC Curve; D011859:Radiography / Q000706:statistics & numerical data; D012680:Sensitivity and Specificity; D013180:Sprains and Strains / Q000175:diagnosis