title: Relevance of adjacent joint imaging in the evaluation of ankle fractures.
abstract: BACKGROUND
  Routinely obtaining adjacent joint radiographs when evaluating patients with ankle fractures may be of limited clinical utility and an unnecessary burden, particularly in the absence of clinical suspicion for concomitant injuries.
  
  
  METHODS
  One thousand, three hundred and seventy patients who sustained ankle fractures over a 5-year period presenting to two level 1 trauma centers were identified. Medical records were retrospectively reviewed for demographics, physical examination findings, and radiographic information. Analyses included descriptive statistics along with sensitivity and predictive value calculations for the presence of adjacent joint fracture.
  
  
  RESULTS
  Adjacent joint imaging (n=1045 radiographs) of either the knee or foot was obtained in 873 patients (63.7%). Of those, 75/761 patients (9.9%) demonstrated additional fractures proximal to the ankle joint, most commonly of the proximal fibula. Twenty-two of 284 (7.7%) demonstrated additional fractures distal to the ankle joint, most commonly of the metatarsals. Tenderness to palpation demonstrated sensitivities of 0.92 and 0.77 and positive predictive values of 0.94 and 0.89 for the presence of proximal and distal fractures, respectively. Additionally, 19/22 (86.4%) of patients sustaining foot fractures had their injury detectable on initial ankle X-rays. Overall, only 5.5% (75/1370) of patients sustained fractures proximal to the ankle and only 0.2% (3/1370) of patients had additional foot fractures not evident on initial ankle X-rays.
  
  
  CONCLUSIONS
  The addition of adjacent joint imaging for the evaluation of patients sustaining ankle fractures is low yield. As such, patient history, physical examination, and clinical suspicion should direct the need for additional X-rays.
  
  
  METHODS
  Level IV.
authors.affiliation: Department of Orthopaedic Surgery, Brown University, Providence, RI, United States.
authors.forename: Valentin
authors.initials: V
authors.lastname: Antoci
authors.affiliation: Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, United States. Electronic address: shaun.p.patel@gmail.com.
authors.forename: Shaun P
authors.initials: SP
authors.lastname: Patel
authors.affiliation: Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, United States.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Weaver
authors.affiliation: Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, United States.
authors.forename: John Y
authors.initials: JY
authors.lastname: Kwon
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016512:Ankle Injuries / Q000000981:diagnostic imaging* / Q000191:economics; D003661:Decision Support Techniques; D005260:Female; D050723:Fractures, Bone / Q000000981:diagnostic imaging* / Q000191:economics; D006801:Humans; D008297:Male; D008875:Middle Aged; D010808:Physical Examination; D011859:Radiography / Q000191:economics / Q000706:statistics & numerical data*; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D014193:Trauma Centers / Q000191:economics*; D015599:Trauma Severity Indices; D014481:United States; D019564:Unnecessary Procedures / Q000191:economics*; D055815:Young Adult
keywords: Ankle fracture; Radiography; Trauma; Utilization; X-Ray