Should pre-manipulation radiographs be obtained in ankle fracture-dislocations?

BACKGROUND: Should pre-manipulation radiographs be obtained in ankle fracture-dislocations? This question remains controversial. The twelfth British Orthopaedic Association Standard for Trauma (BOAST-12) published in August 2016 states that 'Reduction and splinting should be performed urgently for clinically deformed ankles. Radiographs should be obtained before reduction unless this will cause an unacceptable delay'.2 We quantify the delay caused by obtaining a pre-manipulation radiograph, and additionally determine whether a pre-manipulation radiograph influences the adequacy of initial reduction.

METHOD: Radiographs of consecutive adult ankle fractures that underwent open reduction and internal fixation (ORIF) in a major trauma unit over a 12 months period were reviewed. Patients were divided into three groups. Group A -- pre-manipulation but post radiograph frankly displaced ankle fractures not in a cast. Group B - post manipulation ankle fractures in a cast without prior radiograph, and group C -- minimally displaced ankle fractures not in a cast. Data was collected on age, gender, fracture pattern, time and mode of arrival to the ED. Further analysis was undertaken on groups A & B. Delay to, and adequacy of, reduction were recorded. Quality of surgical reduction and fixation was assessed. Cases of post-operative wound infection were identified and analysed. Mid-term patient reported outcome measures (PROMS) at a minimum of 21 months after surgery were recorded.

RESULTS: There were 62 patients in group A and 51 in group B. Obtaining a radiograph prior to manipulation resulted in a mean delay of 71 minutes from time of arrival to a radiograph being taken that confirmed a reduced ankle mortice. Taking a pre-manipulation radiograph did not increase the chances of a successful reduction at the first attempt. There was a trend towards better PROMS in patients who underwent early reduction in the ED.

CONCLUSION: The time taken to achieve a reduced ankle mortise was significantly longer for patients who had a radiograph before manipulation with the potential for exacerbating soft tissue trauma. A pre-plaster radiograph made no difference to the chances of a successful initial attempt at fracture manipulation.

LEVEL OF EVIDENCE: Level 3: Retrospective Comparative Study.