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Revisiting the humble ankle sprain
  1. David Metcalfe1,2,
  2. Sarah Lancaster3,
  3. David Keene1,4
  1. 1 Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK
  2. 2 Emergency Medicine Research in Oxford (EMROx), John Radcliffe Hospital, Oxford, UK
  3. 3 Trauma Service, John Radcliffe Hospital, Oxford, UK
  4. 4 Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
  1. Correspondence to Dr David Metcalfe, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford OX3 9DU, Oxfordshire, UK; david.metcalfe{at}

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Ankle injuries are one of the most common presentations to the Emergency Department (ED), but few emergency physicians would consider them to represent a diagnostic challenge. In our armoury, we already have the Ottawa ankle rules (which are highly sensitive for bony injury) and access to plain radiographs. However, Deutekom et al present a systematic review of studies evaluating the diagnostic accuracy of ultrasound for ankle injuries.1 Why should we consider another diagnostic modality for such a straightforward injury?

There are three good reasons. First, plain radiographs do not detect all fractures around the ankle. Allen et al recruited 100 patients with ankle injuries that had normal radiographs despite fulfilling the Ottawa ankle rules.2 These patients all underwent CT and ultrasound imaging, which revealed 19 important fractures (lateral malleolus, posterior malleolus, calcaneus, cuboid and talus) and 43 avulsion fractures. Second, over-reliance on plain radiographs risks missing soft tissue injuries requiring specific orthopaedic management, such as peroneal tendon dislocation and syndesmotic rupture. Finally, plain radiographs centre the diagnostic process on identifying fractures, which may lead to undertreatment of …

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  • Contributors DM drafted the article with contributions from SL and DK. All authors approved the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests DM was the Emergency Medicine Journal decision editor that handled the manuscript under discussion.

  • Provenance and peer review Commissioned; internally peer reviewed.

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