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Accuracy of ultrasound in diagnosing ankle injuries in emergency care
  1. Fenna E Deutekom1,2,
  2. Milan L Ridderikhof2,
  3. Faridi Van Etten-Jamaludin3,
  4. Tim Schepers4
  1. 1 Faculty of medicine, University of Amsterdam, Amsterdam, The Netherlands
  2. 2 Emergency Medicine, Amsterdam UMC—Locatie AMC, Amsterdam, The Netherlands
  3. 3 Clinical Library, Amsterdam UMC—Locatie AMC, Amsterdam, The Netherlands
  4. 4 Trauma Surgery, Amsterdam UMC—Locatie AMC, Amsterdam, The Netherlands
  1. Correspondence to Fenna E Deutekom, University of Amsterdam, Amsterdam, 1012, The Netherlands; f.e.deutekom{at}


Background Ankle injuries are one of the most common presentations in the ED. Although fractures can be ruled out using the Ottawa Ankle Rules, the specificity is low, which means many patients may still receive unnecessary radiographs. Even once fractures are ruled out, assessment of ankle stability is recommended to rule out ruptures, but the anterior drawer test has only moderate sensitivity and low specificity and should be performed only after swelling has receded. Ultrasound could be a reliable, cheap and radiation free alternative to diagnose fractures and ligamentous injuries. The purpose of this systematic review was to investigate the accuracy of ultrasound in diagnosing ankle injuries.

Methods Medline, Embase and the Cochrane Library were searched up to 15 February 2022 to include studies of patients of 16 years or older presenting to the ED with acute ankle or foot injury, who underwent ultrasound and had diagnostic accuracy as outcome. No restrictions were applied for date and language. Risk of bias and quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluations approach were assessed.

Results Thirteen studies evaluating 1455 patients with bony injuries were included. In 10 studies, the reported sensitivity for fracture was >90%, but varied among studies between 76% (95% CI 63% to 86%) and 100% (95% CI 29% to 100%). In nine studies, the reported specificity was at least 91%, but varied between 85% (95% CI 74% to 92%) and 100% (95% CI 88% to 100%).

Six studies including 337 patients examined the use of ultrasound for ligamentous injuries and found a sensitivity and specificity >94% and 100%. Overall quality of evidence for both bony and ligamentous injuries was low and very low.

Conclusion Ultrasound has the potential to be a reliable method for diagnosing foot and ankle injuries, however, higher grade evidence is needed.

PROSPERO registration number CRD42020215258.

  • emergency department
  • ultrasonography
  • extremity
  • soft tissue injuries
  • fractures

Data availability statement

Data are available in a public, open access repository.

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Data availability statement

Data are available in a public, open access repository.

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  • Handling editor David Metcalfe

  • Contributors FED planned the study, extracted the data, served as main writer of the study and submitted the manuscript. MLR extracted the data, served as writer of the manuscript and critically reviewed the data extraction process and content of the manuscript. FVE-J conducted the search. TS conceived the study, critically revised the manuscript and was responsible for the overall content as guarantor.

  • 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 None declared.

  • Patient and public involvement statement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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