why do that x-ray?

Monday, April 25, 2011

The difference between doctors who look after mere mortals and those who look after elite athletes may have to do with how many tests they can order, regardless of the cost. And when x-ray and MRI reports lead the news, it makes it harder for family doctors to explain why those tests aren’t necessarily appropriate. Yet hope may be on the horizon with the tale of two injured basketball stars.

Chicago Bull Derrick Rose sprained his ankle in a playoff game but was able to hobble off the court. Within 24 hours, he had the joint x-rayed followed by an MRI. Laker Kobe Bryant sprained his ankle in his playoff game and he, too, was able to hobble off the court. However, he elected to forgo any tests over the objection of his coach. Was the use of technology to prove Rose’s sprained ankle appropriate or could the low tech physical exam approach taken by Bryant be as successful.

Ankle sprains are common injuries and historically, patients expected that they would show up in the ER or at their doctor’s office, get an x-ray to prove there were no broken bones and then be on their way. As it turns out, the vast majority of those ankle x-rays were normal and in retrospect could be seen as expensive, wasteful and another opportunity to expose a patient to unneeded radiation. Ian Stiell and his colleagues in Ottawa, Canada proved that the practice was wasteful since less than 15% of those ankle x-rays were positive for a fracture. The rules that they developed are able to guide who needs an ankle x-ray and who doesn’t.

And here are the rules. X-rays are only needed for the following:
• Tenderness over the tip of the lateral malleolus (the fibula bone on the outside of the ankle) and the last 2.5 inches of the bone
• Tenderness of the tip of the medial malleolus( the tibia bone on the inside of the ankle) and the last 2.5 inches of the bone
• Tenderness over the navicular, a bone in the instep, or of the fifth metatarsal base, the bony prominence on the outside of the foot
• Inability to weight bear for 4 steps immediately or in the ER/office

Just because an ankle isn’t broken doesn’t mean that no injury has occurred. An ankle sprain means that the ligaments that keep the ankle stable have been stretched or torn. Treatment includes RICE (rest, Ice, elevation and compression) and anti-inflammatories like ibuprofen or naproxen. Ace bandages help with compression and aircasts or active ankle brace, worn inside the shoe may help with ankle support. Crutches may be used for walking support. Depending upon the degree of injury, physical therapy may be helpful in getting the ankle back to normal.

For a few days, doctors will be able to tell their patients that clinical judgment is alive and well. Kobe Bryant is testament to the fact that high tech path taken by Derrick Rose isn’t always the key to diagnosis, treatment and recovery. Let’s hope that Bryant’s ankle read the textbook and will heal nicely to prove our point.

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