RESEARCH PAPER

Does Patient’s Self-Awareness Predict Ankle
Fractures?

Shaza Aouthmany a Tymon Horn a Mahesh R. Pillai b Edward J. Kakish c Alana M. Kakish d

Coresponding author(s): shaza.aouthmany@utoledo.edu

aDepartment of Emergency Medicine, University of Toledo Medical Center, Toledo, OH 43614, USA,bHuman Research Protection Program, University of Toledo
Medical Center, Toledo, OH 43614, USA,cEmergency Departmen, John D. Dingell VA Medical Center, Detroit MI 48201, USA, and dMichigan State University, East
Lansing MI 48824, USA

Introduction: Ankle injuries represent one of the most com-
mon sports and extremity related complaints presented in emer-
gency departments (ED) with over five million ankle injuries an-
nually arising in the United States. The 2007 US National Health
Statistics Report stated that lower limb and ankle complaints ac-
counted for 4.1% of all reported body sites undergoing injury in
the ED. The purpose of this study was to examine how frequently
a sample of ED patients’ perception of having a possible ankle
fracture was predictively associated with results of their X-ray
evaluation results. Methods: After 2017 IRB approval, a sample
of consented adult patients receiving care at the authors’ two
Ohio and Michigan ED were asked, "Do you think you broke your
ankle?" Regardless of each patient’s answer, they received an
X-ray to evaluate for an ankle fracture that was interpreted by a
radiologist. Results: A total of 69 eligible patients received an
ankle X-ray. The total number of ankle fractures confirmed by X-
ray was 20 (29.4% of sample) while 48 (70.5%) of ankles that were
X-rayed were not fractured. Six (28.5%) out of 21 males and 14
(30.4%) out of 46 females were found to have a confirmed ankle
fracture. The sensitivity of the perceived ankle fracture question
was at or below 50% in all sample subgroups except for smokers
at 67%. Conclusion: These findings support the importance of
an ED clinician’s intuition when considering a patient’s own self-
assessment during their clinical decision-making processes

Ankle injuries represent one of the most common sports andextremity related complaints presented in emergency depart-
ments (ED), with over five million ankle injuries arising annually in
the United States (1,2). The 2007 US National Health Statistics Re-
port stated that lower limb and ankle complaints accounted for 4.1%
of all reported body sites incurring injury in ED (3). The incidence

of ankle injuries presenting in other clinic and athletic settings (4).

Although many such injuries of the ankle and foot (includes lig-
ament and tendon impairment, forms of impingement, lesions, and
stress-related fractures) can result from overuse behaviors, the need
for imaging continues to a key avenue to ankle injury management
(5). The criteria for ordering ankle X-ray is a topic that warrants
further conversation (6). The Ottawa ankle rules have become com-
monplace practice for ankle injury management, providing a widely
validated framework for use by healthcare professionals (7,8). Col-
lectively, the rules account for a patient’s pain locale and weight
bearing capability of the injured ankle immediately following in-
jury in an ED. The original Ottawa ankle study findings have been
validated in large, multi-center studies (9).

Other types of clinical rules, with a sensitivity of 100% and a
specificity of 36% for patients with recent ankle injuries can help
determine which ankle injuries warrant X-ray imaging to rule out
ankle fracture (10). Unfortunately, alternative methods have not
provided comparable observations between patients and clinicians,
and teaching the clinical rules to patients has not proven effective in
reducing ED visit frequency (7).

The healthcare burden of undergoing an X-ray for an ankle in-
jury has remained a discussion point, with the risk and benefit anal-
ysis visited during management (11). With rising healthcare costs,
limiting unnecessary radiographic studies is one way to decrease

Submitted: 08/06/2020, published: 20/01/2021.

Freely available online through the UTJMS open access option

18–22 UTJMS 2020 Vol. 8 translation@utoledo.edu

mailto:shaza.aouthmany@utoledo.edu

healthcare provision costs.

Although the conservative approach is to X-ray the injured an-
kle, it has been shown that less than 15% of all ankle injuries have
actually resulted in a fracture confirmed by X-ray (12). The risk
of radiation exposure also must be weighed in the decision-making
process (13).

The radiation exposure from a combined anterior-posterior and
lateral ankle X-ray is 0.0015 mSv (13). To put this into perspec-
tive, the average person in the US is annually exposed to 3.0 mSv
of background radiation (14). There is epidemiological evidence
to show that acute exposure to greater than 10-50 mSv of radi-
ation increases risk of some cancers (15). However, researchers
have had difficulty quantifying cancer risks to acute exposures less
than 10mSV, which does not necessarily imply that these very small
doses of radiation are negligible.

Even if there are relatively minor cancer risks imposed from
imaging, this can result in a significant public health concern sec-
ondary to the frequency and overall quantity of X-ray imaging (16).

Purpose of Study The purpose of this study was to examine
the potential benefit a pa-tient’s perception can have on health-
care providers’ decision whether patients require X-rays and which
types of patients should just be clinically observed. This study team
wished to correlate the utility of X-ray evaluation based on patients’
perspectives of ankle fracture using a prospective non-randomized
cross-sectional descriptive study design. The null hypothesis of the
authors was that patient perceptions of ankle fracture would have
no significant relationship on X-ray decision-making processes of
sample ED providers.

Materials and Methods

After obtaining 2017 IRB approval, data were collected from an
adult patient sample of participants obtaining ED workup for pos-
sible ankle fracture at the ED of the University of Toledo Medical
Center in Toledo, OH and St. Mary Mercy Hospital in Livonia, MI.
Sampling exclusion criteria consisted of the following: any other
distracting injury, inability to answer the question posed, any pa-
tient who had not undergone a radiographic evaluation for their an-
kle complaint, any non-English speaker, pregnant women and pris-
oners.

Patients who presented to the ED with an ankle injury com-
plaint were first asked if they would like to participate in a study that
involved answering one simple question. If they agreed, they were
presented with an IRB-approved informed consent form to sign. Af-
ter consent was obtained, a researcher (i.e., attending physician or
resident) asked the pa-tient "Do you think you broke your ankle?"
No data were obtained for any patient who could not complete this
process. Regardless of the answer, the patient received an X-ray to
look for an ankle fracture based on the clinician’s decision-making
process.

After the X-ray was obtained and interpreted by a radiologist,
the diagnosis of ankle fracture or no ankle fracture was compared to
the patient’s original verbal answer. The radiologist’s interpretation
of the X-ray was observed as the gold standard for diagnos-ing an-
kle fractures. The research team later populated a paper data sheet
form the chart with the patient’s response and demographic infor-
mation.

The sources of data were from the patient directly or the med-
ical records. Participants were randomly assigned a study number,

which protected their confidentiality. All data were maintained on
a secured drive and only members of the study team, the Principal
Investigator (PI Edward Kakish), co-investigators and the associates
on the team had access to study data. The PI and research coordi-
nator trained all of the chart abstractors in the proper protocol for
medical record data abstraction. Data concerning the fol-lowing
variables were collected: gender, race, smoking status, ambulatory
status and pain score.

Results

A total of 69 patients who met inclusion criteria provided in-
formed consent. Of the 69 patients evaluated, 47 (68.1%) were
female, 21 (30.4%) were male with one (1.4%) patient’s sex not
obtained (Table 1). Only 46 females were included in the analysis
as the X-ray result of one patient was not recorded.

The total number of ankle fractures confirmed by X-ray was 20
(29.4%) while 48 (70.5%) of ankles that underwent an X-ray were
not fractured (Table 1). The total number of males who fractured
their ankle was six (28.5%) out of 21 total who underwent X-ray
(Table 1). The total number of females who fractured their ankle
was 14 (30.4%) out of 46 total who underwent X-ray. (Table 1).
The one sample patient whose sex was not recorded was not found
to have fractured their ankle.

The racial affiliation and demographic characteristics of sample
patients were as follows: 35 (50 %) of white descent, five (7 %) of
African American descent, seven (10 %) were either unknown or
declined to answer and the remaining 22 (32%) participants were of
Hispanic or Asian descent.

The predictive performance of the initial question, "Do you
think you broke your ankle?" was evaluated as a screening measure,
with the radiologist’s interpretation of the ankle X-ray observed as
the gold standard for diagnosing ankle fractures. The sensitivity of
the question was at or below 50% in all sample subgroups with the
exception of smokers at 67%. (Table 2). The specificity of all pa-
tients was 67%, which increased to 79% in patients who were able
to ambulate without assistance. (Table 2).

Overall, the positive predictive value (PPV) of the question
posed was 30% while the false discovery rate (FDR) was 70% (Ta-
ble 3). The negative predictive value (NPV) of the question passed
was 71% while the false omission rate (FOR) was 29%. (Table 3).
The female and male patient statistics were separated to elucidate
any potential discrepancies between the sexes. In total, of the 45 fe-
males included, the PPV was 31% while the FDR was 69%. (Table
3).Of those females who answered "No", the NPV was 70% while
the false omission rate (FOR) was 30%. (Table 3). Of the 21 total
male participants included, the PPV was 33% while the FDR was
67% (Table 3). Of those men who answered "No", the NPV was
73% and the FOR was 27%. (Table 3).

In addition to stratifying patient data by gender, Table 3 includes
the following terms: smoking status and ambulatory status. Smok-
ers and non-smokers had a PPV of 33% and 29% respectively and
the NPV was 67% and 73% respectively. (Table 3.) A total of 22
patients were non-ambulatory in the ED with a PPV of 55% and a
NPV of 46%. (Table 3). Furthermore, a total of 27 patients were
ambulatory without assistance in the ED. The PPV and NPV of this
ambulatory sample subgroup was 17% and 91% respectively (Table
3).

Aouthmany et al. UTJMS 2020 Vol. 8 19

Table 1. Patient X-ray Results

All Patients Male Female Unknown Sex

Fracture 20 (29.4%) 6 (28.5%) 14 (30.4%) 0 (0%)
No fracture 48 (70.5%) 15 (71.5%) 32 (69.6%) 1

Total Evaluated by X-ray 68 21 46 1

Table 2. Sensitivity and Specificity of Question "Do you think you broke your ankle?" as a screening test

All Male Female Smokers Nonmokers No Ambulation Ambulation
Patients ambulation with assistance without assistance

Sensitivity 35% 33% 36% 67% 27% 50% 0% 33
Specificity 67% 73% 66% 33% 74% 50% 62% 79%

Table 3. Table 3. Patient Accuracy When Responding Yes or No to the Question Do you think you broke your ankle?

All Male Female Smokers Nonmokers No Ambulation Ambulation
Patients ambulation with assistance without assistance

PPV 30% 33% 31% 33% 29% 55% 0% 17%
FDR 70% 67% 69% 67% 71% 46% 100% 83%
NPV 71% 73% 70% 67% 73% 46% 62% 90%
FOR 29% 27% 30% 33% 28% 55% 39% 10

PPV =

Positive Predictive Value, FDR = False Detection Rate, NPV = Negative Predictive Value, FOR = False Omission Rate

20 translation@utoledo.edu Aouthmany et al.

Table 4. Pain score mean in patients with and without ankle fracture

Pain Score 95% Confidence
(1-10) Intrval

Fracture 6.5 5.2 - 7.7
No fracture 6.9 6.2 - 7.7

A 10-point pain scale was also administered to patients with 1
being \no pain" and 10 being the \worst pain ever". The mean pain
score for those who fractured their ankle was 6.5 (95% CI 5.2-7.7)
while the mean pain score for those who did not fracture their ankle
was 6.9 (95% CI 6.2-7.7). (Table 4).

Discussion

Ankle injuries are among the most common patient complaints
in the ED settings (1). This study aimed to examine the predictive
association of patients’ perceptions of a possible ankle fracture. Pa-
tients were asked, \Do you think you broke your ankle?", and their
answers were compared to their final ankle X-ray results verified by
a radiologist. Descriptive analyses were performed to investigate
how often a sample patients’ answers matched imaging results dur-
ing their clinical evaluations.

The sensitivity of the screening question "Do you think you
broke your ankle?" was generally low and was less than or equal
to 50% among all groups except smokers (67%). The question’s
low sensitivity demonstrates that it was a relatively poor screen-
ing measure to rule out an ankle fracture. However, its specificity
was greater among most groups and highest among patients who
were ambulatory without assistance (79%), non-smokers (74%),
and males (73%). Therefore, this screening question’s higher speci-
ficity demonstrates it could be somewhat helpful for to ruling ankle
fractures, particularly among ED patients who are ambulatory with-
out assistance.

Based on the low demonstrated PPV (30%), patients’ percep-
tions of their possible an-kle fracture was not generally reliable and
most patients (i.e, 70%) incorrectly thought that they had sustained
an ankle fracture. However, the high NPV (71%) showed a stronger
association with the lack of an ankle fracture diagnosed by X-ray.
Thus, if ED patients stated during this study that they did not think
they had an ankle fracture, they were more likely to be accurate
when confirmed by X-ray.

Of the different patient characteristics analyzed, a patient’s am-
bulatory status was no-tably associated with a patient answering
"Yes" to the screening question confirmed by X-ray. The PPV of
this question was the highest for patients who were non-ambulatory
(55%), compared to patients who were ambulatory with and without

assistance (0% and 17% respectively).

Additionally, the NPV was highest for patients who were
ambulatory without assis-tance (90%), compared to patients who
were ambulatory with assistance (62%) and non-ambulatory (46%).
Thus, sample patients who were ambulatory were more likely to
correctly evaluate their ankle fracture, while patients who were able
to ambulate with-out assistance were more likely to incorrectly per-
ceive their ankle injury. These study findings demonstrates that pa-
tients are more likely to correctly assess their ankle injury when they
have a worse ambulatory status.

Furthermore, we used a validated numerical scale pain score
(17) to record and analyze patients with and without later-confirmed
ankle fractures. However, in this study, the confidence intervals
for pain scale ratings of both patient groups overlapped, show-ing
no significant difference. Thus, these results indicate that use of
numerical pain rating scales may not be as useful during clinical
decision-making processes concern-ing whether to order an X-ray
for a potential ankle fracture in ED settings.

Several potential limitations of this study may be that the patient
data from a smaller convenience sample of ED adult patients who
were stratified by only three factors (i.e., gender, smoking status
and ambulatory status). Although poor ambulatory status ap-peared
to be more closely associated to an accurate self-assessment ankle
fracture than sex or smoking status, it is possible that this outcome
may be associated with other unmeasured factors (e.g., age, socioe-
conomic status or educational level). Also, since this study did not
account for previous ankle injuries, it is possible that patients with
prior ankle injuries could have considered their past experiences
when answering the pre-X-ray screening questions.

Conclusion

Patients commonly present to the ED with ankle injuries. How-
ever, considering rising healthcare costs and radiation exposure,
there is a need to improve the current yield of ankle X-rays and
develop better tools to aid in assessing ankle fractures. This study
aimed to determine the association between ED patients’ self-
assessment of a possible ankle fracture and true ankle fractures di-
agnosed by X-ray.

Conflict of interest

Authors declare no conflict of interest.

Aouthmany et al. UTJMS 2020 Vol. 8 21

Institutional Review Board approval

All procedures performed involving human participants were in
accordance with the ethical standards of the institutional research
committee (University of Toledo Institutional Review Board, Ref-
erence IRB # 200287).

Authors’ contributions

SA: Study concept, design project writing, and project develop-
ment TH: Study concept and design, project develop EJK/MRP:
Study concept and design, data collection, and data analysis;
MRP/AMK: manuscript editing and revision of content. All au-
thors wrote the manuscript, read and approved the final document.
All authors wrote the manuscript, read and approved the final docu-
ment.

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