Adequacy of Lateral Ankle Radiograph Views in Acute Trauma Setting: A Quality Improvement Project

Introduction: Accurate radiographic assessment is critical in the management of ankle trauma, where lateral ankle views play a key role in identifying fractures and assessing joint alignment. Inadequate radiographs can lead to diagnostic delays or mismanagement. This quality improvement project aimed to evaluate and improve the adequacy of lateral ankle radiographs in a trauma setting, in line with British Orthopaedic Association Standards for Trauma (BOAST) guidelines. Methods: A retrospective closed-loop audit was conducted in a UK trauma unit. One hundred lateral ankle radiographs were evaluated in the first cycle based on four criteria for a "true lateral" view: (1) distal fibula superimposed by posterior tibia; (2) talar domes superimposed; (3) open and uniform tibiotalar joint space; and (4) inclusion of anatomical landmarks (lower third of tibia and fibula, talus, calcaneus, and base of the fifth metatarsal). Following the first cycle, targeted interventions, educational sessions, and visual reference posters were implemented. A second cycle of 100 radiographs was then assessed using the same criteria. Statistical comparison between the two cycles was performed using the chi-squared test. Results: In the first cycle, compliance rates were 83% (criterion one), 61% (criterion two), 69% (criterion three), and 99% (criterion four). After the intervention, the second cycle showed improvements across criteria one to three, with compliance rates of 95%, 85%, and 92%, respectively. Criterion four remained unchanged at 99%. The chi-squared analysis demonstrated statistically significant improvements for criteria one (p=0.0129), two (p=0.0002), and three (p=0.0001), but not for criterion four (p=1.0). Conclusion: This audit demonstrated that simple, cost-effective educational interventions significantly improved the adequacy of lateral ankle radiographs in a trauma setting. Sustained improvement requires continued reinforcement of radiographic standards, multidisciplinary collaboration, and routine audit cycles to ensure consistent image quality in acute care.