MRI Utilisation in Acute Lateral Ankle Ligament Injuries: A Clinical Audit of Adherence to Evidence-Based Imaging Guidelines and Impact on Management

BackgroundAcute lateral ankle ligament injuries are common musculoskeletal presentations and are usually diagnosed through clinical assessment supported by plain radiography when indicated.Magnetic resonance imaging (MRI) provides detailed assessment of ligamentous, osteochondral, tendinous, and occult osseous pathology but is generally recommended selectively rather than routinely.Inappropriate or poorly justified MRI utilisation may increase resource use without altering clinical management. ObjectiveTo evaluate MRI utilisation in patients with acute lateral ankle ligament injuries at Kulhudhuffushi Regional Hospital, assess adherence to predefined evidence-based imaging criteria, identify deficiencies in clinical documentation, and determine whether appropriately indicated MRI was associated with changes in patient management. MethodsA retrospective clinical audit was conducted at Kulhudhuffushi Regional Hospital, Maldives.Records of patients managed between February 1, 2025 and May 31, 2026 were reviewed.Fifty-five patients aged 14-65 years who presented within one to three weeks of acute traumatic ankle injury and underwent MRI for suspected lateral ankle ligament injury were included.Clinical documentation, plain radiographs, MRI reports, indications for MRI, and subsequent management were evaluated against predefined standards derived from international recommendations.MRI requests were classified as meeting evidence-based criteria when at least one recognised indication was documented before imaging; requests without a documented recognised indication were classified as potentially inappropriate.The association between MRI appropriateness and subsequent management change was evaluated using Fisher's exact test, with ORs and 95% CIs. ResultsAll 55 patients (100%) underwent plain radiography before MRI.Forty-two MRI requests (76.4%) met predefined evidence-based indications, below the audit target of ≥90%, while 13 (23.6%)had no documented recognised indication and were classified as potentially inappropriate.Documentation was suboptimal for weight-bearing status (43, 78.2%), ligament-specific examination (37, 67.3%), syndesmotic testing (22, 40.0%), and the Ottawa Ankle Rules (16, 29.1%).Anterior talofibular ligament (ATFL) injury was the most frequent MRI finding, occurring in 32 patients (58.2%).Other findings included bone bruising in 11 (20.0%),combined ATFL and calcaneofibular ligament (CFL) injury in nine (16.4%), syndesmotic injury in six (10.9%), osteochondral lesions in four (7.3%), occult fractures in three (5.5%), and tendon injuries in three (5.5%).MRI resulted in a change in management in 19 patients (34.5%).Management changed in 18 of 42 patients (42.9%) whose MRI met evidence-based indications compared with one of 13 patients (7.7%) whose MRI lacked a documented recognised indication (OR: 9.00, 95% CI: 1.07-75.70;Fisher's exact test, p = 0.022). ConclusionsMRI was most clinically useful when requested for patients with documented evidence-based indications.Although compliance with first-line plain radiography was complete, deficiencies were identified in clinical