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19-08-2013 | Orthopaedics | Article

Simple rule for pediatric ankle injury avoids unnecessary radiography


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medwireNews: A clinical decision rule can safely replace diagnostic radiography in the majority of children presenting to hospital with acute ankle injuries, say Canadian researchers.

They call on hospital emergency departments to introduce the Low Risk Ankle Rule for assessing ankle injuries in children in order to reduce unnecessary radiography, which “needlessly exposes children to radiation and is a questionable use of resources,” according to Kathy Boutis (Hospital for Sick Children, University of Toronto, Ontario) and co-authors.

The Low Risk Ankle Rule states that if a child presents with a low-risk ankle injury on examination, ie, tenderness and swelling isolated to the distal fibula and/or adjacent lateral ligaments distal to the tibial anterior joint line, radiography may not be necessary to exclude a high-risk ankle injury.

Boutis et al compared radiography rates among children aged 3 to 16 years with ankle injuries at three emergency departments that introduced the Rule (intervention hospitals, n=1055) with those at three emergency departments that did not introduce the Rule (control hospitals, n=1096).

In the first phase of the study, neither intervention nor control hospitals used the Rule and rates of pediatric ankle radiography were high, at 96.5% and 90.2%, respectively.

In the second phase, the Rule started to be phased-in at the three intervention hospitals through physician education, reminders, and a computerized decision system. In this phase, rates of pediatric ankle radiography fell significantly, to 73.5%, in intervention hospitals but remained high, at 88.3%, in control hospitals.

In the third phase, during which intervention hospitals used only the decision support system, the reduction in rates of pediatric ankle radiography was sustained, at 71.3%, compared with 87.8% in control hospitals.

Importantly, patient and physician satisfaction with treatment was unaffected by the introduction of the Low Risk Ankle Rule. The sensitivity of the Rule was 100% with a specificity of 53.1%, note Boutis et al in the Canadian Medical Association Journal.

“If a subset of minor lateral ankle fractures is missed, evidence shows that these are exceptionally stable and low risk for any future issues and can be treated like an ankle sprain, with superior functional recovery,” the authors write.

They conclude: “Widespread implementation of this rule could safely lead to reduction of unnecessary radiography in this radiosensitive population and a more efficient use of health care resources.”

medwireNews ( is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2013

By Joanna Lyford, Senior medwireNews Reporter

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