ER Physicians Use Low Risk Ankle Rule to Lessen Need for Imaging Children

Canadian researchers have implemented the Low Risk Ankle Rule in six Canadian emergency rooms (ERs) to determine whether it reduced the use of radiography in children.

Radiography is widely used in diagnosing ankle injuries, with 85%–95% in pediatric injuries, although only 12% of these show fractures. “Radiography is unnecessary for most children’s ankle injuries, and these high rates of radiography needlessly expose children to radiation and are a questionable use of resources,” wrote Dr. Kathy Boutis, a pediatric emergency department physician at the Hospital for Sick Children (SickKids; Toronto, Canada) and the University of Toronto (Canada), with coauthors, in their findings published online August 12, 2013, in the Canadian Medical Association Journal.

The Low Risk Ankle Rule is very effective at identifying fractures and can potentially reduce the need for radiography by 60%. It states that if a child with an ankle injury has a low-risk examination, ankle radiography may not be necessary to additionally exclude a high-risk ankle injury. If a subgroup of minor lateral ankle fractures is missed, evidence revealed that these are remarkably stable and low risk for any future issues and can be treated like an ankle sprain. Reducing radiography can lower exposure to low levels of radiation, contain costs, and speed up treatment.

The study involved 2,151 patients (1,055 at intervention and 1,096 at control sites) between the ages of 3 and 16 years who presented at an emergency department with a nonpenetrating ankle injury. By applying the rule, the use of ankle radiography was reduced by approximately 22%. This decrease was consistent in different emergency departments and is similar to the Ottawa Ankle Rule used with adults.

“The implementation of the Low Risk Ankle Rule led to a significant decrease in imaging, associated increase in clinically important fractures being missed or decrease in patient or physician satisfaction,” wrote the authors. “The ankle rule has potential broad applicability to emergency departments throughout most of the developed world, and widespread implementation of this rule could safely lead to reduction of unnecessary radiography in this radiosensitive population and a more efficient use of healthcare resources.”

Related Links:
Hospital for Sick Children
University of Toronto