Pediatric ankle rule significantly lowers use of radiographs, study finds

Physicians who employed the Low Risk Ankle Rule used significantly less radiography when confirmed pediatric ankle fractures compared to physicians who did not apply the rule, according to results of a recently published study.

“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,” Kathy Boutis, MD, MSc, a pediatric emergency department physician from the Hospital for Sick Children in Toronto, stated in a press release.

In the study, Boutis and colleagues noted the rule “states that if a child with an ankle injury has a low-risk examination (i.e., tenderness and swelling isolated to the distal fibula and/or adjacent lateral ligaments distal to the tibial anterior joint line), ankle radiography may not be necessary to further exclude a high-risk ankle injury.”

The researchers employed the rule gradually for 1,055 patients at six Canadian emergency medical centers through three consecutive phases lasting 26 weeks each. The patients were between 3 years and 16 years old and had non-penetrating ankle injuries, according to the release. The patients in the three consecutive phases were matched against a control group of 1,096 patients.

There was no intervention in the first phase. In the second phase, the researchers included teaching sessions for physicians, a computerized decision support system and wall posters explaining the rule. In this phase, the researchers also flagged children’s charts that had ankle injuries. The third phase included only the computerized decision support system.

During the first phase, radiographs were ordered 96.5% of the time compared to 90.2% in the control group, according to the abstract. In the second phase, there was a 21.9% reduction in radiographs ordered in the patient group compared to the control group, and that difference was sustained into the third phase of the trial.

Reference:

Boutis K. Can Med Assoc J. 2013;doi:10.1503/cmaj.122050.

Disclosure: The authors have no relevant financial disclosures.