Ankle Injury: Simple Rule May Lower Radiography Use in Kids

Larry Hand

August 12, 2013

Using a simple rule may enable emergency departments (EDs) to significantly reduce the number of radiographs ordered for children who present with ankle injuries, according to an article published online August 12 in the Canadian Medical Association Journal.

Kathy Boutis, MD, from the Department of Emergency Medicine and the Department of Pediatrics, Hospital for Sick Children, University of Toronto, Ontario, Canada, and colleagues conducted a study involving 6 Canadian emergency departments between January 1, 2009, and August 31, 2011. They assigned 3 hospitals to intervention and 3 as controls. The control EDs received no intervention.

The researchers enrolled 1055 children with ankle injuries at intervention hospitals and 1096 children at control hospitals. They divided the study into 3 phases: a phase of collecting baseline data, a second phase of intervention, and a third phase of just using a decision support system.

During the second phase, physicians underwent training and received pocket cards outlining the Low Risk Ankle Rule. Wall posters about the rule were posted in EDs, and a computerized decision support system was implemented. The system automatically generated a recommendation to use the ankle rule based on key clinical variables entered by physicians, which eliminated the need for memorizing the rule.

Physicians could use either a study form or the decision support system to detail how they managed low-risk ankle injuries in all children, with or without radiography.

According to the Low Risk Ankle Rule, if a child with an ankle injury has a low-risk examination, involving 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 injury. Prior validation studies showed that the small number of fractures missed by the rule could be safely managed similar to an ankle sprain.

During the intervention, physicians reduced the use of radiography almost 22% (between-group difference, −21.9%; 95% confidence interval [CI], −28.6% to −15.2%) compared with control hospitals, without any significant differences in patient or physician satisfaction. The reduction was sustained in the third phase of the study. In the second and third phases of the study, the sensitivity of the Low Risk Ankle Rule was 100% (95% CI, 85.4% - 100%) and the specificity was 53.1% (95% CI, 48.1% - 58.1%).

Physicians used the ankle rule in 430 of 628 (68,5%) cases during the second and third phases at intervention sites, and followed the rule recommendations in 350 (81.4%) cases. Reasons for not following the rule included fear of missing a significant fracture (31.3%) and patient family preference for a radiograph (10.0%);reasons were undocumented in a large proportion of cases (37.5%).

The researchers speculate that if physicians had fully complied with the rule, almost half (49.5%) of the radiography procedures could have been avoided.

The researchers conclude, "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 health care resources."

The research was funded by the Canadian Institutes of Health Research and the Physicians Services Incorporated Foundation. The authors have disclosed no relevant financial relationships.

Can Med Assoc J. Published online August 12, 2013. Full text

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