Applying the Ottawa Ankle Rule in a Pediatric Emergency Department

Background: Ankle and mid-foot injuries constitute one of the most frequent motives to visit the pediatric emergency department (ED) and radiography is performed in almost all cases with only 15% revealing fractures. Ottawa ankle rule (OAR) is a clinical decision rule which predict the need for radiography in these injuries.

Objective: To determine the feasibility of the OAR in a pediatric ED and its reliability to safely manage ankle and mid-foot injuries, the reduction of radiographs and time spent in the ED.

Methods: The prospective study enrolled 90 patients for the control group and 94 for the case group. For the control group the standard of practice was registered and follow-up was made one to three weeks after ED evaluation. In the case group, before beginning enrolment an instruction about OAR was given to all clinicians. Afterwards, OAR was applied according to patient complaints. Similarly to the control group follow-up was also made.

Results: The mean age of the control group was 11.9 (SD, 3.267) and female patients represented 55.6% of the population, while in case group, the mean age was 11.3 (SD, 3.533) and there were 56.4% female patients. No statistically significant difference was seen in the demographic and injury characteristics between groups. A significant difference was verified in the number of radiographs (p-value 0.007) with a reduction of 16.7% in the case group. Furthermore, patients who did not performed radiography spent at least one hour less in ED, in case group. The return to physical activity did not show difference between groups during follow-up. OAR has shown a sensibility of 100% (95% CI, 39.76-100.00) with a negative predictive value of 100%.

Conclusion: The OAR has a high sensibility and negative predictive value which allows clinicians to avoid unnecessary exposure to radiation without missing clinically relevant fractures.