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By Dr.
Kathy Boutis
Ankle injuries in children are commonly
seen in emergency rooms. At present, x-rays are ordered routinely
in most children with ankle trauma, because of patients' and
parents' expectations and physicians' fear of overlooking
serious injury.
This approach may lead to unnecessary
X-rays, resulting in increased radiation exposure and health-care
expenditure, as well as longer waiting times in the emergency
room.
The Ottawa ankle rules reduce the need
for X-rays in a subset of adults with ankle trauma. These
rules state that ankle radiographs are needed only if there
is one or more of the following:
- inability to bear weight
- bone tenderness at the posterior edge
- or bone tenderness at the tip of either
ankle bone
Previous work has shown that the Ottawa
ankle rules could also reduce the need for X-rays in children.
Many young children with a mild isolated ankle injury refuse
to bear weight and are therefore thought to need X-rays according
to the Ottawa ankle rules.
In this study, it was postulated that
in children with clinical findings restricted to the outside
of the ankle bone or the area immediately around it, or both,
X-rays may not determine the course of treatment, thereby
potentially eliminating the need for X-rays.
The
study showed that no children with acute ankle injury and
pain restricted to the outside ankle bone below the level
of the joint line of the ankle or immediately next to it had
a serious problem.
Therefore, nearly two-thirds of the X-rays
currently undertaken could be avoided on the basis of low-risk
examination alone, by contrast there is only 12% reduction
in imaging based on application of the Ottawa algorithm.
This finding could substantially reduce
costs and improve flow of patients in the emergency department,
without increasing the likelihood of missing clinically significant
high-risk fractures.
The low-risk and high-risk findings were
easily distinguished by the clinicians, as assessed by a high
degree of agreement between observers.
Abstracted
from Lancet December 22, 2001; 358: 2118-21
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