Use of the Ottawa Ankle Rules in children: a survey of physicians’ practice patterns

Abstract

Introduction: A number of studies have assessed the diagnostic accuracy of the Ottawa Ankle Rules (OAR) in children; however, the role of the OAR in guiding physician radiograph use is unclear. Objectives: The primary purpose of this study was to determine the extent to which Canadian pediatric emergency physicians report using the OAR. Secondary goals included determining current diagnostic and management strategies for Salter-Harris 1 (SH-1) injuries of the ankle and which fractures physicians deem to be clinically significant. Methods: A self-administered piloted survey was distributed by mail to 215 Canadian pediatric emergency physicians using a modified Dillman technique. Participants were selected through Pediatric Emergency Research Canada (PERC), a national network of health care professionals with an interest in pediatric emergency medicine research. Results: Of 209 surveys, 144 were returned, for a response rate of 68.9%. Of those, 87.5% (126 of 144) reported applying the OAR in children to determine the need for radiographs in acute ankle or midfoot injuries. Of those, 65.1% reported using the OAR always or usually, and 64.5% (93 of 144) of physicians stated that they believe all ankle fractures are clinically significant. Although physicians report that they most commonly order the radiographs, 36.2% of participants indicated that radiographs were requisitioned by nurses or other health care providers at their facilities. SH-1 fractures were reported to be most commonly managed by immobilization (83.3%; 120 of 144), with most patients going on to follow-up with an orthopedic surgeon. Conclusions: The majority of Canadian pediatric emergency physicians indicate that they use the OAR when assessing children with acute ankle and midfoot injuries. Most physicians believe that all ankle fractures, including SH-1, are clinically significant and have a management preference for immobilization and orthopedic follow-up.

Evidence into Practice

“…In 2008, Dowling and Wishart 27 reported that approximately 85% of emergency physicians immobilize Salter-Harris I fractures of the distal fibula with fiberglass/plaster immobilization and refer these to an orthopaedic surgeon. There are very little data in the literature about the use of immobilization strategies for these injuries by orthopaedic surgeons.…”

Accuracy of Ottawa Ankle Rules to Exclude Fractures of the Ankle and Midfoot in Children: A Meta‐analysis

“…At present there is considerable variation in how pediatric emergency physicians choose to manage SH-1 injuries that range from symptomatic treatment only, to below knee casting and follow-up with an orthopedic surgeon. 32 A recent study by Boutis et al 33 suggests that a removable brace for these injuries may lead to better functional outcomes.…”

Pediatric Emergency Physician Opinions on Ankle Radiograph Clinical Decision Rules

“…A recent meta‐analysis demonstrated the OAR to be 98.5% sensitive to the detection of significant fractures in children, 9 but only reduced the need for radiography by 5% to 25% 5–7,9 . Although Canadian pediatric emergency medicine (PEM) physicians reportedly use the OAR frequently, 10 this rule has not significantly changed radiography rates in children with ankle injuries 3 . This may be due to the high false‐positive rate of this rule, 4 resulting in ankle x‐ray rates approaching those when no rules are used 4–6,8,11,12 …”