Is Radiography Necessary for Pediatric Emergency Department Clinicians to Safely Manage Ankle Injuries?

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Ankle radiography in the pediatric emergency department exposes a radiosensitive population to harmful ionizing radiation and is costly to health care systems. This study aimed to determine if ankle injuries in children could be managed safely and effectively without radiography.


This prospective study enrolled 94 patients with ankle injuries between July 14, 2015, and December 16, 2015. Participating clinicians filled out a tick-box questionnaire describing their predicted diagnosis and management. In March 2016, we looked retrospectively at TRAK to determine how these patients were actually managed and compared this with the predictions.


Agreement was calculated for the predicted and actual presence of a fracture, with a κ value of 0.433. The intraclass correlation coefficient was calculated to determine interrater reliability between predicted management and actual management, showing an average score of 0.801. Of the 16 patients found to be Low Risk Ankle Rule positive, none were found to have high-risk fractures.


This study found that radiographs are necessary for the management of pediatric ankle injuries. However, there is scope to reduce radiography by implementing the Low Risk Ankle Rule.

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