It Hurts — But Is an X-Ray Needed?

Ankle injury x ray use decreased at hospitals when new ankle rule was introduced

/ Author:  / Reviewed by: Robert Carlson, M.D Beth Bolt, RPh

(RxWiki News) Twisted and sprained ankles are as common in childhood as hide and seek. Just as parents have to decide when an injury is serious enough to go to the ER, doctors have to decide if x-rays are needed.

A recent study found that using a new rule about ankle injuries in several hospitals reduced the use of x-rays for children's ankle injuries.

The satisfaction of the patients and the doctors did not change between the hospitals using the rule and those not using it.

Reducing the use of x-rays means lower costs and a lower risk of radiation exposure for children.

Though some children will require x-rays for serious injuries, there may be many children getting x-rays at some hospitals when they don't really need them.

"Avoid unnecessary x-rays of your child."

This study, led by Kathy Boutis, MD, of the Division of Emergency Medicine at the University of Toronto's Hospital for Sick Children in Canada, aimed to find out whether instituting a new rule related to ankle injuries in children might reduce the use of x-rays for the kids.

Increased use of x-rays means increased radiation, which has the potential to slightly increase risks of cancer over the long term if a person is exposed frequently to radiation.

Therefore, reducing the use of x-rays as much as possible is often a goal among hospitals and doctors.

In this study, six Canadian hospitals participated in testing the effects of a new policy called the Low Risk Ankle Rule.

The Low Risk Ankle Rule states that if a child with an ankle injury has a low-risk examination, such as tenderness and swelling limited to certain areas, then an x-ray may not be necessary to rule out a high-risk injury.

High-risk injuries include any fracture, dislocation or similar serious injury. Low-risk injuries include sprains and a few minor types of fractures that do not require anything other than a splint.

Three hospitals implemented the rule in three phases that each lasted 26 weeks long.

During the first 26 weeks, the hospitals gathered data without implementing the rule.

During the next 26 weeks, the hospitals implemented the rule and put into place strategies for using it, including educating doctors, creating reminders and adding a computerized system to help care providers make a decision about the rule's use.

During the next 26 weeks, the rule remained in place with the computerized system but no other strategies (doctor reminders, etc.) were used.

At the other three hospitals, nothing was changed while they collected similar data as the three hospitals with the new rule.

Then the researchers compared the way ankle injuries had been managed and treated among children aged 3 to 16 at all six hospitals, specifically in terms of how often x-rays were used.

A total of 2,151 children were seen with ankle injuries across all six hospitals, including 1,055 children at the hospitals with the new rule and 1,096 children at hospitals with no change in practices.

During the first 26 weeks, when no hospital was using the rule, the three hospitals that were about to implement it used x-rays in 96.5 percent of the ankle injury cases and the three comparison hospitals used x-rays in 90.2 percent of the cases.

During the next 26 weeks, when three of the hospitals began using the rule, the use of x-rays in those hospitals decreased to 73.5 percent of the time. The hospitals not using the rule used x-rays 88.3 percent of the time.

During the third 26-week phase, the low rate of x-rays in the hospitals with the new rule continued: hospitals with the rule used x-rays 71.3 percent of the time, and hospitals without the rule used x-rays 87.8 percent of the time.

Meanwhile, no differences were observed in patient or doctor satisfaction about care. About 81 percent of the doctors in the hospitals with the rule followed it with the patients they saw.

Those who did not follow the rule said they either were concerned about missing a serious fracture, preferred a different ankle-injury rule, the family asked for an x-ray or the patient was difficult to examine.

"Implementation of the Low Risk Ankle Rule in several different emergency department settings reduced the rate of pediatric ankle radiography significantly and safely, without an accompanying change in physician or patient satisfaction," the authors wrote.

Although parents may not be aware of what the rules are at a particular hospital for ankle injuries, they may be able to ask a doctor about the need for an x-ray if the ankle injury appears minor.

"There have been many well-validated decision rules in emergency medicine that minimize x-ray use while being sensitive enough that patients don't leave the ER with missed injuries," said Chris Galloway, MD, a dailyRx expert who specializes in emergency medicine.

"Evidence-based decision models are commonly used to evaluate the need for x-rays after neck, knee and ankle injuries in adults," he said. "In the past there has not been as much data when applying these rules in the pediatric population, so often x-rays are performed."  

Yet that can change, he said.

"This study demonstrates that a well-designed, sensitive and specific decision rule can also be effectively applied in the pediatric population," Dr. Galloway said. "This cuts radiation exposure, cost and time in the ER while not missing critical injuries."

This study was published August 12 in the Canadian Medical Association Journal. The authors declared no conflicts of interest.

The research was funded by the Canadian Institutes of Health Research and the Physicians' Services Incorporated Foundation.

Review Date: 
August 13, 2013
Last Updated:
August 22, 2013