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

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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. 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. 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. 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. 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.