For Information Only This document has been archived, much of the original content remains relevant; however, practice in this area develops continually, therefore the content of this document must be used for information only and is only valid as per the original approval date. Head Office: Level 9, 51 Druitt Street, Sydney NSW 2000, Australia Ph: +61 2 9268 9777 Email: [email protected] New Zealand Office: Floor 6, 142 Lambton Quay, Wellington 6011, New Zealand Ph: +64 4 472 6470 Email: [email protected] Web: www.ranzcr.com ABN 37 000 029 863 2015 Education Modules for Appropriate Imaging Referrals PAEDIATRIC ANKLE TRAUMA This document is part of a set of ten education modules which are aimed at improving the appropriateness of referrals for medical imaging by educating health professionals about the place of imaging in patient care. PUBLICATION INFORMATION: ©Royal Australian and New Zealand College of Radiologists 2015 More information is available on The Royal Australian and New Zealand College of Radiologists website: URL: http://www.ranzcr.edu.au/quality-a-safety/program/key-projects/education-modules-for- appropriate-imaging-referrals For educational purposes only. The preferred citation for this document is: Goergen S, Ditchfield M, Babl FE, Oakley E, Yalcin N, Harris C. Paediatric Ankle Trauma. Education Modules for Appropriate Imaging Referrals: Royal Australian and New Zealand College of Radiologists; 2015. ACKNOWLEDGEMENTS: The Education Modules for Appropriate Imaging Referrals project is fully funded by the Australian Government Department of Health and Ageing under the Diagnostic Imaging Quality Projects Program. The project has supported by the RANZCR’s Quality and Safety Program Team: Administrative support: Madeleine Bromhead Jessica Brown Claire King Project management: Jane Grimm TABLE OF CONTENTS Authors: ...................................................................................................................................................................... 3 Reviewer: .................................................................................................................................................................... 3 1. Introduction ............................................................................................................................................................ 3 What is Ankle Trauma? ............................................................................................................................................ 3 Types of Fractures: .............................................................................................................................................. 4 How can clinical decision rules help to standardise pre-test risk evaluation of paediatric patients with Ankle Trauma? .................................................................................................................................................................. 5 2. Clinical Decision Rules ............................................................................................................................................. 8 The Ottawa Ankle Rules ........................................................................................................................................... 8 Review Section .......................................................................................................................................................10 3. Other considerations when performing diagnostic imaging .....................................................................................12 What else do you need to think about, other than pre-test probability of a condition, when you are considering performing diagnostic imaging in a patient with blunt ankle trauma? .....................................................................12 Modality Table: ......................................................................................................................................................13 References .................................................................................................................................................................18 Appendix One: Evidence Summary Table ....................................................................................................................19 Appendix Two: Ottawa Ankle Rules ............................................................................................................................20 Appendix Three: Best Bets Review Table: ...................................................................................................................21 Appendix Four: A Systematic Review ..........................................................................................................................23 Education modules for appropriate imaging referrals – Paediatric Ankle Trauma AUTHORS: Stacy Goergen, MBBS, FRANZCR, MClinEpi Director of Research, Department of Diagnostic Imaging, Monash Health, Melbourne, Australia Adjunct Clinical Professor, Monash University, Department of Surgery, Southern Clinical School Michael Ditchfield, MBBS, MD, FRANZCR Head of Paediatric Imaging, Monash Children’s, Monash Health, Melbourne, Australia Professor, Monash University, Department of Paediatrics, Southern Clinical School Franz E Babl, MD, MPH, FRACP Paediatric Emergency Physician, Royal Children's Hospital, Melbourne, Australia Associate Professor, Emergency Research, University of Melbourne Head, Emergency Medicine Research, Murdoch Children’s Research Institute Ed Oakley, MBBS, FACEM Acting Director Emergency Medicine, Royal Children's Hospital, Melbourne, Australia Director of Paediatric Emergency Medicine, Monash Health, Melbourne Honorary Research Fellow, Murdoch Children’s Research Institute Nilay Yalcin, MBBS, BBioMedSci Monash University, Melbourne, Australia REVIEWER: Chris Harris, MBBS, FRACS Consultant Orthopaedic Surgeon, Royal Children’s Hospital, Melbourne, Australia 1. INTRODUCTION WHAT IS ANKLE TRAUMA? Foot and ankle injuries account for up to 30% of medical visits for sports related injuries, and are the most common sports related presentation in the primary care setting. Around 85% of ankle injuries are sprains with fractures making up to 15% of injuries, and ankle fractures account for about 5% of all paediatric fractures. Ankle injuries are most common in the 10-16 year age group. Ankle sprains are the most common injuries, with the lateral (fibular) ligaments most commonly involved. Younger children have an increased risk of injury to the physis (growth plate) of the ankle. In the immature skeleton most ankle fractures are related to the growth plate and are classified using the Salter-Harris Classification (see Figure 1). Ankle injury is suspected when there is a history of ankle trauma – most commonly inversion and plantar flexion. To aid with identification of injuries not associated with fractures, clinical decision rules have been developed and validated in both adults and children (and can be used with confidence in children as young as 5 years of age). The best CDR is the Ottawa Ankle Rule (OAR)1. Using the OAR allows identification of patients at minimal risk of fracture allowing management to continue without plain radiography (x-ray). All injuries that cannot be excluded by the OAR should undergo plain radiography of the ankle. The Ottawa Ankle Rules have been validated for use in foot and ankle trauma by many studies involving mixed adult and paediatric as well as exclusively paediatric populations. The population sizes in the exclusively paediatric studies are smaller than for the adult studies, especially in the youngest age groups, as they experience fewer injuries. Treatment of ankle sprains is with rest, support of a brace or splint for up to 5 days when weight bearing is not well tolerated, and graded return to functional activity. Fractures are managed according to the displacement or angulation of the bones, and disruption of the ankle mortise. They may require immobilisation with a splint or plaster, manipulation under general anaesthesia or internal fixation to maintain the alignment of the ankle joint. A complicated fracture identified on plain imaging will often be further investigated with CT or MRI to accurately outline the fragment positions and inform operative intervention. As ankle injury is such a frequent problem, and because the incidence of fracture is low there are substantial costs associated with the practice of performing radiography in all cases of paediatric ankle trauma. The financial burden of many unnecessary x-rays, the extra time in the emergency department, the delay in management for the individual patient and unnecessary radiation exposure, all contribute to significant social cost. Therefore judicious use of imaging, guided by validated CDRs is of benefit to the patient and the community. There is no role for CT or MRI in the investigation of any but the most complicated fractures, and certainly no role as the initial investigative tool. ©RANZCR 2015 QUALITY AND SAFETY PROGRAM 3 | P AGE Education modules for appropriate imaging referrals – Paediatric Ankle Trauma TYPES OF FRACTURES: FIGURE 1: SALTER-HARRIS CLASSIFICATION OF FRACTURES INVOLVING THE GROWTH PLATE Type II fractures are the commonest. The fracture line extends along the growth plate as for Type I and then through the distal metaphysis, distinguishing it from a Type I Fracture. Type III fractures extend along the growth