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Ottawa ankle rules sort out sprains from breaks.

STANFORD, CALIF. -- Pediatricians can take some of the guesswork out of evaluating ankle injuries by using the Ottawa Ankle Rules for children and adolescents, devised by Canadian emergency physicians to cut down on the number of needless x-rays of sprains.

"Is it broken? Is it not broken? In the emergency department, it's the bane of our existence," said Dr. Bernard W. Dannenberg, director of pediatric emergency medicine at the Stanford (Calif.) University Medical Center.

Simplicity is key to the rules, first developed for adults and later validated for children at the University of Ottawa and the University of Manitoba in Winnipeg (Acad. Emer. Med. 1999;6:1005-9).

The rules follow several criteria:

* Has the child been able to walk four steps or more on the injured ankle, either at the time of the injury or any time since?

* Is there an absence of significant pain when the physician presses with a thumb on the posterior edge or tip of the lateral or medial malleolar zones?

* Is there an absence of significant tenderness at the base of the fifth metatarsal or navicular bone (in the case of suspicion of a fracture in the mid-foot)?

If the answers to these questions are affirmative, the injury can safely be bandaged with an Ace wrap for comfort and the patient instructed to use crutches without obtaining an x-ray, Dr. Dannenberg said at a pediatric update sponsored by Stanford University.

The rules have proved to be 100% sensitive for a fracture of the ankle or mid-foot in children aged 2-16 years, and 24% and 36% specific for fractures of the ankle and mid-foot, respectively. Following the rules can reduce the number of ankle and mid-foot x-ray series by 16%-29%, according to the authors of the pediatric validation study.

Dr. Dannenberg explained that pressure should not be applied on the actual malleolus or below it, where the ligament attaches, because everyone would be likely to flinch as a result of that maneuver. Pressing behind and above the ankle "is actually moving the bones, and moving broken bones hurts," he said.

Fractures above the joint generally require surgery, while those through or below the joint often can be managed conservatively, he added.


Los Angeles Bureau

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Title Annotation:Clinical Rounds
Author:Bates, Betsy
Publication:Pediatric News
Geographic Code:1CANA
Date:Feb 1, 2008
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