Ankle Injury

Ankle Injury

If even the magnificent Michael Jordan could have his “ankles broke” by Allen Iverson’s maleficent cross-over, then it should come as no surprise that mere mortal children will present to our EDs with ankle injuries.  If the patients were adults, we’d feel comfortable applying the Ottawa Ankle Rules.  The question, then, is whether we can apply any Clinical Decision Rules in a child presenting with an Ankle Injury.


Ankle Injury: Growth Plates Matter

  • Recall, the kids represent a special population with respect to orthopaedic injuries.
    • Ligaments tend to be more resilient to stressors than the physis (growth plate) in children.
    • This makes it more likely to sustain a fracture than a “sprain” compared to adults.
  • The physis does not close symmetrically, which affects how fractures occur.
  • Ankle fractures in kids most often occur between 10-15 years of age (when growth plates begin fusing).


Ankle Injury: Salter-Harris Classification

  • While this classification system can be seen as typical fodder for Pimping, it really does matter.
  • Salter-Harris Classifications range from I to V, with I being least severe and V being the most.
    • SH I – Slipped Physis (~5 %)
    • SH II – through Metaphysis (~75%, most common)
    • SH III – through Epiphysis to articular surface (~10%)
    • SH IV – through Metaphysis and Epiphysis (~10%)
    • SH V – Crushed Physis (rare)
  • One issue to consider is that SH I are often diagnosed clinically, as they are not usually apparent on radiographs.
    • So, you don’t really need an X-ray if you think it is anything less than a SH II.
    • If you got X-rays, and they are “normal,” don’t forget that there still may be a SH I.


Ankle Injury: Clinical Decision Rules

  • There are several Clinical Decision Rules for determining low risk for significant ankle fractures in children.
    • Ottawa Ankle Rules [Plint, 1999]
      • Ankle X-Rays are required only if:
        • Pain in the Malleolar Zone AND
        • Tenderness along the posterior aspect of the distal 6 cm of the lateral malleolus OR
        • Tenderness along the posterior aspect of the distal 6 cm of the Medial Malleolus OR
        • Inability to bear weight both immediately and in the ED.
      • Initial study had sensitivity of 100%.
    • Low Risk Ankle Rules [Boutis, 2001]
      • Ankle X-Rays are not required if:
        • Isolated tenderness and swelling to the distal fibula, distal to the tibial anterior joint line.
      • Defined a low-risk ankle injury as:
        • SH I and SH II distal fibular fractures
        • Avulsion fractures of the distal fibula or lateral talus.
        • All can be managed non-operatively with splinting.
      • Initial study has sensitivity of 100%.
    • Malleolar Zone Algorithm [Dayan, 2004]
      • Patient is Low Risk for malleolar zone fracture if:
        • No bone tenderness at either malleolus or the region just proximal to the fibular malleolus OR
        • Able to walk four steps in ED and had no swelling at either malleolus, even if there was tenderness.
      • Initial study had sensitivity of 100% and specificity of 19.1%.
      • Not validated yet.
  • When compared head to head: [Gravel, 2009]
    • The Ottawa Ankle Rules was found to be the most sensitive for clinically important fractures.
    • The Low Risk Ankle Rules was found to be the most specific for clinically important fractures.
    • The Low Risk Ankle Rules was able to decreased need for radiographs the most.
  • These Clinical Decision Rules are designed to determine who will not benefit from an X-Ray.
    • This does not mean that the patient does not have a fracture.
      • A SH I fracture is not ruled-out by any of the available Clinical Decision Rules.
      • Using the Low Risk Ankle Rules, the patient may still have a SH II fibular fracture.


Ankle Injury: What is Your Tolerance?

  • There is evidence that these Clinical Decision Rules can identify patients who are at low-risk for clinically significant ankle fractures.
  • Each define what is “clinically significant” a little differently:
    • Affects how the perform head-to-head.
    • May influence which one you choose to use.
      • If you are comfortable managing a SH II fibular fracture like a SH I without an X-ray, then choose Low Risk Ankle Rule.
  • Your patient’s access to Orthopaedic follow-up may also influence your selection.
  • It has been shown that, despite the existence of these Clinical Decision Rules to help limit radiographs, there are still many other barriers to reducing X-rays for ankle injury: [Boutis, 2010]
    • Physician tolerance / preference
    • Physician awareness of Clinical Decision Rules
    • Challenges of examining children who are in pain
    • Perception of patient satisfaction
    • Parental preference


Ankle Injury: Moral of the Morsel

  • Anatomy matter – children’s growth plates are weaker than the surrounding ligaments.
  • Clinical Decision Rules are available and can apply to ankle injuries in children to help reduce radiographs.
  • Whether obtaining an X-ray or not, if there is tenderness over region associated with a growth plate, do not forget the SH I ankle injury may be present.  In this case, casting or using velcro type stirrup splint and ensuring Orthopaedic follow-up is warranted.



Ramasubbu B1, McNamara R, Okafor I, Deiratany S. Evaluation of Safety and Cost-Effectiveness of the Low Risk Ankle Rule in One of Europe’s Busiest Pediatric Emergency Departments. Pediatr Emerg Care. 2015 Oct;31(10):685-7. PMID: 26196362. [PubMed] [Read by QxMD]

Boutis K1, Howard A, Constantine E, Cuomo A, Narayanan U. Evidence into practice: emergency physician management of common pediatric fractures. Pediatr Emerg Care. 2014 Jul;30(7):462-8. PMID: 24977995. [PubMed] [Read by QxMD]

Boutis K, Grootendorst P, Willan A, Plint AC, Babyn P, Brison RJ, Sayal A, Parker M, Mamen N, Schuh S, Grimshaw J, Johnson D, Narayanan U. Effect of the Low Risk Ankle Rule on the frequency of radiography in children with ankle injuries. CMAJ. 2013 Oct 15;185(15):E731-8. PMID: 23939215. [PubMed] [Read by QxMD]

Zomorrodi A1, Bennett JE, Attia MW, Loiselle J, Rogers KJ, Kruse R. Consistency between emergency department and orthopedic physicians in the diagnosis and treatment of distal fibular Salter Harris I fractures. Pediatr Emerg Care. 2011 Apr;27(4):301-3. PMID: 21490545. [PubMed] [Read by QxMD]

Boutis K1, Constantine E, Schuh S, Pecaric M, Stephens D, Narayanan UG. Pediatric emergency physician opinions on ankle radiograph clinical decision rules. Acad Emerg Med. 2010 Jul;17(7):709-17. PMID: 20653584. [PubMed] [Read by QxMD]

Gravel J1, Hedrei P, Grimard G, Gouin S. Prospective validation and head-to-head comparison of 3 ankle rules in a pediatric population. Ann Emerg Med. 2009 Oct;54(4):534-540. PMID: 19647341. [PubMed] [Read by QxMD]

Sankar WN1, Chen J, Kay RM, Skaggs DL. Incidence of occult fracture in children with acute ankle injuries. J Pediatr Orthop. 2008 Jul-Aug;28(5):500-1. PMID: 18580361. [PubMed] [Read by QxMD]

Dayan PS1, Vitale M, Langsam DJ, Ruzal-Shapiro C, Novick MK, Kuppermann N, Miller SZ. Derivation of clinical prediction rules to identify children with fractures after twisting injuries of the ankle. Acad Emerg Med. 2004 Jul;11(7):736-43. PMID: 15231460. [PubMed] [Read by QxMD]

Boutis K1, Komar L, Jaramillo D, Babyn P, Alman B, Snyder B, Mandl KD, Schuh S. Sensitivity of a clinical examination to predict need for radiography in children with ankle injuries: a prospective study. Lancet. 2001 Dec 22-29;358(9299):2118-21. PMID: 11784626. [PubMed] [Read by QxMD]

Plint AC1, Bulloch B, Osmond MH, Stiell I, Dunlap H, Reed M, Tenenbein M, Klassen TP. Validation of the Ottawa Ankle Rules in children with ankle injuries. Acad Emerg Med. 1999 Oct;6(10):1005-9. PMID: 10530658. [PubMed] [Read by QxMD]


Sean M. Fox
Sean M. Fox
Articles: 583


  1. There was a very nice study recently published (since this post was written) questioning the significance (radiogrpahically and clinically) of SH-1. Essentially 135 kids with ?SH-1 injury of the distal fibula got an MRI – of these 4 had a MRI confirmed SH1DF – two of which were partial. Those patients with the SH1DF had similar ASK (activity scale for kids) scores at 1 mth. I think this is an important study with respect to to SH1DF. My approach is to treat ?SH1DF as a ankle sprain (knowing that the vast majority are not actually SH1DF injuries) and those that are have similar outcomes to non-SH1DF ankle sprains.

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