title: Evaluation of Safety and Cost-Effectiveness of the Low Risk Ankle Rule in One of Europe's Busiest Pediatric Emergency Departments.
abstract: OBJECTIVE
  Low Risk Ankle Rule (LRAR) has 100% sensitivity for identifying clinically important pediatric ankle fractures (high-risk injuries) and has the potential to safely reduce imaging by approximately 60%. This study investigates the safety and cost-effectiveness of this rule in our institution.
  
  
  METHODS
  All patients triaged during July and August 2013 with an "ankle injury" had a retrospective clinical notes and radiology report review. Data were recorded using Excel and tests of significance, χ test.
  
  
  RESULTS
  One hundred twenty-one patients were included. Of these, 65 were female and 56 were male (no significant difference in sex, P = 0.41). Mean age was 9.95 years. Seventy-eight (64%) had LRAR positive examinations. Of these, 77 (98.7%) had an x-ray and 12 (15%) had fractures. Of those with fractures, none had high-risk injuries.Eighteen (100%) of the doctors in our ED felt that a clinical decision rule would be of use within the department. Only 8 (44%) had heard of the LRAR, and of these, only 4 (50%) would be confident to implement the LRAR. Forty-four (88%) of parents felt that an x-ray is required in the diagnosis of ankle injuries in children, and 41 (82%) would want to know whether their child had an ankle sprain or a low-risk fracture even if the management was not different.
  
  
  CONCLUSIONS
  By implementing the LRAR in our institution, we could reduce ankle x-rays by 64%. This would offer a significant reduction in radiation exposure to a radiosensitive population. Estimated costs of an ankle x-ray and interpretation are Euro 47 ($65), thus with more than 800 carried out per year in The Children's University Hospital, a potential annual saving is Euro 25,000 ($34,500).
authors.affiliation: From the Department of Emergency Medicine, Children's University Hospital, Temple Street, Dublin, Ireland.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Ramasubbu
authors.forename: Roisin
authors.initials: R
authors.lastname: McNamara
authors.forename: Ike
authors.initials: I
authors.lastname: Okafor
authors.forename: Samir
authors.initials: S
authors.lastname: Deiratany
mesh_terms: D000293:Adolescent; D016512:Ankle Injuries / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000191:economics; D002648:Child; D003362:Cost-Benefit Analysis; D004636:Emergency Service, Hospital / Q000191:economics / Q000592:standards / Q000706:statistics & numerical data; D005060:Europe; D005260:Female; D050723:Fractures, Bone / Q000000981:diagnostic imaging* / Q000191:economics; D006801:Humans; D008297:Male; D010808:Physical Examination / Q000379:methods; D011859:Radiography; D012189:Retrospective Studies; D012306:Risk; D012449:Safety / Q000191:economics*; D011795:Surveys and Questionnaires; D014965:X-Rays / Q000009:adverse effects