Toolkit Inspiration 

Paediatric ankle injuries are a very common presenting complaint in both general and paediatric emergency departments. The vast majority of these are low-risk injuries: soft tissue injuries (i.e., sprains) or clinically insignificant fractures that have been shown to heal without specific intervention or orthopedic follow up.

A common approach to investigating ankle injuries is to obtain an x-ray to look for a fracture, but research at SickKids has shown that by applying the Low Risk Ankle Rule, x-rays could be reduced by as much as 60% without missing clinically important injuries. The Low Risk Ankle Rule also shows that most simple ankle fractures can be managed very similarly to ankle injuries without fractures.

Since 2016, the SickKids Choosing Wisely initiative has campaigned to reduce unnecessary ankle x-rays using a combination of educational outreach and electronic health system tools to encourage use of the Low Risk Ankle Rule. In doing so, there has been a sustained reduction in ankle x-rays in patients presenting to the emergency department with ankle injuries from over 90% to approximately 65%. With implementation, there was no evidence of an increase in return visits or missed important fractures.

The Say Nay to the X-Ray toolkit contains the key ingredients of their approach to reduce unnecessary low-risk ankle imaging.