An Intervention to Increase Knowledge and Utilization of the Low Risk Ankle Rule among Pediatric Emergency Department Providers

Kirsten V. Loftus*, Michael A. Gittelman, Michael Fitzgerald, Wendy J. Pomerantz

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Objectives The Low Risk Ankle Rule (LRAR) can assist pediatric emergency department providers in reducing radiographs without missing significant fractures. Most providers are unaware of this tool. This study sought to educate providers about the LRAR then determine their self-reported use immediately and 2 months after education. Methods A web-based survey was e-mailed to providers at one large pediatric emergency department. The survey assessed knowledge and use of the rule. Clinical scenarios, in which radiographs were not indicated, helped determine radiograph ordering practices. After a brief LRAR tutorial, respondents were requeried about radiograph ordering practices along with likelihood of future LRAR use. At 2 months, radiograph ordering was again assessed using the same scenarios; interim LRAR use was also determined. Results Response rates on the initial and follow-up surveys were 61.4% and 96.2%, respectively. A minority (20%) had heard of the LRAR. Providers initially reported ordering radiographs on 84% of ankle injuries and 82.5% ordered radiographs in the scenario. Immediately after education, only 32% ordered a radiograph in the scenario; 85% reported that they would use the tool consistently. At 2 months, there was no significant change in radiograph ordering practices (79.5% vs 84%). In the interim, 30% reported using the rule at least once. Conclusions Most pediatric emergency department providers were unfamiliar with the LRAR. After a brief tutorial, most providers reported that planning to use the tool and self-reported radiograph ordering was significantly reduced; however, at 2 months, clinical practice was unaffected. Further work to implement the tool into practice is necessary.

Original languageEnglish (US)
Pages (from-to)831-836
Number of pages6
JournalPediatric emergency care
Issue number12
StatePublished - Dec 1 2019
Externally publishedYes


  • ankle injury
  • decision rules
  • Low Risk Ankle Rule

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Emergency Medicine


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