Dr. Kathy Boutis and Dr. Amy Plint with landmark study on ankle injuries

Is it a fracture or a sprain?

Dr. Kathy Boutis and colleagues debunk the 50 year doctrine that "children fracture before sprain." The results of this latest study, published January 2016 in JAMA Pediatrics, demonstrated that the commonly made presumptive diagnosis of Salter-Harris type 1 fracture of the distal fibula (SH1DF) is rarely confirmed by MRI. Instead, children most often had sprains, occasionally associated with radiographically occult avulsion fractures. Additionally, they established that children with fractures detectable only by MRI had comparable recovery compared to those with sprains when treated with a removable ankle brace and self-regulated return to activities. 

These results have important implications, including the potential to simplify the care of these common injuries and reduce health care expenditures.  At a glance:

1. Most children with suspected SH1DF were found to have an ankle sprain.
2. The classic approach of 3 to 6 week casting is not necessary and is associated with delayed recovery time. The authors advocate instead for a less conservative approach of a removable splint, which reduces patient discomfort and allows for a speedier return to activities.
3. Repeated radiography and referral to an orthopedic surgeon are also not routinely necessary and should be reserved for patients who are not recovering as expected. 

Congratulations to Dr. Kathy Boutis and colleagues on the publication of this landmark study.

Article:

Boutis K, Plint A, et al. (2016). Radiograph-negative lateral ankle injuries in children. Occult growth plate fracture or sprain? JAMA Pediatrics, 170(1):e154114.

Editorial:

Gill PJ & Klassen T. (2016). Revisiting radiograph-negative ankle injuries in children. Is it a fracture or a sprain? JAMA Pediatrics, 170(1):e154147.

Dr. Kathy Boutis is an Emergency Physician at the Hospital for Sick Children (Sick Kids) and is the TREKK content advisor for fractures.

Second author, Dr. Amy Plint is a an Emergency Physician at the Children's Hospital of Eastern Ontario (CHEO), a TREKK board member, the TREKK content advisor for bronchiolitis, and chair of Pediatric Emergency Research Canada (PERC).