Radiograph-negative ankle injury (peds)

(Redirected from Ankle pain (peds))


  • Pediatric ankle injuries are common (>2 million ED visits in North America per year)[1]
  • Historically, there has been concern about missing a potential growth plate fracture (Salter-Harris Type 1), which can rarely result in growth arrest[1]
    • It was previously taught that the weaker physis would fail before the stronger ligamentous complex.[2]
    • This was commonly treated with immobilization (casting), follow-up imaging, and orthopedic referral (as opposed to adult ankle sprain)
  • Recent studies have questioned the need for this practice[3][4]
    • There was no measurable difference in functional recovery for children with or without Salter Harris Type 1 distal fibula fractures at 1 and 3 months[4]

Clinical Features

  • Lateral ankle pain (tenderness and/or swelling) after inversion injury in a pediatric patient
    • Studies to date have not addressed medial ankle pain

Differential Diagnosis


  • Consider ankle x-rays

Ottawa ankle rule

Ottawa ankle rule

Ankle x-ray needed if:

  • Pain near the maleoli AND
  • Inability to bear weight immediately and in the ED (4 steps) OR
  • Tenderness at posterior edge or tip of lateral malleolus OR
  • Tenderness at posterior edge or tip of medial malleolus

Ottawa foot rules

Ottawa foot rules

Foot x-ray series needed if:

  • Pain in the midfoot AND
  • Inability to bear weight both immediately and in the ED (4 steps) OR
  • Tenderness at the navicular OR
  • Tenderness at the base of the 5th metatarsal


  • Removable ankle brace
  • Return to activities as tolerated by pain

Patients do NOT need

  • Full immobilization (cast or non-removable splint)
  • Referral to orthopedics
  • Repeat x-ray films (or MRI)


  • Discharge with PCP follow-up

See Also

External Links


  1. 1.0 1.1 Gill PJ, Klassen T. Revisiting radiograph-negative ankle injuries in children: is it a fracture or a sprain? JAMA Pediatr. 2016; 170(1):e154147-e154147.
  2. Blackburn EW, Aronsson DD, Rubright JH, Lisle JW. Ankle fractures in children. J Bone Joint Surg Am. 2012; 94(13):1234-1244.
  3. 6. Boutis K, Narayanan UG, Dong FF, et al. Magnetic resonance imaging of clinically suspected Salter-Harris I fracture of the distal fibula. Injury. 2010;41(8):852-856.
  4. 4.0 4.1 Boutis K, Plint A, Stimec J, et al. Radiograph-negative lateral ankle injuries in children: occult growth plate fracture or sprain? JAMA Pediatr. 2016; 170(1):e154114-e154114.