ObjectivesPediatric ankle injuries remain one of the most common presenting complaints to the pediatric emergency department (PED). In this study, we aimed to describe risk factors associated with simple ankle fractures and ankle fractures that require surgery, among adolescents presenting to the PED with ankle injuries.MethodsWe analyzed a retrospective cohort study of adolescents 12 to 16 years old who presented to our PED with an acute ankle injury and received an ankle radiograph from November 1, 2016, to October 31, 2017. Demographic, anthropometric variables, physical examination findings including those of the Ottawa Ankle Rules were obtained. We recorded any surgical interventions required, as well as follow-up and to return to physical activity.ResultsFive hundred fifty-six cases of adolescent ankle injuries were reviewed, of which 109 adolescents had ankle fractures, whereas 19 had ankle fractures requiring surgery. Sports-related injuries remained the most common cause of ankle fractures. Age (adjusted odds ratio [aOR], 0.69; 95% confidence interval [CI], 0.56–0.83; P < 0.001), male sex (aOR, 2.12; 95% CI, 1.34–3.35; P < 0.001), clinical findings of tenderness over the lateral malleolus (aOR, 3.13; 95% CI, 1.74–5.64; P < 0.001) or medial malleolus (aOR, 3.55; 95% CI, 2.18–5.78; P < 0.001), and inability to walk (aOR, 3.09; 95% CI, 1.95–4.91; P < 0.001) were significant independent risk factors for ankle fractures.Patients with a weight more than 90th centile for age were at greater risk of ankle fractures requiring surgery (aOR, 2.64; 95% CI, 1.05–6.64; P = 0.04).ConclusionsWe found that younger age, male sex, and clinical findings in the Ottawa Ankle Rules correlated well with predicting ankle fractures and are well suited for application in the Southeast Asian population. Weight greater than the 90th percentile for age was a significant risk factor for ankle fractures requiring surgery.