Article

Clinical Usefulness of the Ottawa Ankle Rules for Detecting Fractures of the Ankle and Midfoot

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Abstract

Reference Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003;326(7386):417–423. Clinical Question What is the evidence for the accuracy of the Ottawa Ankle Rules as a decision aid for excluding fractures of the ankle and midfoot? Data Sources Studies were identified by searching MEDLINE and PreMEDLINE (Ovid version: 1990 to present), EMBASE (Datastar version: 1990–2002), CINAHL (Winspires version: 1990–2002), the Cochrane Library (2002, issue 2), and the Science Citation Index database (Web of Science by Institute for Science Information). Reference lists of all included studies were also searched, and experts and authors in the specialty were contacted. The search had no language restrictions. Study Selection Minimal inclusion criteria consisted of (1) study assessment of the Ottawa Ankle Rules and (2) sufficient information to construct a 2 × 2 contingency table specifying the false-positive and false-negative rates. Data Extraction Studies were selected in a 2-stage process. First, all abstracts and titles found by the electronic searches were independently scrutinized by the same 2 authors. Second, copies of all eligible papers were obtained. A checklist was used to ensure that all inclusion criteria were met. Disagreements related to the eligibility of studies were resolved by consensus. Both authors extracted data from each included study independently. Methods of data collection, patient selection, blinding and prevention of verification bias, and description of the instrument and reference standard were assessed. Sensitivities (using the bootstrap method), specificities, negative likelihood ratios (using a random-effects model), and their standard errors were calculated. Special interest was paid to the pooled sensitivities and negative likelihood ratios because of the calibration of the Ottawa Ankle Rules toward a high sensitivity. Exclusion criteria for the pooled analysis were (1) studies that used a nonprospective data collection, (2) unknown radiologist blinding (verification bias), (3) studies assessing the performance of other specialists (nonphysicians) using the rules, and (4) studies that looked at modifications to the rules. Main Results The search yielded 1085 studies, and the authors obtained complete articles for 116 of the studies. The reference lists from these studies provided an additional 15 studies. Only 32 of the studies met the inclusion criteria and were used for the review; 5 of these met the exclusion criteria. For included studies, the total population was 15 581 (range = 18–1032), and average age ranged from 11 to 31.1 years in those studies that reported age. The 27 studies analyzed (pooled) consisted of 12 studies of ankle assessment, 8 studies of midfoot assessment, 10 studies of both ankle and midfoot assessment, and 6 studies of ankle or midfoot assessment in children (not all studies assessed all regions). Pooled sensitivities, specificities, and negative likelihood ratios for the ankle, midfoot, and combined ankle and midfoot are presented in the Table. Based on a 15% prevalence of actual fracture in patients presenting acutely after ankle or foot trauma, less than a 1.4% probability of fracture existed. Because limited analysis was conducted on the data from the children, we elected to not include this cohort in our review. Conclusions Evidence supports the use of the Ottawa Ankle Rules as an aid in ruling out fractures of the ankle and midfoot. The rules have a high sensitivity (almost 100%) and modest specificity. Use of the Ottawa Ankle Rules holds promise for saving time and reducing both costs and radiographic exposure without sacrificing diagnostic accuracy in ankle and midfoot fractures.

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... The Ottawa ankle rules represent an important instrument to safely predict fracture possibility due to high sensitivity presented in several studies.[12345678910111213141516] ...
... Several studies validated the Ottawa ankle rules as an effective tool to safety decrease the number of radiographic exams in foot and/or ankle injuries to 28-40%.[567891011121314151617] ...
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Background: Foot and ankle injuries are frequent in emergency departments. Although only a few patients with foot and ankle sprain present fractures and the fracture patterns are almost always simple, lack of fracture diagnosis can lead to poor functional outcomes. Aim: The present study aims to evaluate the reliability of the Ottawa ankle rules and the orthopedic surgeon subjective perception to assess foot and ankle fractures after sprains. Subjects and methods: A cross-sectional study was conducted from July 2012 to December 2012. Ethical approval was granted. Two hundred seventy-four adult patients admitted to the emergency department with foot and/or ankle sprain were evaluated by an orthopedic surgeon who completed a questionnaire prior to radiographic assessment. The Ottawa ankle rules and subjective perception of foot and/or ankle fractures were evaluated on the questionnaire. Results: Thirteen percent (36/274) patients presented fracture. Orthopedic surgeon subjective analysis showed 55.6% sensitivity, 90.1% specificity, 46.5% positive predictive value and 92.9% negative predictive value. The general orthopedic surgeon opinion accuracy was 85.4%. The Ottawa ankle rules presented 97.2% sensitivity, 7.8% specificity, 13.9% positive predictive value, 95% negative predictive value and 19.9% accuracy respectively. Weight-bearing inability was the Ottawa ankle rule item that presented the highest reliability, 69.4% sensitivity, 61.6% specificity, 63.1% accuracy, 21.9% positive predictive value and 93% negative predictive value respectively. Conclusion: The Ottawa ankle rules showed high reliability for deciding when to take radiographs in foot and/or ankle sprains. Weight-bearing inability was the most important isolated item to predict fracture presence. Orthopedic surgeon subjective analysis to predict fracture possibility showed a high specificity rate, representing a confident method to exclude unnecessary radiographic exams.
... Almost all patients admitted to the emergency department with a main complaint of pain in the foot or ankle are exposed to radiographic examinations. Despite the widespread use of OAR, fractures are seen in less than 15% of these patients [16,17]. In studies made, the fracture rate among patients presenting with foot or ankle injury and meeting OAR was reported to be 22% to 39.8% [17,18]. ...
... Despite the widespread use of OAR, fractures are seen in less than 15% of these patients [16,17]. In studies made, the fracture rate among patients presenting with foot or ankle injury and meeting OAR was reported to be 22% to 39.8% [17,18]. In the present study, a lower fracture rate (15.2%) was established. ...
... for Ottawa ankle and foot rules, 98% for Amsterdam wrist rules) but low specificity(26.3% for Ottawa rules and 21% for Amsterdam wrist rules) for detecting fractures [4], [5]. The radiography alone can miss up to 4.1%, 5.4%, 2.8%, and 7.6% of wrist, hand, ankle, and foot fractures respectively [6]. ...
Article
Introduction Point of care ultrasound (POCUS) has variable diagnostic accuracy in diagnosing fractures. Waterbath technique is a modification of the conventional ultrasound technique which may improve diagnostic accuracy by enhancing image quality. Authors studied the diagnostic accuracy of waterbath technique compared to the final diagnosis based on clinical examination and radiology in the identification of fractures of hand and foot. Methods Patients of >18 yrs. age with suspected distal hand and foot fractures presenting to the emergency department of a level 1 trauma center were recruited after informed consent. Unconscious and hemodynamically unstable patients, injuries >72 h old, open fractures, obvious deformities, and old fractures at the affected site were excluded. Cases were subjected to waterbath technique performed by an academic emergency medicine resident and relevant radiographs were ordered and interpreted by an orthopedic specialist. CT/MRI, if done in case of discrepancy, was interpreted by radiologist. The findings of both waterbath technique and radiology were blinded to each other and compared to the final diagnosis made by a cumulative assessment of clinical examination, radiographs, and CT/MRI of the discrepant cases. Results Waterbath technique identified fractures of hand and foot with sensitivity of 97% (95% CI 90%–100%), specificity 94% (95%CI 81%–99%), PPV 98% (95%CI 91%–99%), NPV 94% (95%CI 79%–98%), LR+ 17.5(95% CI 4.5–67.2), LR- 0.03(95% CI 0.01–0.12) and diagnostic accuracy 96% (95%CI 91%–99%). Conclusion This pilot study has demonstrated the utility of Waterbath technique in the diagnosis of fractures of hand and foot in adults in the ED setting. Future well designed studies are required to explore the potential of this novel technique in both adult and pediatric population.
... Using the OAR has decreased the costs and unnecessary radiography [12,13]. One of the reasons for applying the standard was ruling out a fracture without using X-ray in order to save time and provide cost-benefit proper services [14], and the resultant reduction in hospital unnecessary stay [15]. ...
Article
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Introduction: Ankle sprain is one of the most common musculoskeletal injuries that occur most commonly in the active and working population. Ottawa and Burns Laws are tools for physicians to determine the need for a radiograph of an ankle injury. The purpose of this study was to evaluate the accuracy of the Ottawa and Bernese criteria in patients with torsion of the foot and the economical savings resulting from the application of these two criteria. Methods: This prospective study was designed to evaluate the two rules burns of Bernese and Ottawa and their economic savings were designed in two phases. They were referred to Poursina Medical Center, Rasht, Iran from September 2019 to the achieved sample size. Data were analyzed by SPSS software version 24 (Statistical Package for Social Science (SPSS) 21, Chicago, IL, USA). Results: A total of 800 patients were included in this study to determine the accuracy of bronze and Ottawa criteria in ankle torsion and the economic cost of using them. Of the 800 patients studied, 430 (53.7%) were male and 370 (46.3%) were female, with a mean age of 35.77±16.42 years. The diagnostic accuracy of the Ottawa criteria is 90% and the diagnostic accuracy of the Bernese criteria is 90.75%. The sensitivity of the Ottawa evaluation method was 97.6% and the specificity was 88%. The sensitivity of Bernese evaluation method was 91% and specificity was 90.7%. Conclusion: Because of the higher sensitivity of the Ottawa criterion than the Bernese criteria, it is preferred to determine the probability of fracture for emergency unit personnel. Using these two methods can reduce the time, energy and cost of treatment for the patient during the treatment period.
... There is literature to suggest clinicians are not using the OAR routinely in practice 23,24 despite a strong evidence base supporting its use. 25,26 For example, Graham et al 23 examined emergency physicians' awareness and use of the Ottawa ankle and knee rules across five countries and found that although 96% of physicians employed in the United States were aware of the OAR, only 31% self-reported use of the clinical prediction rule "always" or "most of the time". A similar investigation was conducted in athletic training, 24 which also highlighted a large knowledge-to-practice gap regarding OAR use. ...
Article
As the athletic training profession continues to embrace evidence-based practice, athletic trainers should not only critically appraise the best available evidence, but also effectively translate it into clinical practice to optimize patient outcomes. While previous research has investigated the effectiveness of educational interventions on increasing knowledge of critical appraisal of evidence, little attention has been given to strategies for both researchers and clinicians to effectively translate evidence into clinical practice. The use of knowledge translation strategies has potential to bridge the knowledge-to-practice gap, which could lead to reduced health costs, improved patient outcomes, and enhanced quality of care. The purpose of this paper is to 1) highlight current challenges prohibiting successful translation of evidence into practice, 2) discuss knowledge translation and describe conceptual frameworks behind effectively translating evidence into practice, and 3) identify considerations for athletic trainers as they continue to provide high quality patient care in an evidence-based manner.
... Uteslut total eller partiell ruptur av akillessenan. [34]. Vid utebliven effekt efter 6 månaders ickeoperativ be handling rekommenderas remiss till ortopedspecia list. ...
... Stable injury without diastasis can be managed conservatively with immobilization in a short walker boot and limited weight-bearing for 2 weeks, followed by weight-bearing as TABLE Are x-rays needed to differentiate ankle injuries? Ottawa Ankle Rules a often provide an answer [15][16][17] An ankle series is indicated when: ...
Article
A missed diagnosis of one of these conditions risks delay in referral for orthopedic evaluation and surgical management-possibly leading to complications.
... Then clinicians can confidently adopt a CPR that has been externally validated and proven to improve relevant clinical outcomes. For example, the Ottawa ankle rules showed robust predictive performance in wide range of populations and settings [77][78][79] and reduced utilization of radiography without jeopardizing clinical outcomes in impact studies [80][81][82][83]. Many GPs recognize and use Ottawa ankle rules in clinical practice despite lack of clinical guidelines on use of these CPRs at the point of care [9]. ...
Article
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Background Researchers should examine existing evidence to determine the need for a new study. It is unknown whether developers evaluate existing evidence to justify new cardiovascular clinical prediction rules (CPRs). Objective We aimed to assess whether authors of cardiovascular CPRs cited existing CPRs, why some authors did not cite existing CPRs, and why they thought existing CPRs were insufficient. Method Derivation studies of cardiovascular CPRs from the International Register of Clinical Prediction Rules for Primary Care were evaluated. We reviewed the introduction sections to determine whether existing CPRs were cited. Using thematic content analysis, the stated reasons for determining existing cardiovascular CPRs insufficient were explored. Study authors were surveyed via e-mail and post. We asked whether they were aware of any existing cardiovascular CPRs at the time of derivation, how they searched for existing CPRs, and whether they thought it was important to cite existing CPRs. Results Of 85 derivation studies included, 48 (56.5%) cited existing CPRs, 33 (38.8%) did not cite any CPR, and four (4.7%) declared there was none to cite. Content analysis identified five categories of existing CPRs insufficiency related to: (1) derivation (5 studies; 11.4% of 44), (2) construct (31 studies; 70.5%), (3) performance (10 studies; 22.7%), (4) transferability (13 studies; 29.5%), and (5) evidence (8 studies; 18.2%). Authors of 54 derivation studies (71.1% of 76 authors contacted) responded to the survey. Twenty-five authors (46.3%) reported they were aware of existing CPR at the time of derivation. Twenty-nine authors (53.7%) declared they conducted a systematic search to identify existing CPRs. Most authors (90.7%) indicated citing existing CPRs was important. Conclusion Cardiovascular CPRs are often developed without citing existing CPRs although most authors agree it is important. Common justifications for new CPRs concerned construct, including choice of predictor variables or relevance of outcomes. Developers should clearly justify why new CPRs are needed with reference to existing CPRs to avoid unnecessary duplication.
... Jepkin et al. [16] reported that the sensitivity of OAR was 98%, specifity was 39.8%, and the fracture rate was 24.32%; Bachmann et al. [9] reported a sensitivity of 97.3%; Aslan et al. reported a fracture detection rate of 42.3%, a sensitivity of 98-100%, and a specifity of 22-45% [1]. Stiell et al. showed that the sensitivity of OAR was 99% [17]. ...
Article
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Aim: This study was a prospective validation of the Ottawa Ankle Rules (OAR) in our patient population with ankle injury. Materials and Methods: This was a prospective study conducted. Each patient’s demographic characteristics, radiography results, and status of meeting OAR criteria were recorded on a previously prepared study form. The descriptive statistics were presented as Mean, Standard Deviation, and percentage. Categorical variables were analyzed using Chi-Square test. The correlation between OAR positivity and presence of a fracture was analyzed using the Spearman’s correlation analysis. Results: The sensitivity of OAR was 100%, specificity 27%, negative predictive value 100%, and the positive predictive value 17%. Conclusion: A careful physical examination and use of OAR may allow avoiding unnecessary tests.
... Sensitivity represents the number of patients with the condition and with a positive test. [14] For this reason, an OAR (-) finding is a reasonable indication that no fracture is present. Specificity represents the number of patients without the condition and with a negative test. ...
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Background: The present objective was to assess implementation of the Ottawa ankle rules (OAR) as a method of fracture prediction in the emergency department (ED) of a Turkish state hospital. Methods: Patients who presented to the ED of our hospital with acute ankle injury were evaluated. All were examined by a general practitioner, after which a series of ankle and foot x-rays (anteroposterior and lateral) were performed. Radiography was examined by a radiologist and an orthopedic surgeon, both of whom were blinded to OAR results. Radiographic results were compared to results of OAR implementation. Sensitivity and specificity of the OAR in the diagnosis of fracture was calculated. Results: A total of 251 (61.97%) patients were diagnosed as positive (+) for fracture after OAR implementation, 154 (38.02%) as negative (-). Clinically significant fracture was detected in 62 (15.3%) patients. A total of 61 (98.4%) patients with significant fracture were OAR (+); 1 (1.6%) was OAR (-). However, 190 (55.4%) patients without fracture were OAR (+); 153 (44.6%) were OAR (-) (p<0.001). Sensitivity, specificity, and positive and negative predictive values of OAR implementation in the prediction of fracture were 98.39%, 44.61%, 24.30%, and 99.35%, respectively. Area under the curve (AUC) was 0.71. According to these results, it was determined that use of radiography could be reduced by 38.02% if the OAR were implemented. Conclusion: The OAR are a highly sensitive means of screening of patients with acute ankle and mid-foot injuries. Application of the OAR by well-trained general practitioners can lead to significant reduction in the number of x-rays performed, thereby reducing cost of treatment and radiation exposure, in addition to saving time for patients and staff.
... Sensitivity represents the number of patients with the condition and with a positive test. [14] For this reason, an OAR (-) finding is a reasonable indication that no fracture is present. Specificity represents the number of patients without the condition and with a negative test. ...
Article
BACKGROUND: The present objective was to assess implementation of the Ottawa ankle rules (OAR) as a method of fracture prediction in the emergency department (ED) of a Turkish state hospital. METHODS: Patients who presented to the ED of our hospital with acute ankle injury were evaluated. All were examined by a general practitioner, after which a series of ankle and foot x-rays (anteroposterior and lateral) were performed. Radiography was examined by a radiologist and an orthopedic surgeon, both of whom were blinded to OAR results. Radiographic results were compared to results of OAR implementation. Sensitivity and specificity of the OAR in the diagnosis of fracture was calculated. RESULTS: A total of 251 (61.97%) patients were diagnosed as positive (+) for fracture after OAR implementation, 154 (38.02%) as negative (-). Clinically significant fracture was detected in 62 (15.3%) patients. A total of 61 (98.4%) patients with significant fracture were OAR (+); 1 (1.6%) was OAR (-). However, 190 (55.4%) patients without fracture were OAR (+); 153 (44.6%) were OAR (-) (p<0.001). Sensitivity, specificity, and positive and negative predictive values of OAR implementation in the prediction of fracture were 98.39%, 44.61%, 24.30%, and 99.35%, respectively. Area under the curve (AUC) was 0.71. According to these results, it was determined that use of radiography could be reduced by 38.02% if the OAR were implemented. CONCLUSION: The OAR are a highly sensitive means of screening of patients with acute ankle and mid-foot injuries. Application of the OAR by well-trained general practitioners can lead to significant reduction in the number of x-rays performed, thereby reducing cost of treatment and radiation exposure, in addition to saving time for patients and staff.
... Ottawa-kriterierna används för att bedöma behov av slätröntgenundersökning av fotleden i akutskedet [15] och är lika användbara på vårdcentralen som på akutmottagningen [3]. Beslutet baseras på palpationsömhet bakom malleolerna re spektive över båtbenet och basen av femte strålbenet. ...
... The possible reduction of 51% in the radiographs means that the OARs protocol will allow doctors to spend more time examining the patients, reduce waiting time for the patients, and decrease the radiation hazard to both patients and emergency staff. In the present era of cost containment, increased awareness of unnecessary tests and procedures will only become more significant (13). Accordingly, clinicians will need to use these rules to cut cost for both the hospital and patient. ...
Article
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Ankle injuries are one of the most common presentations in emergency department. Ottawa Ankle Rules (OARs) have been used to predict the requirement of radiographs. This study aimed to validate the OARs protocol for predicting ankle and midfoot fractures in Indian population. A prospective study was conducted in a teaching hospital in north India, during a period of nine months, including all patients who presented with complaints in the ankle region and evolution of less than 48 hours. The study excluded patients with multiple trauma and Glasgow coma scale of less than 15. All patients underwent clinical evaluation, followed by radiographs depending upon the location of the complaints. Radiographic study results were evaluated by orthopedic surgeons who had not seen the patient. We evaluated 140 patients (84 males and 60 females) with the mean age of 35.2 (range, 8 - 76 years). Of the 140 evaluable patients, 71 had positive criteria for radiological evaluation of which 43 presented with fracture, 69 had negative criteria for radiography with no fracture. The sensitivity of OARs to detect fractures was 100%. The implementation of the OARs appears to have the potential to reduce the number of radiographs for the assessment of these patients by about 51%. The implementations of OARs have the potential to reduce the number of X-ray graphics needed to assess these patients by about 51%. The results of this study demonstrate no false negatives and are in agreement with results from other similar studies. It encourages us to implement these criteria in our services urgently, with all the resulting socio-economic implications.
... With the application of the OAC, exposure to radiation is significantly reduced without compromising diagnostic thoroughness, time is saved and healthcare costs are reduced.[6,7]In a study by Jenkin et al.,[8]OAC sensitivity was reported to be 98%. In the current study, there was no problem about 29 patients whose OAC (−) and who wasn't felt to be any need for any imaging study. ...
Article
Background: The aim of this study was to suggest a safe management method for the diagnosis and treatment of ankle sprains in pregnant patients. Methods: Between November 2005 and January 2013, 96 pregnant patients with ankle sprains referred to the department of orthopedics and traumatology were evaluated, retrospectively. The Ottawa ankle rules were used to assess the need for radiologic evaluation. Radiological procedures: Surface USG, X-ray (0,6 mGy, mortise view), MRI (T1 and STIR) and fluoroscopy with 0,8 mGy/s doses 0,4 ms single shot views in surgery room. The results of the operated patients were evaluated with AOFAS scoring system. Results: Forty-four (45,8%) patients were treated with conservative methods and there was no need for radiological evaluation. USG was used in 17 (17,7%), MRI in 24 (25%), X-ray in 4 (4,1%) and both USG and MRI in 7 (7,2%) patients during diagnosis. An algorithm was created for the diagnosis and treatment of pregnant patients with ankle sprains. No complications due to radiological and surgical procedures occurred over pregnancies. The AOFAS score was 83 (65-100) in the operated patients. Conclusion: There is no standard management method for the diagnosis and treatment of pregnant patients with ankle sprains. The algorithm presented in this study may be useful. Good results can be obtained with an appropriate preparation and surgical technique.
... Ottawa-kriterierna används för att bedöma behov av slätröntgenundersökning av fotleden i akutskedet [15] och är lika användbara på vårdcentralen som på akutmottagningen [3]. Beslutet baseras på palpationsömhet bakom malleolerna re spektive över båtbenet och basen av femte strålbenet. ...
... B.R. was unable to bear weight to walk on her right foot and had distinct point tenderness at the posterior edge of the right lateral malleolus (6 cm) with swelling. Following application of the Ottawa Ankle Rules (Jenkin, Sitler, & Kelly, 2010), B.R. was transported to the local emergency department (ED) for a right ankle x-ray, which was negative for fracture. She was given a written return-to-work report from the ED physician to provide to her employer, indicating she could return to work on her next work day, that she must wear a semi-rigid ankle brace, apply ice 20 minutes four times daily, and elevate her foot as much as possible. ...
Article
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Many older adults are working beyond what was considered a "normal" retirement age in past generations. If work-related injury occurs, older adults may have increased vulnerabilities due to age and comorbid conditions not shared by their younger working peers. This article presents an individual example in which these vulnerabilities are explored, and unique processes within the work environment are noted. Awareness of the risks to older workers will aid clinicians in any setting to maximize prevention and management of co-morbidities that improve health status, function, and employment performance for older workers.
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Musculoskeletal injuries are a common reason for emergency department and primary care visits in the pediatric population. The prevalence of these injuries is likely related to children and adolescents participating in sports activities, physical activity, and exercise that can lead to these injuries. It is important for health care professionals and practitioners to understand the assessment, evaluation, and treatment of musculoskeletal injuries, but also to understand when to refer for expert consultation. [Pediatr Ann. 2022;51(9):e330-337.].
Article
Objective: The aim of the study was to evaluate the validity and safety of Ottawa's Ankle Rules (OAR) in the urgency department of referral hospital in Peru Methods: An observational - transversal study was conducted for a duration of 5 months (april-june 2016). Target population were all patients older than 18 years with a foot and ankle injury who came to the urgency department. A convenience non-randomized sampling was used. The OAR test was applied and X-rays of the foot and/or ankle were performed in all patients who met the inclusion and exclusion criteria. The data obtained was analysed using the SPSS 20.0 software. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and likelihood ratio (LR) positive and negative, were calculated from statistical analysis. Results: 428 patients were evaluated. The OAR test’s sensitivity was 97.2%, specificity was 30.3%, PPV was 22.0%, NPV was 98.2%, LR positive (LR+ = 1.39) and LR negative (LR- = 0.09) were reported. With the application of the OAR test, a reduction of 31.2% of the total X-rays was evidenced, which could generate a saving of US $ 1,165. Conclusions: In conclusion, OAR’s validity and safety in our environment are comparable to international data, with a reduction in the unnecessary use of radiographs. Multicentric studies involving a larger sample and longer study time are necessary to protocolize OAR in emergency units. Level of evidence: 3
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Resumen Objetivo Evaluar la validez y seguridad de las reglas de Ottawa para medio pie y tobillo (ROmPT) en el servicio de urgencias de un hospital de referencia en Perú. Materiales y métodos El estudio fue observacional, transversal con duración de 5 meses (de febrero a junio de 2016). La población fueron los pacientes mayores de 18 años con un traumatismo de pie y/o tobillo que acudieron al servicio de urgencias. Se realizó un muestreo no aleatorizado por conveniencia. Se aplicaron las ROmPT y se realizaron rayos X de pie y/o tobillo a los pacientes que cumplieron los criterios de inclusión y exclusión. Los datos fueron tabulados y analizados con el programa SPSS v. 20.0. Se calcularon medidas de validez diagnóstica (sensibilidad, especificidad), seguridad diagnóstica (valor predictivo positivo, valor predictivo negativo) y likelihood ratio positiva y negativa. Resultados Se evaluaron 428 pacientes. El uso de las ROmPT obtuvo una sensibilidad del 97,2%, una especificidad del 30,3%, un valor predictivo positivo del 22,0%, un valor predictivo negativo del 98,2%, una likelihood ratio positiva de 1,39 y negativa de 0,09. Con la aplicación de las ROmPT, se evidenció una reducción del 31,2% del total de rayos X, que pudo generar un ahorro de 1.165 $. Conclusiones Se concluye que la validez y seguridad de las ROmPT en nuestro medio son comparables a las de estudios internacionales, con una posible reducción del uso de rayos X. Son necesarios estudios multicéntricos, con mayor tiempo de duración y cantidad de pacientes, para protocolizar el uso de este método en servicios de urgencias.
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The Ottawa ankle rules (OAR) indicate that any patient with the inability to ambulate up to four steps or with tenderness at either malleoli should receive diagnostic imaging for an acute ankle injury. Current trends indicate that health care providers tend to order more images in practice than necessary according to OAR. The purpose of this study is to analyze OAR in geriatric versus nongeriatric patients. Secondarily, we hope to refine these guidelines for ankle imaging in the hopes that health care providers will be comfortable in adhering to these guidelines more strictly. A retrospective chart review was conducted of 491 adult patients with an average (± standard deviation) age of 54.4 ± 21.6 years (range 18 to 96). Applying the current OAR resulted in a sensitivity of 98.2% and a specificity of 58.6% in this entire cohort. The calculated sensitivities were comparable between the nongeriatric and geriatric cohorts, at 98.60% and 97.99%, respectively. The specificities varied between the nongeriatric and geriatric cohorts, at 60.13% and 33.33%. We propose new guidelines that would mandate imaging studies for any patient ≥65 years of age presenting to the emergency department with ankle pain. When applying these proposed guidelines, the sensitivity of the entire study population was found to be improved to 99.0%, whereas the specificity dropped to 56.7%. The slight decrease in specificity was deemed acceptable because these guidelines are meant to be used as a screening tool and because the risk of OAR not correctly identifying ankle fracture (2% of geriatric fractures) was completely mitigated in the geriatric population.
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Physical activity is becoming an increasingly popular lifestyle choice as people are encouraged to make healthier choices. Extreme sports, such as running marathons, have become mainstream, resulting in a higher incidence of training injuries that stem from individuals with previously low levels of activity prepping for high-intensity workouts. Primary health care providers must diagnose and manage many common lower extremity injuries and refer severe injuries to specialists. This article will focus on the evaluation, diagnosis, and management of 4 common foot and ankle injuries.
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Participation at university-sponsored summer sport camps is popular among youth athletes; however, there is a dearth of information to describe the injuries/illnesses experienced by camp participants. Data from a university-sponsored sport camp program from 2008 to 2011 were accessed retrospectively. The sport camp program had approximately 80 camps for 28 sports over 12 weeks annually. Male and female participants were 10 to 17 years old. Athletic trainers maintained medical documentation and provided medical referrals. Referrals were made for 9.9% (n = 478) of all injuries/illnesses. Emergency department referrals were made for 2.9% of injuries/illnesses. University health services received 42.5% of referrals. There were 1.1 referrals per 100 participants. Boys comprised 60.7% of referrals. Rugby had the highest referral rate-5.0 per 100 participants. These data help increase physician preparedness and guide the delivery of sports medicine services for related sport camp programs as a means to improve quality of care delivered to participants.
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Objective: To present recommendations for athletic trainers and other allied health care professionals in the conservative management and prevention of ankle sprains in athletes. Background: Because ankle sprains are a common and often disabling injury in athletes, athletic trainers and other sports health care professionals must be able to implement the most current and evidence-supported treatment strategies to ensure safe and rapid return to play. Equally important is initiating preventive measures to mitigate both first-time sprains and the chance of reinjury. Therefore, considerations for appropriate preventive measures (including taping and bracing), initial assessment, both short- and long-term management strategies, return-to-play guidelines, and recommendations for syndesmotic ankle sprains and chronic ankle instability are presented. Recommendations: The recommendations included in this position statement are intended to provide athletic trainers and other sports health care professionals with guidelines and criteria to deliver the best health care possible for the prevention and management of ankle sprains. An endorsement as to best practice is made whenever evidence supporting the recommendation is available.
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To summarise the evidence on accuracy of the Ottawa ankle rules, a decision aid for excluding fractures of the ankle and mid-foot. Systematic review. Electronic databases, reference lists of included studies, and experts. Data were extracted on the study population, the type of Ottawa ankle rules used, and methods. Sensitivities, but not specificities, were pooled using the bootstrap after inspection of the receiver operating characteristics plot. Negative likelihood ratios were pooled for several subgroups, correcting for four main methodological threats to validity. 32 studies met the inclusion criteria and 27 studies reporting on 15 581 patients were used for meta-analysis. The pooled negative likelihood ratios for the ankle and mid-foot were 0.08 (95% confidence interval 0.03 to 0.18) and 0.08 (0.03 to 0.20), respectively. The pooled negative likelihood ratio for both regions in children was 0.07 (0.03 to 0.18). Applying these ratios to a 15% prevalence of fracture gave a less than 1.4% probability of actual fracture in these subgroups. Evidence supports the Ottawa ankle rules as an accurate instrument for excluding fractures of the ankle and mid-foot. The instrument has a sensitivity of almost 100% and a modest specificity, and its use should reduce the number of unnecessary radiographs by 30-40%.
Article
In a sports medicine center, we prospectively evaluated the Ottawa Ankle Rules over 1 year for their ability to identify clinically significant ankle and midfoot fractures and to reduce the need for radiography. We also developed a modification to improve specificity for malleolar fracture identification. Patients with acute ankle injuries (< or = 10 days old) had the rules applied and then had radiographs taken. Sensitivity, specificity, and the potential reduction in the use of radiography were calculated for the Ottawa Ankle Rules in 132 patients and for the new "Buffalo" rule in 78 of these patients. There were 11 clinically significant fractures (fracture rate, 8.3% per year). In these 132 patients, the Ottawa Ankle Rules would have reduced the need for radiography by 34%, without any fractures being missed (sensitivity 100%, specificity 37%). In 78 patients, the specificity for malleolar fracture for the new rule was significantly greater than that of the Ottawa Ankle Rules malleolar rule (59% versus 42%), sensitivity remained 100%, and the potential reduction in the need for radiography (54%) was significantly greater. The Ottawa Ankle Rules could significantly reduce the need for radiography in patients with acute ankle and midfoot injuries in this setting without missing clinically significant fractures. The Buffalo modification could improve specificity for malleolar fractures without sacrificing sensitivity and could significantly reduce the need for radiography.
Article
To develop decision rules that will predict fractures in patients with ankle injuries, thereby assisting clinicians in being more selective in their use of radiography. Prospective survey of emergency department patients over a five-month period. Two university hospital EDs. One hundred fifty-five adults in a pilot stage and 750 in the main study; all presented with acute blunt ankle injuries. Thirty-two standardized clinical variables were assessed and recorded on data sheets by staff emergency physicians before radiography. Variables were assessed for reliability by the kappa coefficient and for association with significant fracture on both ankle and foot radiographic series by univariate analysis. The data then were analyzed by logistic regression and recursive partitioning techniques to develop decision rules for predicting fractures in each radiographic series. All 70 significant malleolar fractures found in the 689 ankle radiographic series performed were identified among people who had pain near the malleoli and were age 55 years or more, had localized bone tenderness of the posterior edge or tip of either malleolus, or were unable to bear weight both immediately after the injury and in the ED. This rule was 100% sensitive and 40.1% specific for detecting malleolar fractures and would allow a reduction of 36.0% of ankle radiographic series ordered. Similarly, all 32 significant midfoot fractures on the 230 foot radiographic series performed were found among patients with pain in the midfoot and bone tenderness at the base of the fifth metatarsal, the cuboid, or the navicular. Highly sensitive decision rules have been developed and will now be validated; these may permit clinicians to confidently reduce the number of radiographs ordered in patients with ankle injuries.
Article
A retrospective survey of over 2000 patients with inversion injuries of the ankle joint was undertaken to examine the validity of criteria commonly used in an accident and emergency department to assess severity. Swelling alone is an unreliable indicator of the severity of the injury. Patients with severe pain and inability to weight bear show a high incidence of fractures and must be X-rayed. Conversely, a combination of minimal pain and swelling, and ability to bear weight are indicative of a soft-tissue injury. Young people sustain most inversion injuries and have a lower incidence of significant fractures of the lateral malleolus. Analysis of presenting features did not reveal any reliable indicants which could be used to reduce the number of radiographs requested, without substantially increasing the risk of missing patients with significant fractures. However, it has been possible to formulate guidelines for the more rational and consistent use of X-rays in the initial assessment of patients with ankle sprains.
Article
Inversion injuries of the ankle are a common cause of referral and presentation to accident units. They impose a load on radiographic services. A prospective trial was carried out to determine the accuracy of clinical examination. All patients were assessed clinically then examined radiographically, the clinical assessment missed 5% of the fractures. These, however, were all minor avulsion fractures or crush fractures and Tubigrip support was sufficient. Clinical examinations is, therefore, accurate and the need for most x-ray examination is questionable. X-ray examination should be reserved for patients with continuing pain or those who clinically have a fracture requiring immobilisation. This would produce a large saving in NHS resources.
Article
Diagnosis is an important aspect of physical therapist practice. Selecting tests that will provide the most accurate information and evaluating the results appropriately are important clinical skills. Most of the discussion in physical therapy to date has centered on defining diagnosis, with considerably less attention paid to elucidating the diagnostic process. Determining the best diagnostic tests for use in clinical situations requires an ability to appraise evidence in the literature that describes the accuracy and interpretation of the results of testing. Important issues for judging studies of diagnostic tests are not widely disseminated or adhered to in the literature. Lack of awareness of these issues may lead to misinterpretation of the results. The application of evidence to clinical practice also requires an understanding of evidence and its use in decision making. The purpose of this article is to present an evidence-based perspective on the diagnostic process in physical therapy. Issues relevant to the appraisal of evidence regarding diagnostic tests and integration of the evidence into patient management are presented.
Article
The Ottawa ankle rule (OAR) is a clinical decision rule used in emergency departments to identify which patients with acute ankle/midfoot injury require radiography. The purpose of this study was to implement the OAR, with a modification to improve the specificity for identifying malleolar fractures (the "Buffalo rule"), in a sports medicine center and measure impact on physician practice and cost savings. All pediatric and adult patients presenting to a university sports medicine walk-in clinic with acute (< or = 10 d old) ankle/midfoot injury had the rule applied by primary care providers. Exclusion criteria included pregnancy, isolated skin injury, > 10 d since injury, second evaluation for same injury, obvious deformity of ankle or foot, or altered sensorium. In 217 patients (mean age, 23.3 +/- 8.5 yr; range, 10-64 yr) there were 24 clinically significant (i.e., nonavulsion) fractures (fracture rate 3.7% per year for 3 yr), all of which were identified by the rule (100% sensitivity). In 193 patients with malleolar pain, the sensitivity for malleolar fracture (with 95% confidence intervals) was 100% (78-100%) and specificity was 45% (43-46%). In 24 patients with midfoot pain, sensitivity was 100% (65-100%) and specificity was 35% (21-49%). Thirty-five percent of radiographic series (76 of 217) were foregone for a cost savings of almost $6000. One hundred percent follow-up on those patients for whom x-rays were obtained found no missed fractures and they were subjectively satisfied with their care. The OAR reduced radiography in acute ankle/midfoot injury and saved money in relatively younger patients in the outpatient sports urgent care setting without missing any clinically significant fractures. The specificity of the Buffalo malleolar rule in the present implementation study, however, was not a significant improvement over the OAR malleolar rule. Widespread application of the OAR could save substantial resources without compromising quality of care.
Article
The Ottawa rules have been shown to decrease the need for films by about 30%. If a patient does not exhibit any of the criteria, radiographs are not needed after trauma.
Ottawa Ankle Rules accurately assess injuries and reduce reliance on radiographs Address correspondence to Michael R Address e-mail to sitler @ temple.edu
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Nugent PJ. Ottawa Ankle Rules accurately assess injuries and reduce reliance on radiographs. J Fam Pract. 2004;53(10):785–788. Address correspondence to Michael R. Sitler, EdD, ATC, FNATA, Temple University, Pearson Hall 114, Broad and Montgomery Streets, Philadelphia, PA 19122. Address e-mail to sitler @ temple.edu. 482 Volume 45 N Number 5 N October 2010