Ottawa Ankle Rules: Difference between revisions
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'''Original Editor '''- [[User:Jill Nicole Hickey|Jill Nicole Hickey]] | '''Original Editor '''- [[User:Jill Nicole Hickey|Jill Nicole Hickey]] | ||
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} | '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} | ||
</div> | </div> | ||
== Purpose | == Purpose == | ||
Ankle sprains are a common occurrence in athletes as well as the general population. Traditionally, physicians would order radiographs for all ankle injuries although | Ankle sprains are a common occurrence in athletes as well as the general population. Traditionally, physicians would order radiographs for all ankle injuries, although less than 15% would have a clinically significant fracture,<ref name="brooks 1981">Brooks SC, Potter BT, Rainey JB. Inversion injuries of the ankle: clinical assessment and radiographic review. BMJ 1981; 282: 607-608</ref> and add to healthcare costs. The Ottawa Ankle Rules were established to help physicians decide which patients should have an x-ray following an acute ankle injury.<ref name="Stiell et al 1993">Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, Stewart JP, Maloney J. Decision rules for the use of radiography in acute ankle injuries. JAMA 1993;269:1127-32.</ref> | ||
== Variables: == | == Variables<ref name="Stiell et al 1994">Stiell IG, McKnight RD, Greenberg GH, McDowell I, Nair RC, Wells GA, Johns C, Worthington JR. Implementation of the Ottawa Ankle Rules. JAMA 1994;271:827-32.</ref> == | ||
[[Image:Ottawa ankle rules.png|left|700x283px|OAR]] | [[Image:Ottawa ankle rules.png|left|700x283px|OAR]] | ||
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<br> | <br> | ||
<br> '''Figure 1'''. Palpation locations within the malleolar and midfoot zones. (Image from CDR Ankle Poster<ref>http://www.ohri.ca/emerg/cdr/docs/cdr_ankle_poster.pdf</ref> | <br> '''Figure 1'''. Palpation locations within the malleolar and midfoot zones. (Image from CDR Ankle Poster)<ref>http://www.ohri.ca/emerg/cdr/docs/cdr_ankle_poster.pdf</ref> | ||
<br> A. | <br> A. Bony tenderness along distal 6 cm of posterior edge of fibula or tip of lateral malleolus | ||
B. Bony tenderness along distal 6 cm of posterior edge of tibia/tip of medial malleolus | B. Bony tenderness along distal 6 cm of posterior edge of tibia/tip of medial malleolus | ||
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D. Bony tenderness at the navicular | D. Bony tenderness at the navicular | ||
E. Inability to bear weight both immediately after injury and for 4 steps during intial evaluation | E. Inability to bear weight both immediately after injury and for 4 steps during intial evaluation | ||
<ref name="Stiell et al 1994">Stiell IG, McKnight RD, Greenberg GH, McDowell I, Nair RC, Wells GA, Johns C, Worthington JR. Implementation of the Ottawa Ankle Rules. JAMA 1994;271:827-32.</ref> | == Method of Use<ref name="Stiell et al 1994">Stiell IG, McKnight RD, Greenberg GH, McDowell I, Nair RC, Wells GA, Johns C, Worthington JR. Implementation of the Ottawa Ankle Rules. JAMA 1994;271:827-32.</ref> == | ||
An ankle x-ray series is only required if there is pain in the malleolar zone AND any of variables A or B or E. | |||
A foot x-ray series is only required if there is pain in the midfoot zone AND any of variables C or D or E. | |||
== Recommendations<ref name="Stiell et al 1994">Stiell IG, McKnight RD, Greenberg GH, McDowell I, Nair RC, Wells GA, Johns C, Worthington JR. Implementation of the Ottawa Ankle Rules. JAMA 1994;271:827-32.</ref> == | |||
<ref name="Stiell et al 1994">Stiell IG, McKnight RD, Greenberg GH, McDowell I, Nair RC, Wells GA, Johns C, Worthington JR. Implementation of the Ottawa Ankle Rules. JAMA 1994;271:827-32.</ref> | |||
Ensure to apply the Ottawa Ankle Rules accurately by... | Ensure to apply the Ottawa Ankle Rules accurately by... | ||
#Palpating the entire distal 6cm of the tibia and fibula | #Palpating the entire distal 6cm of the tibia and fibula | ||
#Not neglecting the importance of medial malleolar tenderness | #Not neglecting the importance of medial malleolar tenderness | ||
#Using the rules only on those over the age of 18<br> | #Using the rules only on those over the age of 18<br> | ||
Be sure to give written instructions and encourage follow-up in 5-7 days if pain and walking ability have not improved. | Be sure to give written instructions and encourage follow-up in 5-7 days if pain and walking ability have not improved. | ||
== Evidence == | |||
A systematic review of 27 studies by Bachmann et al found the pooled sensitivity of the Ottawa Ankle Rules to be 97.6%, with a median specificity of 31.5%.<ref name="Bachmann et al 2003">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;326:417-23.</ref><span style="line-height: 1.5em; font-size: 13.28px;"> The pooled negative likelihood ratio for the ankle and midfoot were 0.08 and 0.08 respectively whereas in children it was 0.07. The authors applied these ratios to the reported 15% fracture prevalence and determined the probability of a fracture after negative testing following implementation of the Ottowa Ankle Rules to be less than 1.4%. The authors concluded the instrument should reduce the number of unneccessary radiographs by 30-40%.</span><ref name="Bachmann et al 2003" /> | |||
A systematic review of 27 studies by Bachmann et al<ref name="Bachmann et al 2003">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;326:417-23.</ref> | |||
=== '''Reliability''' === | === '''Reliability''' === | ||
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=== '''Validation''' === | === '''Validation''' === | ||
In children aged 2-16, the Ottawa Ankle Rules were found to have a sensitivity of 1.0 (95% CI .95-1.0) for malleolar fractures and 1.0 (95%CI, .82-1.0) for midfoot.<ref name="plint 1999">Plint AC, Bulloch B, Osmond MH, et al. Validation of the Ottawa Ankle Rules in children with ankle injuries. Acad Emerg Med. 1999 Oct;6(10):1005-9</ref><br> | In children aged 2-16, the Ottawa Ankle Rules were found to have a sensitivity of 1.0 (95% CI, .95-1.0) for malleolar fractures and 1.0 (95% CI, .82-1.0) for midfoot fractures.<ref name="plint 1999">Plint AC, Bulloch B, Osmond MH, et al. Validation of the Ottawa Ankle Rules in children with ankle injuries. Acad Emerg Med. 1999 Oct;6(10):1005-9</ref><br> | ||
=== '''Clinical Significance''' === | === '''Clinical Significance''' === | ||
When implementing the Ottawa Ankle Rules in the emergency setting, the relative reduction in ankle radiography was reduced by 28% compared to a 2% increase | When implementing the Ottawa Ankle Rules in the emergency or clinic setting, the relative reduction in ankle radiography was reduced by 28% compared to a 2% increase in a control setting not using the rules (P<.001). Foot radiography was reduced by 14% at an intervention hospital and increased by 13% at the control hospital (P<.05). Significant differences in time spent in emergency department (P<.0001) and a lower estimated total medical costs for physician visits and radiography (P<.001) were also found.<ref name="stiell 1994" /> | ||
== Resources == | |||
http://www.ohri.ca/emerg/cdr/ankle_rule_flash.html | |||
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) == | == Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) == | ||
<div class="researchbox"> | <div class="researchbox"><rss>http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1pMPQVclnMMahoAQKaDUYVUNUO8dCMGJKsvHOvjWe0xGNjksuY|short|max=10</rss></div> | ||
== References: == | == References: == | ||
<references /> | <references /> | ||
[[Category:Ankle]] | [[Category:Assessment]] [[Category:Ankle]] [[Category:Ankle Injuries]][[Category:Musculoskeletal/Orthopaedics]] |
Revision as of 19:04, 21 May 2016
Original Editor - Jill Nicole Hickey
Top Contributors - Evan Thomas, Admin, Kim Jackson, Jill Nicole Hickey, Naomi O'Reilly, Adam Vallely Farrell, Ben Kasehagen, Claire Knott, Carina Therese Magtibay, Simisola Ajeyalemi, Shaimaa Eldib, Selena Horner, Ahmed M Diab, Kai A. Sigel, WikiSysop, Fasuba Ayobami, 127.0.0.1, Rachael Lowe, Rucha Gadgil, Wanda van Niekerk, Michael Conaway, Jess Bell, Andrea Nees and Khloud Shreif
Purpose[edit | edit source]
Ankle sprains are a common occurrence in athletes as well as the general population. Traditionally, physicians would order radiographs for all ankle injuries, although less than 15% would have a clinically significant fracture,[1] and add to healthcare costs. The Ottawa Ankle Rules were established to help physicians decide which patients should have an x-ray following an acute ankle injury.[2]
Variables[3][edit | edit source]
Figure 1. Palpation locations within the malleolar and midfoot zones. (Image from CDR Ankle Poster)[4]
A. Bony tenderness along distal 6 cm of posterior edge of fibula or tip of lateral malleolus
B. Bony tenderness along distal 6 cm of posterior edge of tibia/tip of medial malleolus
C. Bony tenderness at the base of 5th metatarsal
D. Bony tenderness at the navicular
E. Inability to bear weight both immediately after injury and for 4 steps during intial evaluation
Method of Use[3][edit | edit source]
An ankle x-ray series is only required if there is pain in the malleolar zone AND any of variables A or B or E.
A foot x-ray series is only required if there is pain in the midfoot zone AND any of variables C or D or E.
Recommendations[3][edit | edit source]
Ensure to apply the Ottawa Ankle Rules accurately by...
- Palpating the entire distal 6cm of the tibia and fibula
- Not neglecting the importance of medial malleolar tenderness
- Using the rules only on those over the age of 18
Be sure to give written instructions and encourage follow-up in 5-7 days if pain and walking ability have not improved.
Evidence[edit | edit source]
A systematic review of 27 studies by Bachmann et al found the pooled sensitivity of the Ottawa Ankle Rules to be 97.6%, with a median specificity of 31.5%.[5] The pooled negative likelihood ratio for the ankle and midfoot were 0.08 and 0.08 respectively whereas in children it was 0.07. The authors applied these ratios to the reported 15% fracture prevalence and determined the probability of a fracture after negative testing following implementation of the Ottowa Ankle Rules to be less than 1.4%. The authors concluded the instrument should reduce the number of unneccessary radiographs by 30-40%.[5]
Reliability[edit | edit source]
The Ottawa Ankle Rules have been found to have sensitivities of 1.0 (95% confidence interval (CI), .95-1.0) for detecting malleolar fractures and 1.0 (95% CI, .82-1.0) for detecting midfoot fractures.[6]
Validation[edit | edit source]
In children aged 2-16, the Ottawa Ankle Rules were found to have a sensitivity of 1.0 (95% CI, .95-1.0) for malleolar fractures and 1.0 (95% CI, .82-1.0) for midfoot fractures.[7]
Clinical Significance[edit | edit source]
When implementing the Ottawa Ankle Rules in the emergency or clinic setting, the relative reduction in ankle radiography was reduced by 28% compared to a 2% increase in a control setting not using the rules (P<.001). Foot radiography was reduced by 14% at an intervention hospital and increased by 13% at the control hospital (P<.05). Significant differences in time spent in emergency department (P<.0001) and a lower estimated total medical costs for physician visits and radiography (P<.001) were also found.[6]
Resources[edit | edit source]
http://www.ohri.ca/emerg/cdr/ankle_rule_flash.html
Recent Related Research (from Pubmed)[edit | edit source]
References:[edit | edit source]
- ↑ Brooks SC, Potter BT, Rainey JB. Inversion injuries of the ankle: clinical assessment and radiographic review. BMJ 1981; 282: 607-608
- ↑ Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, Stewart JP, Maloney J. Decision rules for the use of radiography in acute ankle injuries. JAMA 1993;269:1127-32.
- ↑ 3.0 3.1 3.2 Stiell IG, McKnight RD, Greenberg GH, McDowell I, Nair RC, Wells GA, Johns C, Worthington JR. Implementation of the Ottawa Ankle Rules. JAMA 1994;271:827-32.
- ↑ http://www.ohri.ca/emerg/cdr/docs/cdr_ankle_poster.pdf
- ↑ 5.0 5.1 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;326:417-23.
- ↑ 6.0 6.1 Stiell IG, McKnight RD, Greenberg GH, McDowell I, Nair RC, Wells GA, et al. Implementation of the Ottawa ankle rules. JAMA 1994; 271: 827-832
- ↑ Plint AC, Bulloch B, Osmond MH, et al. Validation of the Ottawa Ankle Rules in children with ankle injuries. Acad Emerg Med. 1999 Oct;6(10):1005-9