EBQ:Ottawa Ankle Rule Study - Revision history

Danbot: Added Criticisms section

2026-03-21T22:39:49Z

Added Criticisms section

← Older revision		Revision as of 22:39, 21 March 2026
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	*The rules have been validated in assessing children 2-16 years old, with 100% sensitivity <ref>Plint AC. et al. Validation of the Ottawa Ankle Rules in children with ankle injuries. Acad Emerg Med. 1999 Oct;6(10):1005-9.</ref>		*The rules have been validated in assessing children 2-16 years old, with 100% sensitivity <ref>Plint AC. et al. Validation of the Ottawa Ankle Rules in children with ankle injuries. Acad Emerg Med. 1999 Oct;6(10):1005-9.</ref>
	**However in 1 of the 2 centers in this study, the decision rules would have increased the use of x-ray for ankle injuries, suggesting that the benefit of these decision rules may not be as great in a pediatric setting.		**However in 1 of the 2 centers in this study, the decision rules would have increased the use of x-ray for ankle injuries, suggesting that the benefit of these decision rules may not be as great in a pediatric setting.

			==Criticisms==
			*High sensitivity but relatively low specificity leads to continued high rates of radiography
			*Validated primarily in adults; pediatric applicability is limited (though subsequently validated in children >5 years)
			*Does not account for patients who may have injuries that are not initially tender (e.g., stress fractures)
			*Implementation studies show variable physician adherence to the rule in clinical practice
			*The rule was derived in a predominantly ambulatory ED population and may not apply to polytrauma patients

	==Funding==		==Funding==

Rossdonaldson1: /* Major Points */

2017-02-17T17:15:25Z

Major Points

← Older revision		Revision as of 17:15, 17 February 2017
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	''Rule had 100% sensitivity and 49% specificity for identifying 50 clinically significant malleolar zone fractures in the prospective validation study.''		''Rule had 100% sensitivity and 49% specificity for identifying 50 clinically significant malleolar zone fractures in the prospective validation study.''

	~~[[File:footxrays.jpg\|thumbnail]]~~
	{{Ottawa Foot Rules}}		{{Ottawa Foot Rules}}

Rossdonaldson1: /* Major Points */

2017-02-17T17:14:49Z

Major Points

← Older revision		Revision as of 17:14, 17 February 2017
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	==Major Points==		==Major Points==
	~~===Ankle Rules===~~
	[[File:anklexray.jpg\|thumbnail]]		[[File:anklexray.jpg\|thumbnail]]
	{{Ottawa Ankle Rules}}		{{Ottawa Ankle Rules}}
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	''Rule had 100% sensitivity and 49% specificity for identifying 50 clinically significant malleolar zone fractures in the prospective validation study.''		''Rule had 100% sensitivity and 49% specificity for identifying 50 clinically significant malleolar zone fractures in the prospective validation study.''

	~~===Foot Rules===~~
	[[File:footxrays.jpg\|thumbnail]]		[[File:footxrays.jpg\|thumbnail]]
	{{Ottawa Foot Rules}}		{{Ottawa Foot Rules}}

ClaireLewis: /* Patient Demographics */

2016-07-14T02:18:09Z

Patient Demographics

← Older revision		Revision as of 02:18, 14 July 2016
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	Similar characteristics in stage 1 (refinement) vs. stage 2 (validation)		Similar characteristics in stage 1 (refinement) vs. stage 2 (validation)
	*Mean age: 35 vs. 36		*Mean age: 35 vs. 36
	*Male ~~gender~~: 52% vs. 52%		*Male sex: 52% vs. 52%
	*Pt at Ottawa Clinic: 60% vs. 64%		*Pt at Ottawa Clinic: 60% vs. 64%
	*Twisting mechanism: 84% vs. 86%		*Twisting mechanism: 84% vs. 86%

Ostermayer: Text replacement - "Category:Ortho" to "Category:Orthopedics"

2016-03-22T15:47:49Z

Text replacement - "Category:Ortho" to "Category:Orthopedics"

← Older revision		Revision as of 15:47, 22 March 2016
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	<references/>		<references/>

	[[Category:EBQ]][[Category:~~Ortho~~]]		[[Category:EBQ]][[Category:Orthopedics]]

Ostermayer at 16:24, 20 February 2016

2016-02-20T16:24:25Z

← Older revision		Revision as of 16:24, 20 February 2016
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	\| fulltexturl= http://jama.jamanetwork.com/article.aspx?articleid=403941		\| fulltexturl= http://jama.jamanetwork.com/article.aspx?articleid=403941
	\| pdfurl=http://www.udel.edu/PT/PT%20Clinical%20Services/journalclub/caserounds/05_06/apr06/ottawa2.pdf		\| pdfurl=http://www.udel.edu/PT/PT%20Clinical%20Services/journalclub/caserounds/05_06/apr06/ottawa2.pdf
	\| status=~~Completed~~		\| status=Complete
	}}		}}
	==Clinical Question==		==Clinical Question==

Ostermayer at 13:10, 23 September 2015

2015-09-23T13:10:49Z

← Older revision		Revision as of 13:10, 23 September 2015
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	\| fulltexturl= http://jama.jamanetwork.com/article.aspx?articleid=403941		\| fulltexturl= http://jama.jamanetwork.com/article.aspx?articleid=403941
	\| pdfurl=http://www.udel.edu/PT/PT%20Clinical%20Services/journalclub/caserounds/05_06/apr06/ottawa2.pdf		\| pdfurl=http://www.udel.edu/PT/PT%20Clinical%20Services/journalclub/caserounds/05_06/apr06/ottawa2.pdf
	\| status=~~Under Review~~		\| status=Completed
	}}		}}
	==Clinical Question==		==Clinical Question==

Catierey: further discussion

2015-09-21T18:51:27Z

further discussion

← Older revision		Revision as of 18:51, 21 September 2015
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	''Rule had 100% sensitivity and 49% specificity for identifying 50 clinically significant malleolar zone fractures in the prospective validation study.''		''Rule had 100% sensitivity and 49% specificity for identifying 50 clinically significant malleolar zone fractures in the prospective validation study.''



	===Foot Rules===		===Foot Rules===
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	==Study Design==		==Study Design==
	*Conducted in 2 stages in 2 Canadian EDs		*Conducted in 2 stages in 2 Canadian EDs, both prospective cohort studies
	*Both prospective cohort studies		*First stage
	*~~In the first~~ stage~~, each~~ patient was evaluated for 15 clinical variables as defined by previously derived clinical decision rules. All patients then underwent radiographs--standard ankle series for patients with pain in malleolar zone vs. standard foot series for patients with pain in the midfoot zone.		**Each patient was evaluated for 15 clinical variables as defined by previously derived clinical decision rules. All patients then underwent radiographs--standard ankle series for patients with pain in malleolar zone vs. standard foot series for patients with pain in the midfoot zone.
	*Original decision rule then refined by univariate and recursive partitioning analyses.		**Original decision rule then refined by univariate and recursive partitioning analyses.
	*~~In the second~~ stage~~, each~~ patient was evaluated for 6 clinical variables, and the decision rule was applied to determine necessity of radiographs.		*Second stage
	*In both studies, a subset of patients were also assessed by second EM physician independently.		**Each patient was evaluated for 6 clinical variables, and the decision rule was applied to determine necessity of radiographs.
	*Clinically significant fracture seen in ankle or foot radiographic series was the primary outcome~~, defined~~ as bone fragments greater than 3 mm in breadth.		*In both studies, a subset of patients were also assessed by second EM physician independently when possible.
			*Clinically significant fracture seen in ankle or foot radiographic series was the primary outcome
			**Defined as bone fragments greater than 3 mm in breadth.
	*All radiographic series were interpreted by qualified radiologists who were blinded to the data collection sheets.		*All radiographic series were interpreted by qualified radiologists who were blinded to the data collection sheets.

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	===Inclusion Criteria===		===Inclusion Criteria===
	*Patients who presented to the emergency department with pain or tenderness 2/2 to blunt ankle trauma due to any mechanism ~~of trauma~~		*Patients who presented to the emergency department with pain or tenderness 2/2 to blunt ankle trauma due to any mechanism
	*Ankle defined as area commonly involved in twisting injuries		*Ankle defined as area commonly involved in twisting injuries
	**Malleolar zone		**Malleolar zone
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	==Interventions==		==Interventions==
			*Refinement stage was a prospective observational study
			*In validation phase, the clinical decision rule was applied. If patients were positive for any 1 of the 6 clinical variables (listed in major points), an x-ray series was performed.
			**Standard ankle series completed in patients with positive Ottawa Ankle Rule, standard foot series completed in patients with positive Ottawa Foot Rule

	==Outcomes==		==Outcomes==
	First stage (validation and refinement of original rules): n=1032 enrolled and assessed <br/>		First stage (validation and refinement of original rules): n=1032 enrolled and assessed <br/>
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	==Further Discussion==		==Further Discussion==
	*Rules may not be useful in patients with multiple painful injuries, altered sensorium, intoxication, paraplegia, or bone disease		*Rules may not be useful in patients with multiple painful injuries, altered sensorium, intoxication, paraplegia, or bone disease
	*~~Limited~~ experience with uncommon fractures		*During the study, the rule had limited experience with uncommon fractures
	**2 fractures of talus		**2 fractures of talus
	**12 fractures of midfoot other than base of 5th metatarsal		**12 fractures of midfoot other than base of 5th metatarsal
	*A subsequent study by Stiell in 1994 confirmed the high sensitivity and demonstrated reduction the number of ankle X-rays by 36%<ref>Stiell IG et al. Implementation of the Ottawa ankle rules. JAMA. 1994 Mar 16;271(11):827-32.</ref>		*A subsequent study by Stiell in 1994 confirmed the high sensitivity and demonstrated reduction the number of ankle X-rays by 36% <ref>Stiell IG et al. Implementation of the Ottawa ankle rules. JAMA. 1994 Mar 16;271(11):827-32.</ref>
	*The rules have been shown to be easily applied with education in multiple centers<ref>Stiell I. et al. Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle injuries. Multicentre Ankle Rule Study Group. BMJ. 1995 Sep 2;311(7005):594-7</ref> but due to poor interrater reliability from the general public, self application of the rule to decrease ED visits was not possible<ref>Blackham JE et al. Can patients apply the Ottawa ankle rules to themselves? Emerg Med J. 2008 Nov;25(11):750-1.</ref>		*The rules have been shown to be easily applied with education in multiple centers <ref>Stiell I. et al. Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle injuries. Multicentre Ankle Rule Study Group. BMJ. 1995 Sep 2;311(7005):594-7</ref> but due to poor interrater reliability from the general public, self application of the rule to decrease ED visits was not possible <ref>Blackham JE et al. Can patients apply the Ottawa ankle rules to themselves? Emerg Med J. 2008 Nov;25(11):750-1.</ref>
			*The rules have been validated in assessing children 2-16 years old, with 100% sensitivity <ref>Plint AC. et al. Validation of the Ottawa Ankle Rules in children with ankle injuries. Acad Emerg Med. 1999 Oct;6(10):1005-9.</ref>
			**However in 1 of the 2 centers in this study, the decision rules would have increased the use of x-ray for ankle injuries, suggesting that the benefit of these decision rules may not be as great in a pediatric setting.

	==Funding==		==Funding==
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	==See Also==		==See Also==
	*[[Ottawa ~~Ankle Rules~~]]		*[[Ottawa ankle rules]]

	==References==		==References==

Catierey: created templates

2015-09-21T18:03:27Z

created templates

← Older revision		Revision as of 18:03, 21 September 2015
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	{{JC info		{{JC info
	\| title= Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation.		\| title= Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation.
	\| abbreviation= Ottawa Ankle Rule		\| abbreviation= Ottawa Ankle Rule Study
	\| expansion= Ottawa Ankle Rule		\| expansion= Ottawa Ankle Rule Study
	\| published= 1993		\| published= 1993
	\| author= Stiell I. et al.		\| author= Stiell I. et al.
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	===Ankle Rules===		===Ankle Rules===
	[[File:anklexray.jpg\|thumbnail]]		[[File:anklexray.jpg\|thumbnail]]
	Ankle ~~x-ray needed if:~~		{{Ottawa Ankle Rules}}
	*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

	''Rule had 100% sensitivity and 49% specificity for identifying 50 clinically significant malleolar zone fractures in the prospective validation study.''		''Rule had 100% sensitivity and 49% specificity for identifying 50 clinically significant malleolar zone fractures in the prospective validation study.''
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	===Foot Rules===		===Foot Rules===
	[[File:footxrays.jpg\|thumbnail]]		[[File:footxrays.jpg\|thumbnail]]
	Foot ~~x-ray series needed if:~~		{{Ottawa Foot Rules}}
	*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

	''Rule had 100% sensitivity and and 79% specificity for identifying 19 clinically significant midfoot fractures in the prospective validation study.''		''Rule had 100% sensitivity and and 79% specificity for identifying 19 clinically significant midfoot fractures in the prospective validation study.''

Ostermayer: /* Criticisms & Further Discussion */

2015-09-20T16:27:01Z

Criticisms & Further Discussion

← Older revision		Revision as of 16:27, 20 September 2015
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	===Subgroup analysis===		===Subgroup analysis===

	==~~Criticisms &~~ Further Discussion==		==Further Discussion==
	*Rules may not be useful in patients with multiple painful injuries, altered sensorium, intoxication, paraplegia, or bone disease		*Rules may not be useful in patients with multiple painful injuries, altered sensorium, intoxication, paraplegia, or bone disease
	*Limited experience with uncommon fractures		*Limited experience with uncommon fractures
	**2 fractures of talus		**2 fractures of talus
	**12 fractures of midfoot other than base of 5th metatarsal		**12 fractures of midfoot other than base of 5th metatarsal
			*A subsequent study by Stiell in 1994 confirmed the high sensitivity and demonstrated reduction the number of ankle X-rays by 36%<ref>Stiell IG et al. Implementation of the Ottawa ankle rules. JAMA. 1994 Mar 16;271(11):827-32.</ref>
			*The rules have been shown to be easily applied with education in multiple centers<ref>Stiell I. et al. Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle injuries. Multicentre Ankle Rule Study Group. BMJ. 1995 Sep 2;311(7005):594-7</ref> but due to poor interrater reliability from the general public, self application of the rule to decrease ED visits was not possible<ref>Blackham JE et al. Can patients apply the Ottawa ankle rules to themselves? Emerg Med J. 2008 Nov;25(11):750-1.</ref>

	==Funding==		==Funding==