Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review

doi:10.1136/bmj.326.7386.417

BMJ 2003;326:417 ( 22 February )

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Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review

Lucas M Bachmann, senior research fellow, ^a Esther Kolb, research fellow, ^a Michael T Koller, research fellow, ^a Johann Steurer, professor, ^a Gerben ter Riet, clinical epidemiologist. ^b

^a Horten Centre, Zurich University, Postfach Nord, CH-8091 Zurich, Switzerland, ^b Academic Medical Center, Department of General Practice, Meibergdreef 15, 1105 AZ Amsterdam, Netherlands

Correspondence to: L M Bachmann lucas.bachmann{at}evimed.ch

Objective: To summarise the evidence on accuracy of theOttawa ankle rules, a decision aid for excluding fractures ofthe ankle and mid-foot.
Design: Systematicreview.
Data sources: Electronic databases, reference lists of includedstudies, andexperts.
Review methods: 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 inspectionof the receiver operating characteristics plot. Negative likelihoodratios were pooled for several subgroups, correcting for fourmain methodological threats tovalidity.
Results: 32 studies met the inclusion criteria and27 studies reporting on 15 581 patients were used for meta-analysis.The pooled negative likelihood ratios for the ankle and mid-footwere 0.08 (95% confidence interval 0.03 to 0.18) and 0.08 (0.03to 0.20), respectively. The pooled negative likelihood ratio forboth regions in children was 0.07 (0.03 to 0.18). Applying theseratios to a 15% prevalence of fracture gave a less than 1.4% probabilityof actual fracture in thesesubgroups.
Conclusion: Evidence supports the Ottawa ankle rules asan accurate instrument for excluding fractures of the ankle andmid-foot. The instrument has a sensitivity of almost 100% anda modest specificity, and its use should reduce the number ofunnecessary radiographs by 30-40%.

What is already known on this topic
Although most patients with ankle sprains who present to emergency departments undergo radiography, less than 15% have a fracture

The Ottawa ankle rules is a clinical decision aid designed to avoid unnecessary radiography

What this paper adds
The Ottawa ankle rules is highly accurate at excluding ankle fractures after sprain injury

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