Although the majority of ankle injuries are radiographed, fewer than 15 percent of these patients are found to have fractures of the ankle or foot. The oar are a reliable tool to exclude fractures in children over 5 years of age when applied by physicians. Accuracy of ottawa ankle rules to exclude fractures of the ankle and midfoot. Ottawa ankle rules canadian chiropractic specialty college of. Use of these rules reduced radiographic examinations by 28% for the ankle and 14% for the foot. A group of ottawa emergency physicians developed two rules to identify clinically important fractures of the malleoli and the midfoot. Validation of the ottawa ankle rules in children with ankle injuries. The ottawa ankle rule project demonstrated that more than 95% of patients with ankle injuries had radiographic examinations but that 85% of the films showed no fractures. Ankle and foot ottawa ankle rules guideline for the administered by the alberta medical association this guideline has been adapted by an alberta clinical practice guidelines program working group from the ottawa ankle rules developed by dr. Thirteen percent 36274 patients presented fracture. The ottawa ankle rules modified buffalo rule the buffalo rule was derived to increase the diagnostic accuracy of the ottawa ankle rules, with the point tenderness criterion directed to the crest or midportion of the malleoli distal 6 cm of the fibula and tibia, reducing the likelihood of palpating over injured ligament structures. Data sources electronic databases, reference lists of included studies, and experts. To validate and refine previously derived clinical decision rules that aid the efficient use of radiography in acute ankle injuries. Using the diagram below we can determine when an ankle series is required.
More recent evidence also supports the ottawa ankle rules as an accurate instrument for excluding fractures of the ankle and mid foot. To conduct an incremental costeffectiveness analysis of implementation of the ottawa ankle rules in emergency departments in the united states and canada. Pdf assessing the use of the ottawa ankle rules when. Ottawa ankle rules the ottawa ankle rules are simple guidelines developed to aid emergency physicians in deciding when to use radiography for patients with injuries to the ankle. Mar 06, 20 how to use the ottawa ankle and foot rule. The oar have been proven that their application reduces unnecessary radiography. The ottawa ankle rules were developed to identify those subjects with an ankle sprain who required radiographs to rule out the presence of subtle or frank fracture. Racgp the ottawa knee rules a useful clinical decision. Implementation of the ottawa ankle rules jama network. Mar 04, 2014 ottowa ankle and foot rules ankle radiographs are only required if there is pain in the malleolar area and any one of the following.
The ottawa ankle rules oar are a clinical decision tool used to minimize unnecessary radiographs in ankle and foot injuries. Bachmann lm, kolb e, koller mt, steurer j, ter riet g. Ian stiell and his colleagues developed the ottawa ankle rules 12 to facilitate this decision. All were examined by a general practitioner, after which a series of ankle and foot xrays anteroposterior. In medicine, the ottawa ankle rules are a set of guidelines for clinicians to help decide if a patient with foot or ankle pain should be offered xrays to diagnose a possible bone fracture. Pdf the sonographic ottawa foot and ankle rules study. Specificities are approximately 41% for the ankle and 79% for the foot, though the rule is not designed or intended for specific diagnosis.
Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip. Ottawa ankle rules for ankle injury radiography an ankle xray series is only required if there is any pain in the malleolar zone and any of these findings. A foot xray series is only required if there is any pain the midfoot zone and. Implementation of the ottawa ankle rules by resident orthopaedic. Unable to bear weight both immediately and in the emergency room department for 4 steps. Thus, if a patient does not pass the full set of clinical criteria, the treating provider must do further clinical evaluation in order to assess for a fracture and whether an xray is required for management. Comparison of ottawa ankle rules and bernese ankle rules. The ottawa ankle and foot rules to image or not to. Patients waited less, were not dissatisfied with their treatment, and significant fractures did not go undetected. The aim of this study is to consider these injured patients in the light of the ottawa ankle rules and the bernese ankle rules. This guideline makes recommendations for adults aged. Methods patients who presented to the ed of our hospital with acute ankle injury were evaluated. The need for need for radiography is reduced by 36% saving patients money and time. An ankle xray is required only if there is any pain in malleolar zone and any of these findings.
Of those requiring radiographs in accordance with the ottawa foot and ankle rules, approximately 22% have a fracture. They have nearly perfect sensitivity for identifying clinically significant ankle fractures. Before the introduction of the rules most patients with ankle injuries would have been imaged. Potential reduction in radiography for ankle and foot series estimated to be 34% and 30%. This study was performed during a 24month period in the suleyman. These rules were refined and validated prospectively on 453 patients 5. The above research led to a final set of decision rules, named the ottawa ankle rules, for the use of radiography in ankle. The ankle component of the oar states that radiographic evaluation of the ankle is only necessary if there is pain in the malleollar zone and one of the. The ottawa ankle rules are a clinical decisionmaking strategy for determining which patients require radiographic imaging for ankle and midfoot injuries. An ankle xray series is required only if there is pain in the malleolar region and any one of the following. Data sources medline, embase, cinahl, sportdiscus and cochrane library. The ottawa ankle rule was derived to aid efficient use of radiography in acute ankle and midfoot injuries. Is to remember that an xray of the foot is required if the patient has pain at the basis of the 5th metatarsal of at the 5caphoid 66pm. All 2342 adults seen with acute ankle injuries during 5month periods before and after the intervention.
Eligibility criteria for selecting studies primary diagnostic studies reporting. Ankle rules for ankle injury radiography a an ankle xray series is only required if there is any pain in malleolar zone and any of these findings. The original and modified ottawa ankle rules oars were developed as clinical decision rules for use in emergency departments. Patients with osseous pain in the lower 6 cm of the fibula or tibia or inability to bear weight immediately after injury. The ottawa ankle rules were developed and clinically tested to show that they led to a decrease in the use of ankle radiography, waiting times, and costs without. Decision rules for the use of radiography in acute ankle. The implementation of the ottawa ankle rules by emergency department physicians. Use only for injuries ottawa ankle rule range from the high 90% to 100% range for clinically significant ankle and midfoot fractures. For most patients, fractures cannot be ruled out without radiography. Radiographic examinations showed 19 fractures out of 100 investigated patients table 1.
Ottawa knee and ankle rules pdf ottawa knee and ankle rules pdf ottawa knee and ankle rules pdf download. Pdf implementation of the ottawa ankle rules by general. Ben yates, in clinical skills in treating the foot second edition, 2005. Ottawa ankle rules ottawa health research institute. Background the ottawa ankle rules oar are clinical decision guidelines used to identify whether patients with ankle injuries need to undergo radiography. Analogous rules have been formulated for knee and head injuries. Below the form you can read more about the rules and their interpretation. Sensitivity and specificity of oar were 100% and 77% respectively. Basketball season is back and with it comes a new season of early morning conditioning runs, late night pickup games, and of course, a few ankle sprains along the way. Update on acute ankle sprains american family physician. Racgp the ottawa knee rules a useful clinical decision tool. Awareness and use of the ottawa ankle and knee rules in 5 countries.
An ankle radiographic series is only required if there is any pain in the malleolar zone and any of these findings. The ottawa knee rules are useful in ruling out fracture high sensitivity when negative, but poor for ruling in fractures many false positives. The ottawa ankle rules oar are a set of clinical decision rules that were derived and validated by stiell et al. Specificities for the ottawa ankle rule are approximately 41% for the ankle and 79% for the foot, although the rule. Ottawa ankle rules calculator this ottawa ankle rules calculator predicts the need for foot xray or ankle imaging in common injuries based on the accurate ottawa foot rules. Tenderness of patella is significant only if an isolated finding. Is to remember that an xray is required if the patients is unable to walk 4 steps at the moment of the accident and during the physical examination 55. Essentially, the rules are based on the presence or absence of bony tenderness and the ability or inability to bear weight. Imaging is required if there is pain in the mid foot zone and any of the following. Jan 11, 20 trauma of the foot and ankle is commonly seen in the emergency service. Ankle radiographs are suggested if there is pain in the malleolar region with any of the following. The ottawa ankle rules are physical exam findings that help predict the likelihood of an osseous ankle injury.
The ottawa knee, ankle and foot rules are a guideline for doctors to aid them in deciding if a patient with foot or ankle pain should be offered xrays to diagnose a possible bone fracture. Stage 2 validation physicians correctly classified patients according to the ankle and foot decision rules in 99% and 100%. Review methods data were extracted on the study population, the type of ottawa ankle rules used, and methods. Implementation of the ottawa ankle rules jama jama network. The specificity of the ottawa ankle rules does not help rule in an ankle or foot fracture.
A foot xray is required if there is any pain in the midfoot zone and any of these findings. The ottawa ankle and foot rules are highly sensitive and widely used as a tool to reduce unnecessary imaging in emergency departments. A decision analytic approach to technology assessment. Pdf diagnostic accuracy and reproducibility in the. Clinical decision rules that allow physicians to be more selective in their use of radiography were compared with current practice in a decision analytic model. Rules have been prospectively validated on multiple occasions. Full text get a printable copy pdf file of the complete article 915k, or click on a page image below to browse page by page. The ottawa ankle rule oar is extensively documented in the emergency department setting and has been subjected to repeated validation. Ottawa ankle rules oar the ottawa ankle and foot rules are clinical decision rules derived for predicting which patients have a fracture following acute ankle foot injury in order to assist in selecting those who require radiography 4.
Validation of the ottawa ankle rules for acute foot and ankle. Pdf validation of the ottawa ankle rules for acute foot and. The instrument has a sensitivity of almost 100% and a modest specificity, and its use should reduce the number of unnecessary radiographs by 3040% 3. Ottawa ankle rules this guideline will aid you in determining which patients require an xray of their. Proportions of patients referred for standard ankle and foot radiographic series. Diagnostic accuracy and reproducibility in the interpretation of ottawa ankle and foot rules by specialized emergency nurses. Use only for injuries ottawa ankle rules does not help rule in an ankle or foot fracture. Unable to transfer weight twice onto each lower limb regardless of limping. Ottawa knee, ankle and foot rules resources pulse today. Decision rules for the use of radiography in acute ankle injuries. Foot and ankle injuries are common in the emergency department ed.
The ottawa ankle rules and subjective perception of foot andor ankle fractures were evaluated on the questionnaire. The ottawa ankle rule is useful for ruling out fracture high sensitivity, but poor for ruling in fractures many false positives. Oct 10, 2016 the ottawa ankle rules, developed by stiell, specifies the criteria to be met before ordering xrays for a patient presenting with an acute ankle injury. Ottawa ankle rules an overview sciencedirect topics. Validation of the ottawa ankle rules for acute foot and ankle injuries.
Recursive partitioning of 20 predictor variables yielded refined decision rules for ankle and foot radiographic series. Less than 2% of patients in most subgroups who were negative for fracture according to the ottawa ankle rules actually had a fracture. In medicine, the ottawa ankle rules are a set of guidelines for clinicians to help decide if a patient with foot or ankle pain should be offered xrays to diagnose a. Accuracy of ottawa ankle rules to exclude fractures of the ankle and mid foot. Ottawa ankle rules an accurate clinical procedure for excluding the diagnosis of ankle and mid foot fractures and reducing the number of unnecessary xrays. Ottaaw knee rule for knee injury radiography stiell ig, greenberg gh, wells ga, mcdowell i, cwinn aa, smith na, cacciotti tf, sivilotti mla. Ankle radiography is indicated only if a patient has pain in the malleolar zone and any of the following findings. Objectives the purpose of this study was to assess the. Ottawa knee and ankle rules pdf ottawa ankle and foot rules.
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. We summarised the accuracy of the ottawa ankle rules for excluding fractures of the ankle and mid foot in patients presenting to emergency departments with an acute ankle sprain. The ottawa ankle rule rules out clinically significant foot and ankle fractures to reduce use of xray imaging. The sonographic ottawa foot and ankle rules study the. The ottawa ankle rules were established to help physicians decide which patients should have an xray following an acute ankle injury. Accuracy of ottawa ankle rules to exclude fractures of the. Ottawa ankle rules definition of ottawa ankle rules by. Ian stiell, professor in the department of emergency medicine at the university of ottawa, discussing the assessment of an ankle andor foot injury using the ottawa ankle. Ottawa rules simplify the management of ankle injuries. Ankle and foot injuries are common presentations to the emergency department, and it can often be difficult to know whether imaging is required. Background the judicious use of ankle and foot radiography should balance a correct diagnosis in all cases of traumatic distal lower limb fractures with the avoidance of unnecessary radiation exposure for the patient. We use rules like the ottawa ankle rules all the time.
Bone tenderness at the base of the fifth metatarsal c. There are three sets of rules, one each for the foot, ankle and knee. Our study is a randomized, prospective clinical study. Em in 5 blog is a series of 5 minute emergency medicine lectures on high yield topics. Prospective validation of a decision rule for the use of radiography in acute knee injuries. Pdf the sonographic ottawa foot and ankle rules study the. Costeffectiveness analysis of the ottawa ankle rules.
Xray requesting patterns before and after introduction of the ottawa knee rules in a uk emergency department. Comparison of ottawa ankle rules and bernese ankle rules in acute ankle and midfoot injuries injury during daily walking, and the remaining reported other reasons. Foot and ankle injuries are common presentations to the emergency department. Interobserver agreement between physicians for ankle and foot decision rules was 56% and 69%. Clinical usefulness of the ottawa ankle rules for detecting fractures of the ankle and midfoot. Comparison of ottawa ankle rules and bernese ankle rules in. Apr 03, 2008 the mnemonic 445566pm helps to remember the components of the ottawa ankle and foot rule. While all of these rules can be used in patients under the age of 18, they should be used with caution. We conclude that implementing ottawa ankle rule can identify all clinically relevant fractures of ankle and foot. Clinical value of the ottawa ankle rules for diagnosis of. Ottawa ankle rules ottawa hospital research institute. Diagnostic accuracy of the ottawa ankle and midfoot rules. Accuracy of ottawa ankle rules to exclude fractures of the ankle and midfoot in children. Eligibility criteria for selecting studies primary diagnostic studies.
Rules out clinically significant foot and ankle fractures to reduce use of xray imaging. Ottawa ankle and foot rules an ankle xray is required only if there is any pain in malleolar zone and any of these findings. Bone tenderness over the distal 6cm of the posterior edge or tip of the lateral malleolus bone tenderness over the distal 6cm of the posterior edge or tip of the medial malleolus. Ankle injuries are extremely common but many features on history and physical examination are unreliable the combined ottawa ankle and foot rules have a sensitivity of 97.
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