The rules appear on the front page of this document. 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. The ottawa ankle rule was derived to aid in the efficient use of radiography in acute ankle and midfoot injuries. Key recommendations usethe ottawa knee rules okr to exclude fractures and reduce unnecessary imaging.
Jun 15, 2012 clinical recommendation evidence rating references. Several studies have examined the effectiveness of the ottawa knee rules, with each reporting the rules leading to a decrease in the use of knee radiography. This obviates the need for obtaining ankle radiographs in certain patients, reducing cost, resource utilization, radiation exposure, and potentially, emergency department length of stay. Ottawa ankle rules ottawa hospital research institute. Editor,further to previous correspondence i think the use of the ottawa ankle rule needs some clarification. Multi trial to introduce the ottawa ankle rule for the use of radiography in acute ankle injuries the fifth study assessed the feasibility and impact of. Because ankle injuries are one of the most common orthopedic injuries and the validity of these clinical decision rules is well established, the acha benchmarking committee selected adherence to the ottawa ankle and foot rules in assessing patients with ankle injuries as an evidencebased acute care benchmark. Implementation of the ottawa ankle rules jama jama network. Pdf application of ottawa ankle rules researchgate. 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.
Ottawa knee rule ottawa hospital research institute. The validation of this rule involved thousands of patients in a structured programme to generate rigorous rules with exceptional performance as a diagnostic test. To conduct an incremental costeffectiveness analysis of implementation of the ottawa ankle rules in emergency departments in the united states and canada. Eligibility criteria for selecting studies primary diagnostic studies reporting. Advice tips from the creators at the university of ottawa. However, the number of preschool children included in all these studies was small. Palpate the entire distal 6 cm of the fibula and tibia. Awareness and use of the ottawa ankle and knee rules in 5 countries. Bone tenderness at the posterior edge or tip of the lateral malleolus a. This screening tool was developed because of the need for a rapid and accurate way to avoid unnecessary imaging. The ottawa ankle rules oar are a set of guidelines to help the physician as to decision making regarding need for x ray examination after ankle and midfoot injury. Accuracy of ottawa ankle rules to exclude fractures of the ankle and midfoot. Ian stiell and his colleagues developed the ottawa ankle rules 12 to facilitate this decision.
Accuracy of ottawa ankle rules to exclude fractures of the. Ankle radiography is indicated only if a patient has pain in the malleolar zone and any of the following findings. Implementation of the ottawa ankle rules by emergency department physicians in the intervention hospitals using meetings, posters, pocket cards, and data forms. Yes no for patients with acute trauma to the ankle bone tenderness at a bone tenderness at b inability to bear weight both immediately and in the ed an ankle radiographic series is only required if there is any pain in the malleolar zone and any of these. Future studies should address the generalizability of these decision rules in a variety of. The oars were applied to all appropriate ankle injuries at 2 colleges athletics and club sports and 21 high schools. Ottawa ankle rules an overview sciencedirect topics. Ottawa ankle rules for the injured ankle british journal. Costeffectiveness analysis of the ottawa ankle rules. During the postintervention period, posters alone were used to sustain the intervention effect. Before the introduction of the rules most patients with ankle injuries would have been imaged. The ottawa ankle rules are a clinical decisionmaking strategy for determining which patients require radiographic imaging for ankle and midfoot injuries. The metaanalysis of bachmann, with a moderate risk of bias, summarizes the accuracy of the oar from 1990 to 2002.
Report by mancheuk yuen, senior medical officer checked by fiona saunders, specialist registrar a 5 year old boy attends the emergency department after sustaining a twisting injury to his left ankle. Future studies should address the generalizability of these decision rules in a variety of hospital settings. Sensitivity and specificity of oar were 100% and 77% respectively. Patients with osseous pain in the lower 6 cm of the fibula or tibia or inability to bear weight immediately after injury should have anterior. It has been prospectively validated on multiple occasions in different populations and in both children and adults. Xray requesting patterns before and after introduction of the ottawa knee rules in a uk emergency department. Studies published in any language were selected if they evaluated the ottawa ankle rules for diagnosing fractures of the ankle or midfoot and reported sufficient data to calculate the false positive and false negative rates. Feb 22, 2003 we summarised the accuracy of the ottawa ankle rules for excluding fractures of the ankle and midfoot in patients presenting to emergency departments with an acute ankle sprain.
The ottawa ankle rules should be used to rule out fractures and prevent unnecessary radiography in patients with suspected ankle sprain. Less than a decade ago, clinical epidemiologist ian stiell, working with emergency department physicians, formulated the ottawa ankle rules. 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. Comparison of ottawa ankle rules and bernese ankle rules in acute ankle and midfoot injuries article pdf available in turkish journal of emergency medicine 10 january 2010 with 2,929 reads. The specificity of the ottawa ankle rules does not help rule in an ankle or foot fracture. Data sources medline, embase, cinahl, sportdiscus and cochrane library. Using the ottawa ankle rules, xray imaging can be reduced 34% for the ankle series and 30% for the foot series. 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. The ottawa ankle rules oar are a clinical decision tool used to minimize unnecessary radiographs in ankle and foot injuries. A clinical decision rule to determine the need for diagnostic imaging for knee trauma. The ottawa ankle rules and missed fractures of the talus.
The applicability of the ottawa ankle rules in children aged 216 years has been confirmed with 100% sensitivity for significant fractures of the ankle and midfoot. Ottawa ankle rules many trials evaluate the validity of the ottawa ankle rules oar for excluding fractures of the ankle in patients with an ankle sprain. They are also careful to point out several groups in whom they do not feel the rules should be applied, such as the intoxicated, the multiply injured, or. An ankle xray series is only required if there is any pain in the malleolar zone and any of these findings. Ottawa ankle rules accurately assess injuries and reduce. The ottawa knee rules are a set of rules used to help physicians determine whether an xray of the knee is needed they state that an xray is required only in patients who have an acute knee injury with one or more of the following. Pdf comparison of ottawa ankle rules and bernese ankle. The ottawa ankle rules determine the need for radiographs in acute ankle injuries. This became known as the ottawa ankle rules, using bony tenderness and inability to. A group of ottawa emergency physicians developed two rules to identify clinically important fractures of the malleoli and the midfoot. Ankle and foot injuries are common presentations to the emergency department, and it can often be difficult to know whether imaging is required. 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.
A clinical decision rule to determine the need for diagnostic imaging for ankle andor foot trauma. The above research led to a final set of decision rules, named the ottawa ankle rules, for the use of radiography in ankle injury. Pdf abstract ankle injury is a common injury sustained in an outdoor activity or as a sport injury presenting to the emergency department. The rules were also associated with a reduction in waiting times and costs. Discuss the history, exam findings, and ottawa rules with patients. Ottawa ankle rule oar to rule out ankle and midfoot fractures in patients presenting with acute ankle sprain and. It is anticipated that application of the ottawa ankle rules in preschool children is difficult as the rules rely on their ability to report tenderness. The ottawa ankle rules oar are a set of clinical decision rules that were derived and validated by stiell et al. Ottaaw knee rule for knee injury radiography stiell ig, greenberg gh, wells ga, mcdowell i, cwinn aa, smith na, cacciotti tf, sivilotti mla. An ankle xray series is only required if there is any pain in the malleolar zone and.
A decision analytic approach to technology assessment. 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. Diagnostic accuracy of the ottawa ankle and midfoot rules. There are three sets of rules, one each for the foot, ankle and knee. In the united states, most ankle injuries are evaluated radiographically, 1,2 even though only about 15% are found to involve fractures. Yes no for patients with acute trauma to the ankle. The most important step in ankle fracture management is identifying stable verses unstable fractures. Multi trial to introduce the ottawa ankle rule for the use of radiography in acute ankle injuries the fifth study assessed the feasibility and impact of introducing the ottawa ankle rules in a wide variety. A clinical decision rule to determine the need for diagnostic imaging for alert and stable trauma patients gcs 15 with neck pain.
This would allow a reduction in radiographs of the ankle of 16% and of the foot by 29%, without missing any clinically significant fracture. The ottawa ankle rules in children emergency medicine. The ottawa ankle rule rules out clinically significant foot and ankle fractures to reduce use of xray imaging. We electronically searched databases, checked the reference lists of included studies, and contacted experts and authors in the specialty see appendix on. Safety and efficiency of the ottawa ankle rule in a swiss population. While all of these rules can be used in patients under the age of 18, they should be used with caution. The ottawa ankle rules and the buffalo modification of the ottawa rules should be judiciously applied to adult patients with ankle trauma to decrease the total number of ankle radiographs obtained.
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. Evidence supports the ottawa ankle rules as an accurate instrument for excluding fractures of the ankle and midfoot. A previous best evidence topic report examined whether these rules could be applied to children. Advise patients to seek followup care if their pain or ability to bear weight has not improved in five to seven days. The ottawa ankle rules ankle fracture clinical prediction rule duration. Validation of the ottawa ankle rules for acute foot and. We summarised the accuracy of the ottawa ankle rules for excluding fractures of the ankle and midfoot in patients presenting to emergency departments with an acute ankle sprain. 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.
Comparison of ottawa ankle rules and bernese ankle rules. Sep 06, 2018 there are three sets of rules, one each for the foot, ankle and knee. Since the publication of this study, the ottawa ankle rule have been well validated and have been shown to limit the number of radiographs obtained for ankle injuries, decreased patient wait times and cost. Update on acute ankle sprains american family physician. Ottaaw ankle rules for ankle injury radiography stiell ig, mcknight rd, greenberg gh, et al. The ottawa ankle rules can significantly decrease the number of unnecessary ankle radiographs. 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 oar are a reliable tool to exclude fractures in children over 5 years of age when applied by physicians. An ankle xray is required only if there is any pain in malleolar zone and any of these findings. The ottawa ankle rule can be used in the evaluation of ankle injuries to identify patients who have a low likelihood of fracture. Implementation of the ottawa ankle rules in france. Use of the ottawa ankle rule by paramedics in the outof. The ottawa ankle rule is useful in ruling out fracture high sensitivity, but does poorly at ruling in fractures many false positives. Imaging is required if there is pain in the midfoot zone and any of the following. Are the ottawa ankle rules helpful in ruling out the need. Less than 2% of patients in most subgroups who were negative for fracture according to the ottawa ankle rules actually had a fracture. The ottawa ankle and foot rules are highly sensitive and widely used as a tool to reduce unnecessary imaging in emergency departments. The ottawa ankle rules are used as a clinical prediction rule to rule out an ankle fracture in an acute situation without the need for an xray. A group of ottawa emergency physicians developed two rules to identify clinically important fractures of the malleoli and the. Radiographic examinations showed 19 fractures out of 100 investigated patients table 1. 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.
Ottawa ankle rule in the evaluation for fractures in blunt. Prospective validation of a decision rule for the use of radiography in acute knee injuries. 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. If a patient does not exhibit any of the criteria of the ottawa ankle rules, radiographs of the foot or ankle are unnecessary sor.
Ottawa ankle rules for the injured ankle british journal of. The ottawa ankle rules have a high sensitivity for. Validation of the ottawa ankle rules for acute foot and ankle injuries in journal of. The ottawa ankle rules were established to help physicians decide which patients should have an xray following an acute ankle injury. The ottawa knee rule describes criteria for minor knee trauma patients that are so low risk as not to warrant knee imaging. Apr 09, 2014 the ottawa ankle and foot rule duration. You know that the ottawa ankle rules are applicable in adult patients and you. The rules are intended to guide clinical decisions about the efficient use of radiography in the diagnosis of malleolar zone fractures and midfoot zone fractures, minimising expenditure. Racgp the ottawa knee rules a useful clinical decision. Use of the ottawa ankle rule by paramedics in the outofhospital setting introduction the ottawa ankle rule oar is extensively documented in the emergency department setting and has been subjected to repeated validation. Rule out a complete tear of the ligaments by doing drawer testing of the ankle before discharging the patient or at the first followup visit ottawa knee rules a knee xray is only required for knee injury patients with any of these findings. Eligibility criteria for selecting studies primary diagnostic studies. On examination there is swelling and tenderness over the lateral malleolus. Comparison of ottawa ankle rules and bernese ankle rules in.
Implementation of the ottawa ankle rules led to a decrease in use of ankle radiography, waiting times, and costs without patient dissatisfaction or missed fractures. The ottawa ankle rules in children emergency medicine journal. Ottowa ankle rules order form unc school of medicine. We focused on studies in which the ottawa ankle rules was used to diagnose fractures of the ankle or midfoot.
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