Validation of the Ottawa Ankle Rules in France: A Study in the Surgical Emergency Department of a Teaching Hospital,☆☆,,★★

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Abstract

Study objective: To validate the Ottawa ankle rules to predict fractures in a French clinical setting when they are used by physicians not involved in their development.

Methods: We used a prospective patient survey by emergency physicians in a surgical emergency department of a university teaching hospital of the Assistance Publique-Hôpitaux de Paris. The study group consisted of 416 consecutive patients aged 18 years and older who presented with acute ankle or midfoot injuries in the surgical ED during a 4-month period. Radiography was performed in each patient after clinical evaluation findings were recorded.

Results: Forty-nine ankle and 22 midfoot fractures were diagnosed. The decision rules had a sensitivity of .98, a specificity of .45, and a negative predictive value of .99 in detecting ankle fractures, a sensitivity of 1.0, a specificity of .29, and a negative predictive value of 1.0 in detecting midfoot fractures. The rules failed to predict one avulsion fracture in the ankle group. Application of these rules by emergency physicians would have reduced ankle or midfoot radiography requests by 33%.

Conclusion: Use of the Ottawa ankle rules by French emergency physicians not involved in the rules’ development resulted in 99% sensitivity and had a potential of reducing radiography requests by 33%.

[Auleley G-R, Kerboull L, Durieux P, Cosquer M, Courpied J-P, Ravaud P: Validation of the Ottawa ankle rules in France: A study in the surgical emergency department of a teaching hospital. Ann Emerg Med July 1998;32:14-18.]

Section snippets

INTRODUCTION

Acute ankle injuries are among the most frequent presentation complaints in surgical emergency departments. Most ankle injury patients undergo radiography, whereas less than 15% have significant fractures or avulsion fractures.1, 2, 3, 4, 5, 6 Rationalizing the use of ankle radiography may reduce ED waiting time, excessive radiation for patients, and direct costs of radiography for the health care system.7, 8, 9 Therefore predicting high-risk significant fracture or avulsion fracture is

MATERIALS AND METHODS

A prospective validation survey was conducted in the surgery ED of a Paris university teaching hospital during a 4-month period. The ED of this 1,100–acute bed hospital treats approximately 30,000 patients annually. The local institutional review board determined that the study was exempt from review requirements and could be conducted without informed consent. All patients older than 18 years with acute ankle or midfoot injuries, regardless of the mechanism, who presented within 10 days of the

RESULTS

Four hundred sixteen consecutive patients who presented with acute ankle or midfoot injuries during 4 months were studied (Table 1).

. Characteristics of the 416 patients with ankle or midfoot injuries.

CharacteristicsNo.%
Age, mean (range, yr)34 (18-90)
Male19847.6
Mechanism of injury
Twisting25962.3
Direct blow327.7
Undefined12530.0
Significant fractures7117.1
Malleolar zone4911.8
Lateral malleolus389.1
Medial malleolus51.2
Bimalleolar3.7
Talus2.5
Others1.2
Midfoot zone225.3
Base of fifth metatarsal112.6

DISCUSSION

We confirmed that the Ottawa ankle rules are applicable by users external to their development process and in a different health care system with a 98% sensitivity in the malleolar zone and a 100% sensitivity in the midfoot zone. The application of these rules would result in a 33% reduction in the use of ankle or midfoot radiographies in our clinical setting.

Numerous predictive rules have been developed to decide which patients with ankle injuries need radiographic examination,1, 2, 6, 7, 8, 10

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    From the Délégation à l’Evaluation Médicale–Direction de la Prospective et de L’Information Médicale, Assistance Publique-Hôpitaux de Paris,* and the Department of Orthopedics, Cochin Hospital, Paris, France.

    ☆☆

    Supported by the Délégation à l’Evaluation Médicale, Direction de la Prospective et de L’Information Médicale of the Assistance Publique-Hôpitaux de Paris.

    Reprint no. 47/1/90890

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    Address for reprints: Philippe Ravaud, MD, PhD, Clinique de Rhumatologie, Hôpital Cochin, Université René Descartes, 27, Rue du faubourg Saint Jacques, 75014 Paris, France, 33 1 42 34 18 87, Fax 33 1 43 25 78 84, E-mail [email protected]

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