Validation of the Ottawa Ankle Rules in France: A Study in the Surgical Emergency Department of a Teaching Hospital☆,☆☆,★,★★
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 No. % Age, mean (range, yr) 34 (18-90) Male 198 47.6 Mechanism of injury Twisting 259 62.3 Direct blow 32 7.7 Undefined 125 30.0 Significant fractures 71 17.1 Malleolar zone 49 11.8 Lateral malleolus 38 9.1 Medial malleolus 5 1.2 Bimalleolar 3 .7 Talus 2 .5 Others 1 .2 Midfoot zone 22 5.3 Base of fifth metatarsal 11 2.6
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
References (31)
- et al.
The ankle injury: Indications for the selective use of x-rays
Injury
(1983) - et al.
A study to develop clinical decision rules for the use of radiography in acute ankle injuries
Ann Emerg Med
(1992) - et al.
Sensitivity of the Ottawa rules
Ann Emerg Med
(1995) - et al.
Evaluation of the Ottawa clinical decision rules for the use of radiography in acute ankle and midfoot injuries in the emergency department: An independent site assessment
Ann Emerg Med
(1994) Limited assurances
Am J Cardiol
(1989)Need for radiographs in the acutely injured ankle
Lancet
(1988)- et al.
Evaluation et traitement de l’entorse externe de la cheville dans un milieu de soins de première ligne: la radiographie systématique est-elle essentielle?
Can Med Assoc J
(1986) - et al.
Inversion injuries of the ankle: Clinical assessment and radiographic review
BMJ
(1981) - et al.
Reasons for requesting radiographs in an accident department
BMJ
(1979) - et al.
Rationalising requests for x-ray examination of acute ankle injuries
BMJ
(1979)
Incidence of minor fractures in twisting injuries of the ankle
Injury
Limiting the use of routine radiography for acute ankle injuries
Can Med Assoc J
Can more efficient use be made of x-ray examinations in the accident and emergency department?
BMJ
The “overutilization” of x-rays
N Engl J Med
Decision rules for the use of radiography in acute ankle injuries: Refinement and prospective validation
JAMA
Cited by (59)
Validation of the Ottawa ankle rules: Strategies for increasing specificity
2021, InjuryCitation Excerpt :Stiell et al. [8–10] developed the OARs, having established clinical criteria that assess the ability to carry out load and pain under palpation of pre-defined anatomical areas in order to rationalize the use of radiographs. Since then, several groups have carried out identical studies for local validation that generally confirmed the conclusions of the original study. [3, 11–15] The most recent systematic reviews [16,17] demonstrate that OARs, although presenting good levels of average sensitivity (99.4%), nevertheless have relatively low average specificity values (35.3%), not allowing the exclusion of imaging tests of a large number of patients.
Ultrasound-assisted triage of ankle trauma can decrease the need for radiographic imaging
2013, American Journal of Emergency MedicineCitation Excerpt :Most of those patients experience an inversion injury of the ankle. In many studies, less than 15% of all patients who have sustained inversion sprains have a fracture; however, it may be difficult to establish the correct diagnosis by clinical examination alone [3-5]. Excluding a fracture is an important clinical decision because most ankle fractures need surgical treatment and/or immobilization, whereas almost all sprains can be treated with early mobilization including physiotherapy, sometimes using a functional brace during the rehabilitation [1].
Nurse practitioners treating ankle and foot injuries using the Ottawa Ankle Rules: A comparative study in the emergency department
2013, Australasian Emergency Nursing JournalCitation Excerpt :This practice is promoted by the nature of emergency treatment whereby high case-volumes are coupled with brief ED-Dr contact.5 Validation studies of the OARs conducted in Australia,16 Switzerland,17 Hong Kong,18 France,19 Iran20 and Greece21 have been able to reproduce high sensitivities (98–100%) in detecting ankle and foot fractures. A meta-analysis of twelve validation studies for application of the OAR in children revealed a pooled sensitivity of 98.5%: ten studies showed sensitivities in the range of 96.8–100%.13
Would it be possible to develop a set of Ottawa wrist rules to facilitate clinical decision-making?
2008, Revista Espanola de Cirugia Ortopedica y TraumatologiaExperience using the «Shetty test» for initial foot and ankle fracture screening in the Emergency Department
2018, Revista Espanola de Cirugia Ortopedica y TraumatologiaAccuracy of the Ottawa Ankle Rules applied by non-physician providers in a pediatric emergency department
2018, Canadian Journal of Emergency Medicine
- ☆
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
- ★★
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]