Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7386.417 (Published 22 February 2003) Cite this as: BMJ 2003;326:417
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Compare with exactly the same diagram in BMJ Vol 311 pp594, 2/9/1995
for correction.
Competing interests:
None declared
Competing interests: No competing interests
The authors of this paper, when considering the wide variation in
specificity, cite "subtlety of palpation technique" as a possible
contributing factor. They are, of course, quite correct. If you palpate an
ankle, or anything else for that matter, and ask the patient "is that
sore?", you will invariably get a much higher positive response rate than
if you palpate silently and simply observe for a "non-verbal" response.
The moment you rely on a patient to "give you" your clinical sign,
then you're no longer dealing with an objective sign, such as an enlarged
liver or a heart murmur, but rather you're dealing with an extension of
symptomatology, with all the subjectivity that this entails. It's no
wonder then that studies which rely on the estimation of bony tenderness
are frequently associated with wide variations in specificity.
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Am I the only one to notice the error in Figure 1 accompanying this
article (right hand text should read foot xray series rather than ankle
xray series) or just the only one sad enough to bother sending a response
to point it out?
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Editor
We read this excellent meta-analysis with great interest. When originally
published, the Ottawa ankle rule was said to have 100% sensitivity &
40% specificity for detecting ankle fractures.1Therefore, all patients who
truly had a fracture would still get a radiograph, but a good many who did
not have fractures would be weeded out -36% by the investigators
estimate1.However subsequent independent studies2 3,4reported lower
sensitivity (89% to 95%) and specificity (6%-26%) than originally thought.
A sensitivity of almost 100% was confirmed in this paper by Bechmann et
al. and a possible overall 30-40% reduction in the number of x-rays were
also estimated.Stiell’s et al1 original paper was first published in 1992
and since then these rules has been studied repeatedly and published in
over hundred well established,peer reviewed journals.
Despite being very
popular topic for the journals, the Ottawa ankle rules are still not very
popular in UK and in many other countries. Out of 50 A&E deptts. in
Southeast of England,only 15 were following Ottawa rules in 19975.We
fully agree with the author that despite being a well recognised decision
making tool, its use and change of clinical implementation are limited.
Failure to diagnose ankle fractures can have serious medicolegal
consequences and we believe that perhaps,this is the main cause of poor
clinical implementation of Ottawa ankle rules in UK hospitals. Apart from
this, we have certain reservations against the ankle rules.
1.The most common complain of the pt. with ankle injury is the inability
to bear wt. with vague tenderness around ankle. Following the Ottawa rules
a significant proportions of pts will qualify for the x-ray.
2.Its difficult to follow the rules if the pt. can’t communicate properly
owing to altered mental status, alcohol intoxications or other problems.
3.In grossly swollen ankle, its difficult to appreciate the bony
tenderness.
4.Talar fractures is difficult to exclude by rule.
5.Many a times the patient preferences influence the test ordering. We
believe that its also important to educate the pt. about the Ottawa ankle
rules by providing them with booklet/leaflets.
References
1.Steill IG, Greenberg GH,McKnight RD et al.A study to develop
clinical decision rules for the use of radiography in acute ankle
injuries. Ann Emergency Med 1992;21(4):384-90
2.Auleley GR, Kerboull L, Durieux P, Courpied JP, Ravaud P.Validation of
the Ottawa rules in France: A study in the surgical emergency departments
of a teaching hospital.AnnEmergencyMed1998;32:14–18.
3.ChandraA; SchafmayerA .Dignostic value of a clinical test for exclusion
of fractures after acute ankle sprains. A prospective study for evaluating
the Ottowa Ankle Rules in Germany. Unfallchirurg 2001;104(7):617-21
4. Glas AS; Pijnenburg BA; Lijmer JG; Bogaard K et al. Comparison of
diagnostic decision rules and structured data collection in assessment of
acute ankle injury. CMAJ 2002 ;166(6):727-33
5.KeoghSP,Shafi A et al.Comparison of Ottawa ankle rules and current local
guidelines for use of radiography in acute ankle injuries. J R Coll Surg
Edinb 1998;43:341-343
Competing interests:
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In his editorial supporting the use of the Ottawa rules, Heyworth1
suggests that injured ankles should be separated into 2 groups: those with
‘simple ligamentous injury to soft tissue or a small avulsion fracture’
and those with ‘more serious fractures requiring immobilisation’. The
latter statement unfortunately reflects the casual treatment given to
patients with ligamentous ankle sprains in British A&E departments. Up
to a third of patients with an ankle sprain may go on to develop disabling
problems such as recurrent instability or chronic pain.
Doctors and nurses should be aware that the Ottawa rules are simply
guidelines to decide on which group of patients should have radiographs.
Patients with severe ankle sprains (e.g. those who cannot weight bear)
need more than a tubigrip and advice on ice and elevation – they also need
protection in an ankle stirrup or cast, and they should be referred for
physiotherapy for stretching, strengthening, balance and return to sports
exercises. A more thorough approach to patients with severe ankle sprains
should prevent long-term problems – this requires a culture change in
British A&E departments to recognise that ligament sprains can be more
disabling injuries than fractures.
The decreased popularity of the Ottawa rules in the United States and
mainland Europe could also possibly be explained by the use of stress
radiographs etc in their patients with ankle sprains.
Dishan Singh
Consultant Orthopaedic Surgeon,
Foot and Ankle Unit,
Royal National Orthopaedic Hospital,
Stanmore, Middx HA7 4LP
dishansingh@aol.com
1 Heyworth J. Ottawa rules for the injured ankle. BMJ 2003; 326:405-
6. (22 February)
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He's right!
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I suspect the diagram showing the medial ankle view should indicate
"B Posterior edge or tip of MEDIAL malleolus", not "B Posterior edge or
tip of LATERAL malleolus" as indicated (my emphasis).
Competing interests:
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Is the Ottawa Rules bad English?
Is the Ottawa Rules bad English?
Editor
The paper entitled “Accuracy of Ottawa ankle rules to exclude
fractures of the ankle and mid-foot: systematic review”, by Bachmann and
colleagues from Zurich and Amsterdam is an excellent assessment of the
evidence in regard to this sensible approach to ordering ankle x-rays in
Casualty departments.
But the insistence on considering the rules to be singular is not
supported by the only statement of these rules in Fig 1, which clearly
identifies two major rules (regarding pain in either the malleolar zone or
the midfoot zone), each of which has three further sub-sections.
This is an example of a “singular plurality” – but in normal English
the subject of a sentence should agree with the verb (1). We are
accustomed to the Queensberry Rules in boxing, or the McNaughton Rules in
law. “Too much importance is attached to grammarians’ fetishes, and too
little to choosing the right words” (2), but illiteracy is another thing,
and Gowers adds “we cannot have grammar jettisoned altogether: that
would mean chaos”. What price the readability of British or American
medical prose?
DAVID HADDEN
Honorary Professor of Endocrinology
Regional Centre for Endocrinology and Diabetes,
Royal Victoria Hospital, Belfast BT12 6BA
david.hadden@royalhospitals.n-i.nhs.uk
1. Albert T. Medical Journalism. The writers guide. Oxford;
Radcliffe Medical Press 1992: 62.
2. Gowers E. The Complete Plain Words.
3rd ed: revised by Greenbawm S and Whitcut J:
Her Majesty’s Stationery Office: 98.
3. Weeks WB, Wallace AE, Readability of British and American
medical prose at the start of the 21st century. BMJ 2002: 325: 1451-
2.
Competing interests:
None declared
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