Validation of the Ottawa Ankle Rules in Children with Ankle Injuries

Open Access
Publisher Website
Google Scholar
Abstract
Objectives: The Ottawa Ankle Rules (OAR) have been found to be 100% sensitive in adult patients with ankle injuries, and application of the OAR has resulted in a 28% reduction in the number of x‐rays ordered. The objectives of this study were to determine the sensitivity and specificity of the OAR in children and to determine the potential change in x‐ray utilization. Methods: Children, aged 2‐16 years, presenting to the EDs of two children's hospitals, with an ankle injury in the previous 48 hours, were enrolled. All patients were assessed by either staff physicians or fellows. X‐rays were ordered according to standard clinical practice. Prior to reviewing x‐rays, the physical examination was recorded on a standardized form. Positive outcomes (clinically significant) were defined as fractures with fragments ≥3 mm. Patients not x‐rayed and asymptomatic at five to seven days postinjury were considered to have no significant fracture. Results: Six hundred seventy patients were enrolled. The OAR were 100% sensitive (95% CI = 95% to 100%) for significant ankle fractures, with a specificity of 24% (95% CI = 20% to 28%). The OAR were 100% sensitive (95% CI = 82% to 100%) for the midfoot, with a specificity of 36% (95% CI = 29% to 43%). If the OAR had been followed, there would have been a reduction of ankle x‐rays by 16% and foot x‐rays by 29% without missing any clinically significant fracture. However, analysis of the two hospitals showed that if the rules had been applied, one would have a reduction in x‐rays, while the other center would have an increase. Conclusions: This study demonstrates the OAR to be sensitive for detecting clinically significant (≥3 mm) ankle and midfoot fractures in children. The application of these rules may reduce the number of x‐rays ordered. A further study is required to determine the effect of using the OAR in clinical practice.