Accuracy of Ottawa Ankle Rules to Exclude Fractures of the Ankle and Midfoot in Children: A Meta‐analysis

Abstract

Objectives: The objectives were to conduct a systematic review to determine the diagnostic accuracy of the Ottawa Ankle Rules (OAR) to exclude ankle and midfoot fractures in children and the extent to which x-ray use could be reduced without missing significant fractures. Methods:The authors conducted comprehensive searches of electronic databases and gray literature sources. Independent reviewers applied standard inclusion and exclusion criteria. The criterion standard diagnostic test was an ankle and ⁄ or foot x-ray or proxy measure to ensure no missed fractures. Standard 2 · 2 tables were constructed. Sensitivities and specificities were pooled using an approximation of the inverse variance; 95% confidence intervals (95% CIs) were calculated using the exact method. Likelihood ratios (LR ±) and diagnostic odds ratios were combined under DerSimonian and Laird random effects model.Results: A pooled analysis of 12 studies (N = 3,130) identified 671 fractures (prevalence = 21.4%). Ten studies reported Salter-Harris Type I (SH-I) fractures. The pooled sensitivity was 98.5% (95% CI = 97.3 to 99.2), suggesting that the OAR can be used to rule out a fracture. Four of 10 missed fractures were characterized: 1 SH-I, 1 SH-IV, and 2 ''insignificant fractures'' (either SH-I or avulsion fractures <3 mm). The pooled estimate for rate of x-ray reduction was 24.8% (95% CI = 23.3% to 26.3%; range = 5% to 44%). Conclusions:The OAR appear to be a reliable tool to exclude fractures in children greater than 5 years of age presenting with ankle and midfoot injuries. Employing the OAR would significantly decrease x-ray use with a low likelihood of missing a fracture.

National Athletic Trainers' Association Position Statement: Conservative Management and Prevention of Ankle Sprains in Athletes

“…Several groups 63,188,18 have also shown positive outcomes in terms of reduced ankle sprains and measures of balance and postural control after exercise programs focused on progressive balance training, closed chain strengthening, and hopping exercises. 9 These exercise programs varied, but all consisted of single-legged-stance activities that demanded balance in challenging environments (unstable surfaces, movement, additional upper extremity tasks, etc). Mohammadi 189 used a singlelegged-stance activity performed for 30 minutes every day during a soccer season.…”

“…A systematic review of studies of the accuracy of the OARs to exclude fracture of the ankle and midfoot in children was conducted by Dowling et al 9 Twelve studies of 3130 children (age range ¼ 6 to 19 years) who presented to the emergency room after ankle trauma demonstrated 671 fractures (prevalence ¼ 21.4%). The pooled sensitivity of the OARs to exclude fracture of the ankle or midfoot was 98.5%, whereas specificity was 7.9% to 50%.…”

“…The Ottawa Ankle Rules (OARs) are a valid clinical tool to determine the need for radiographs of the acutely injured ankle or midfoot. 8,9 Evidence Category: A 8. Stress radiography is an unreliable tool to detect acute ligamentous disruption after ankle sprain.…”

Diagnostic Accuracy of History, Physical Examination, and Bedside Ultrasound for Diagnosis of Extremity Fractures in the Emergency Department: A Systematic Review

“…The study was not able to report for the adult population because of insufficient published data. 46 Dowling et al 47 published a meta-analysis of the Ottawa ankle rule in pediatric patients including 12 studies with a fracture prevalence of 21.4%. The authors reported a pooled sensitivity of 98.5%.…”

Can We Safely Apply the Ottawa Ankle Rules to Children?

“…A meta-analysis of 15,581 patients (adults and children) from 27 studies demonstrated an overall sensitivity and specificity for the OAR of 97.6 and 31.5%, respectively. 7 In this issue of Academic Emergency Medicine, Dowling et al 8 present a well-designed and executed metaanalysis of the Ottawa Ankle Rules for the identification of ankle and midfoot fractures in children. In a pooled analysis of 12 studies representing 3,130 children with 671 fractures, the authors report a pooled sensitivity of 98.5% (95% confidence interval = 97.3% to 99.2%) and a negative likelihood ratio of 0.11.…”