Emergency Medicine| June 01 2003 Do All Ankle Injuries Need Radiographs? AAP Grand Rounds (2003) 9 (6): 67. https://doi.org/10.1542/gr.9-6-67 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Do All Ankle Injuries Need Radiographs?. AAP Grand Rounds June 2003; 9 (6): 67. https://doi.org/10.1542/gr.9-6-67 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: ankle injuries, diagnostic radiologic examination, ottawa ankle rules Source: Bachman LM, Kolb E, Koller MT, et al. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003;326:417–419. Acute ankle sprains are very common injuries. Although radiographs are often routinely obtained by physicians evaluating a patient with an ankle injury, fractures of the ankle or mid-foot are present in less than 15% of these patients.1 Eleven years ago, a group of physicians from the University of Ottawa, Ontario, Canada, developed a set of clinical decision rules to decide which patients with acute ankle sprains need radiographs.2 According to the guidelines, ankle radiographs should be obtained if there is bone tenderness along the posterior edge or tip of either malleolus or if the patient cannot walk 4 steps both immediately after the injury and at the emergency department. Radiographs of the foot should be obtained to rule out a mid-foot fracture if there is bone tenderness at the base of the fifth metatarsal, over the cuboid, or over the navicular, or if the patient cannot ambulate. (The original article also suggests radiographs if the patient is over age 55.) The guidelines have become known as the Ottawa ankle rules and have undergone scientific validation in many studies, several of which have focused on children and adolescents.3,4 Researchers from the Academic Medical Center, Department of General Practice in Amsterdam, Netherlands, performed an extensive search of the medical literature and identified 27 methodologically sound studies that evaluated the Ottawa ankle rules for sensitivity and specificity. From the results of these studies the authors calculated a pooled sensitivity and pooled likelihood ratio of a negative result, which is the likelihood of obtaining a negative result among those with a fracture compared to the likelihood of obtaining a negative result among those without a fracture. The 27 studies included 15,581 patients with 47 (0.3%) false negative results. Pooled sensitivities were high in all studies, ranging from 99.6% on studies evaluating patients within 48 hours of injury, to 96.4% on studies of combined assessment of both the ankle and mid-foot, to 99.3% for studies applying the rule to children (95% CI, 98.3–100). Median specificity for all studies was 31.5% (95% CI, 23.8–44.4) with a range from 47.9% in studies with a low prevalence of fractures (fewer than 25% of study population with fracture) to 26.3% in studies with a combined assessment of ankle and foot. Assuming a 15% prevalence of fracture, the negative likelihood ratio for all studies was 0.1 (95% CI, 0.06–0.16) for a probability of a fracture after negative testing of 1.73% (95% CI, 1.05–2.75). In the 7 studies involving only children, the negative likelihood ratio was 0.07 (95% CI, 0.03–0.18) for a probability of a fracture after negative testing of 1.22% (95% CI, 0.53–3.08). The original study of these clinical decision rules demonstrated 100% sensitivity and, therefore, 100% negative predictive value.2 It is not surprising that subsequent studies that have attempted to validate those initial... You do not currently have access to this content.