Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: A meta-analysis

Shawn Dowling, Carol H. Spooner, Yuanyuan Liang, Donna M. Dryden, Carol Friesen, Terry P. Klassen, R. Bruce Wright

Research output: Contribution to journalArticle

67 Citations (Scopus)

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.

Original languageEnglish (US)
Pages (from-to)277-287
Number of pages11
JournalAcademic Emergency Medicine
Volume16
Issue number4
DOIs
StatePublished - Apr 2009
Externally publishedYes

Fingerprint

Ankle Fractures
Ankle
Meta-Analysis
X-Rays
Confidence Intervals
Ankle Injuries
Proxy
Routine Diagnostic Tests
Foot
Odds Ratio
Databases
Sensitivity and Specificity

Keywords

  • Ottawa ankle rules
  • Pediatric ankle injury
  • Systematic review

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Dowling, S., Spooner, C. H., Liang, Y., Dryden, D. M., Friesen, C., Klassen, T. P., & Wright, R. B. (2009). Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: A meta-analysis. Academic Emergency Medicine, 16(4), 277-287. https://doi.org/10.1111/j.1553-2712.2008.00333.x

Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children : A meta-analysis. / Dowling, Shawn; Spooner, Carol H.; Liang, Yuanyuan; Dryden, Donna M.; Friesen, Carol; Klassen, Terry P.; Wright, R. Bruce.

In: Academic Emergency Medicine, Vol. 16, No. 4, 04.2009, p. 277-287.

Research output: Contribution to journalArticle

Dowling, S, Spooner, CH, Liang, Y, Dryden, DM, Friesen, C, Klassen, TP & Wright, RB 2009, 'Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: A meta-analysis', Academic Emergency Medicine, vol. 16, no. 4, pp. 277-287. https://doi.org/10.1111/j.1553-2712.2008.00333.x
Dowling, Shawn ; Spooner, Carol H. ; Liang, Yuanyuan ; Dryden, Donna M. ; Friesen, Carol ; Klassen, Terry P. ; Wright, R. Bruce. / Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children : A meta-analysis. In: Academic Emergency Medicine. 2009 ; Vol. 16, No. 4. pp. 277-287.
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