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 journalArticlepeer-review

78 Scopus citations


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
Issue number4
StatePublished - Apr 2009
Externally publishedYes


  • Ottawa ankle rules
  • Pediatric ankle injury
  • Systematic review

ASJC Scopus subject areas

  • Emergency Medicine


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