Presented at the Cochrane Colloquium, Sao Paulo, Brazil, October 23–27, 2007; and the Canadian Association of Emergency Physicians, Ottawa, Ontario, Canada, June 2–6, 2008.
Accuracy of Ottawa Ankle Rules to Exclude Fractures of the Ankle and Midfoot in Children: A Meta-analysis
Article first published online: 2 FEB 2009
© 2009 by the Society for Academic Emergency Medicine
Academic Emergency Medicine
Volume 16, Issue 4, pages 277–287, April 2009
How to Cite
Dowling, S., Spooner, C. H., Liang, Y., Dryden, D. M., Friesen, C., Klassen, T. P. and 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: 277–287. doi: 10.1111/j.1553-2712.2008.00333.x
A related commentary appears on page 352.
- Issue published online: 6 APR 2009
- Article first published online: 2 FEB 2009
- Received June 17, 2008; revisions received August 22 and September 24, 2008; accepted September 24, 2008.
- Ottawa Ankle Rules;
- pediatric ankle injury;
- systematic review
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.