Prospective evaluation of the Ottawa Ankle Rules in a university sports medicine center. With a modification to increase specificity for identifying malleolar fractures

ACR Appropriateness Criteria® Acute Trauma to the Ankle

Acute injuries to the ankle are frequently encountered in the setting of the emergency room, sport, and general practice. This ACR Appropriateness Criteria defines best practices for imaging evaluation for several variants of patients presenting with acute ankle trauma. The variants include scenarios when Ottawa Rules can be evaluated, when there are exclusionary criteria, when Ottawa Rules cannot be evaluated, as well as specific injuries. Clinical scenarios are followed by the imaging choices and their appropriateness with an accompanying narrative explanation to help physicians to order the most appropriate imaging test. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: a systematic review with meta-analysis

OBJECTIVE

To review the diagnostic accuracy of the Ottawa Ankle and Midfoot Rules and explore if clinical features and/or methodological quality of the study influence diagnostic accuracy estimates.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, SPORTDiscus and Cochrane Library.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Primary diagnostic studies reporting the accuracy of the Rules in people with ankle and/or midfoot injury were retrieved. Diagnostic accuracy estimates, overall and for subgroups (patient's age, profession of the assessor and setting of application), were made. Sensitivity analyses included studies with a low risk of bias and studies where all patients received radiographs.

RESULTS

66 studies were included. Ankle and Midfoot Rules presented similar accuracies, which were homogeneous and high for sensitivity and negative likelihood ratios and poor and heterogeneous for specificity and positive likelihood ratios (mean, 95% CI pooled sensitivity of Ankle Rules: 99.4%, 97.9% to 99.8%; specificity: 35.3%, 28.8% to 42.3%). Sensitivity of the Ankle Rules was higher in adults than in children, but the profession of the assessor did not appear to influence accuracy. Specificity was higher for Midfoot than for Ankle Rules. There were not enough studies to allow comparison according to setting of application. Studies with a low risk of bias and where all patients received radiographs provided lower accuracy estimates. Specificity heterogeneity was not explained by assessor training, use of imaging in all patients and low risk of bias.

CONCLUSIONS

Study features and the methodological quality influence estimates of the diagnostic accuracy of the Ottawa Ankle and Midfoot Rules.

ACR Appropriateness Criteria acute trauma to the ankle

Acute ankle injuries are frequently diagnosed and treated in emergency departments and outpatient clinics. Recent evidence-based clinical treatment guidelines and systematic review of economic analyses support the use of 3-view (anteroposterior, lateral, and mortise) radiographic evaluation of patients meeting the criteria of the Ottawa ankle rules. Cross-sectional imaging has a limited secondary role primarily as a tool for preoperative planning and as a problem-solving technique in patients with persistent symptoms and suspected of having occult fractures. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Knowledge Translation Tools are Emerging to Move Neck Pain Research into Practice

Development or synthesis of the best clinical research is in itself insufficient to change practice. Knowledge translation (KT) is an emerging field focused on moving knowledge into practice, which is a non-linear, dynamic process that involves knowledge synthesis, transfer, adoption, implementation, and sustained use. Successful implementation requires using KT strategies based on theory, evidence, and best practice, including tools and processes that engage knowledge developers and knowledge users. Tools can provide instrumental help in implementing evidence. A variety of theoretical frameworks underlie KT and provide guidance on how tools should be developed or implemented. A taxonomy that outlines different purposes for engaging in KT and target audiences can also be useful in developing or implementing tools. Theoretical frameworks that underlie KT typically take different perspectives on KT with differential focus on the characteristics of the knowledge, knowledge users, context/environment, or the cognitive and social processes that are involved in change. Knowledge users include consumers, clinicians, and policymakers. A variety of KT tools have supporting evidence, including: clinical practice guidelines, patient decision aids, and evidence summaries or toolkits. Exemplars are provided of two KT tools to implement best practice in management of neck pain—a clinician implementation guide (toolkit) and a patient decision aid. KT frameworks, taxonomies, clinical expertise, and evidence must be integrated to develop clinical tools that implement best evidence in the management of neck pain.

National Athletic Trainers' Association position statement: conservative management and prevention of ankle sprains in athletes

OBJECTIVE

To present recommendations for athletic trainers and other allied health care professionals in the conservative management and prevention of ankle sprains in athletes.

BACKGROUND

Because ankle sprains are a common and often disabling injury in athletes, athletic trainers and other sports health care professionals must be able to implement the most current and evidence-supported treatment strategies to ensure safe and rapid return to play. Equally important is initiating preventive measures to mitigate both first-time sprains and the chance of reinjury. Therefore, considerations for appropriate preventive measures (including taping and bracing), initial assessment, both short- and long-term management strategies, return-to-play guidelines, and recommendations for syndesmotic ankle sprains and chronic ankle instability are presented.

RECOMMENDATIONS

The recommendations included in this position statement are intended to provide athletic trainers and other sports health care professionals with guidelines and criteria to deliver the best health care possible for the prevention and management of ankle sprains. An endorsement as to best practice is made whenever evidence supporting the recommendation is available.

Electronic decision support for diagnostic imaging in a primary care setting

METHODS

Clinical guideline adherence for diagnostic imaging (DI) and acceptance of electronic decision support in a rural community family practice clinic was assessed over 36 weeks. Physicians wrote 904 DI orders, 58% of which were addressed by the Canadian Association of Radiologists guidelines.

RESULTS

Of those orders with guidelines, 76% were ordered correctly; 24% were inappropriate or unnecessary resulting in a prompt from clinical decision support. Physicians followed suggestions from decision support to improve their DI order on 25% of the initially inappropriate orders. The use of decision support was not mandatory, and there were significant variations in use rate. Initially, 40% reported decision support disruptive in their work flow, which dropped to 16% as physicians gained experience with the software.

CONCLUSIONS

Physicians supported the concept of clinical decision support but were reluctant to change clinical habits to incorporate decision support into routine work flow.

Clinical usefulness of the Ottawa Ankle Rules for detecting fractures of the ankle and midfoot

Reference:

Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003;326(7386):417–423.

Clinical Question:

What is the evidence for the accuracy of the Ottawa Ankle Rules as a decision aid for excluding fractures of the ankle and midfoot?

Data Sources:

Studies were identified by searching MEDLINE and PreMEDLINE (Ovid version: 1990 to present), EMBASE (Datastar version: 1990–2002), CINAHL (Winspires version: 1990–2002), the Cochrane Library (2002, issue 2), and the Science Citation Index database (Web of Science by Institute for Science Information). Reference lists of all included studies were also searched, and experts and authors in the specialty were contacted. The search had no language restrictions.

Study Selection:

Minimal inclusion criteria consisted of (1) study assessment of the Ottawa Ankle Rules and (2) sufficient information to construct a 2 × 2 contingency table specifying the false-positive and false-negative rates.

Data Extraction:

Studies were selected in a 2-stage process. First, all abstracts and titles found by the electronic searches were independently scrutinized by the same 2 authors. Second, copies of all eligible papers were obtained. A checklist was used to ensure that all inclusion criteria were met. Disagreements related to the eligibility of studies were resolved by consensus. Both authors extracted data from each included study independently. Methods of data collection, patient selection, blinding and prevention of verification bias, and description of the instrument and reference standard were assessed. Sensitivities (using the bootstrap method), specificities, negative likelihood ratios (using a random-effects model), and their standard errors were calculated. Special interest was paid to the pooled sensitivities and negative likelihood ratios because of the calibration of the Ottawa Ankle Rules toward a high sensitivity. Exclusion criteria for the pooled analysis were (1) studies that used a nonprospective data collection, (2) unknown radiologist blinding (verification bias), (3) studies assessing the performance of other specialists (nonphysicians) using the rules, and (4) studies that looked at modifications to the rules.

Main Results:

The search yielded 1085 studies, and the authors obtained complete articles for 116 of the studies. The reference lists from these studies provided an additional 15 studies. Only 32 of the studies met the inclusion criteria and were used for the review; 5 of these met the exclusion criteria. For included studies, the total population was 15 581 (range  =  18–1032), and average age ranged from 11 to 31.1 years in those studies that reported age. The 27 studies analyzed (pooled) consisted of 12 studies of ankle assessment, 8 studies of midfoot assessment, 10 studies of both ankle and midfoot assessment, and 6 studies of ankle or midfoot assessment in children (not all studies assessed all regions). Pooled sensitivities, specificities, and negative likelihood ratios for the ankle, midfoot, and combined ankle and midfoot are presented in the Table. Based on a 15% prevalence of actual fracture in patients presenting acutely after ankle or foot trauma, less than a 1.4% probability of fracture existed. Because limited analysis was conducted on the data from the children, we elected to not include this cohort in our review.

Conclusions:

Evidence supports the use of the Ottawa Ankle Rules as an aid in ruling out fractures of the ankle and midfoot. The rules have a high sensitivity (almost 100%) and modest specificity. Use of the Ottawa Ankle Rules holds promise for saving time and reducing both costs and radiographic exposure without sacrificing diagnostic accuracy in ankle and midfoot fractures.

Understanding acute ankle ligamentous sprain injury in sports

This paper summarizes the current understanding on acute ankle sprain injury, which is the most common acute sport trauma, accounting for about 14% of all sport-related injuries. Among, 80% are ligamentous sprains caused by explosive inversion or supination. The injury motion often happens at the subtalar joint and tears the anterior talofibular ligament (ATFL) which possesses the lowest ultimate load among the lateral ligaments at the ankle. For extrinsic risk factors to ankle sprain injury, prescribing orthosis decreases the risk while increased exercise intensity in soccer raises the risk. For intrinsic factors, a foot size with increased width, an increased ankle eversion to inversion strength, plantarflexion strength and ratio between dorsiflexion and plantarflexion strength, and limb dominance could increase the ankle sprain injury risk. Players with a previous sprain history, players wearing shoes with air cells, players who do not stretch before exercising, players with inferior single leg balance, and overweight players are 4.9, 4.3, 2.6, 2.4 and 3.9 times more likely to sustain an ankle sprain injury. The aetiology of most ankle sprain injuries is incorrect foot positioning at landing – a medially-deviated vertical ground reaction force causes an explosive supination or inversion moment at the subtalar joint in a short time (about 50 ms). Another aetiology is the delayed reaction time of the peroneal muscles at the lateral aspect of the ankle (60–90 ms). The failure supination or inversion torque is about 41–45 Nm to cause ligamentous rupture in simulated spraining tests on cadaver. A previous case report revealed that the ankle joint reached 48 degrees inversion and 10 degrees internal rotation during an accidental grade I ankle ligamentous sprain injury during a dynamic cutting trial in laboratory. Diagnosis techniques and grading systems vary, but the management of ankle ligamentous sprain injury is mainly conservative. Immobilization should not be used as it results in joint stiffness, muscle atrophy and loss of proprioception. Traditional Chinese medicine such as herbs, massage and acupuncture were well applied in China in managing sports injuries, and was reported to be effective in relieving pain, reducing swelling and edema, and restoring normal ankle function. Finally, the best practice of sports medicine would be to prevent the injury. Different previous approaches, including designing prophylactice devices, introducing functional interventions, as well as change of games rules were highlighted. This paper allows the readers to catch up with the previous researches on ankle sprain injury, and facilitate the future research idea on sport-related ankle sprain injury.

Knowledge translation: putting the "practice" in evidence-based practice

Knowledge translation (KT) is an iterative process that involves knowledge development, synthesis, contextualization, and adaptation, with the expressed purpose of moving the best evidence into practice that results in better health processes and outcomes for patients. Optimization of the process requires engaged interaction between knowledge developers and knowledge users. Knowledge users include consumers, clinicians, and policy makers. KT is highly reliant on understanding when research evidence needs to be moved into practice. Social, personal, policy, and system factors contribute to how and when change in practice can be accomplished. Evidence-based practitioners need to understand a conceptual basis for KT and the evidence indicating which specific KT strategies might help them move best evidence into action in practice. Audit and feedback, knowledge brokering, clinical practice guidelines, professional standards, and "active-learning" continuing education are examples of KT strategies.

[Ankle injury without fracture in children: cast immobilization versus symptomatic treatment. Impact on absenteeism and quality of life]

Treatment methods for ankle injury in children are numerous and have comparable results. The impact on absenteeism and quality of life is an interesting criterion to consider in order to help doctors in their initial treatment choice.

OBJECTIVE

The objective of this study was to compare two therapeutic strategies for ankle injury without fracture in children in terms of the impact on school absenteeism, parents' professional absenteeism, and quality of life. The strategies compared were cast immobilization of the ankle and a purely symptomatic treatment with no immobilization.

MATERIALS AND METHOD

We conducted a prospective, comparative, and randomized study. The population comprised children between 8 and 15 years of age, consulting for a first episode of ankle injury in a pediatric-emergency department of a hospital center in Marseille, France. A clinical and radiographical report was systematically done. Children were seen after 1 week to provide the clinical monitoring, assess the child's and parents' absenteeism, and assess the quality of life.

RESULTS

Sixty-two patients were studied. There was no difference in clinical progression after 7 days between the two treatment groups. Quality of life was also comparable. However, the children's absenteeism and the parents' absenteeism were higher in the casted group.

Review for the generalist: evaluation of pediatric foot and ankle pain

Foot and ankle pain is common in children and adolescents. Problems are usually related to skeletal maturity and are fairly specific to the age of the child. Evaluation and management is challenging and requires a thorough history and physical exam, and understanding of the pediatric skeleton. This article will review common causes of foot and ankle pain in the pediatric population.

Comparison of a lateral hop test versus a forward hop test for functional evaluation of lateral ankle sprains

The purposes of this study were to determine whether a lateral hop test was a more sensitive functional test over time than a forward hop test in assessing lateral ankle sprains, and whether lateral hop performance can predict a subjective score from an ankle rating scale. At the United States Military Academy, cadets presenting with ankle sprains during an 8-month period were included in this observational study. Patients were asked to perform a lateral hop for distance and a forward hop for distance on both the injured and uninjured lower extremities. The order of testing was randomized. After the hop trials, individuals completed a subjective questionnaire designed to assess functional ankle health. The lateral hop and subjective scores are components of the Sports Ankle Rating System. Patients were evaluated at the day of consent and at 1 week, 3 weeks, and 6 weeks. There were 29 patients, ages 18 to 22 years; 8 were women and 21 were men. A multivariable regression of analysis was performed to determine which subjective factors best predict the individual's subjective score. Although both the lateral and forward hop were statistically significant factors, neither was determined to be better than the other.

Validation of the Ottawa Ankle Rules in Iran: a prospective survey

Background

Acute ankle injuries are one of the most common reasons for presenting to emergency departments, but only a small percentage of patients – approximately 15% – have clinically significant fractures. However, these patients are almost always referred for radiography. The Ottawa Ankle Rules (OARs) have been designed to reduce the number of unnecessary radiographs ordered for these patients. The objective of this study was to validate the OARs in the Iranian population.

Methods

This prospective survey was done among 200 patients with acute ankle injury from January 2004 to April 2004 in the Akhtar Orthopedics Hospital Emergency Department. Main outcome measures of this survey were: sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratios (positive and negative) of the OARs.

Results

Sensitivity of the OARs for detecting 37 ankle fractures (23 in the malleolar zone and 14 in the midfoot zone) was 100% for each of the two zones, and 100% for both zones. Specificity of the OARs for detecting fractures was 40.50% for both zones, 40.50% for the malleolar zone, and 56.00% for the midfoot zone. Implementation of the OARs had the potential for reducing radiographs by 33%.

Conclusion

OARs are very accurate and highly sensitive tools for detecting ankle fractures. Implementation of these rules would lead to significant reduction in the number of radiographs, costs, radiation exposure and waiting times in emergency departments.

Treatment of cuboid syndrome secondary to lateral ankle sprains: a case series

STUDY DESIGN

Case series.

BACKGROUND

Plantar flexion/inversion ankle sprains are one of the most frequently occurring sports injuries. Cuboid syndrome, which is difficult to diagnose, may result from a plantar flexion/ inversion ankle injury and could become the source of lateral ankle/midfoot pain. The objective of this case series is to describe the examination, evaluation, and treatment of the cuboid syndrome following a lateral ankle sprain.

CASE DESCRIPTION

Seven patients were seen in our clinic 1 to 8 weeks following a lateral ankle sprain with a chief complaint of lateral ankle/midfoot pain. In these 7 patients, the presence of cuboid syndrome was identified independently by 2 examiners. Treatment consisted of a cuboid manipulation.

OUTCOMES

All 7 patients returned to sports activities following 1 to 2 treatments consisting of the "cuboid whip" manipulation. No recurrence of symptoms was reported upon immediate return to competition or during the remainder of the season (mean follow-up, 5.7 months; range, 2 to 8 months).

DISCUSSION

Based on those 7 patients, our results suggest that patients who are properly diagnosed with cuboid syndrome and receive the cuboid manipulation can return to competitive activity within 1 or 2 visits without injury recurrence.

Clinical Examination of the Foot and Ankle

The foot and ankle are critical components in our ability to ambulate. Injuries to either can significantly interfere with a patient's ability to carry out normal activities. In severe cases, they can be devastating to a patient's independence. Careful examination of the foot and ankle using established mechanical tests, along with understanding of the anatomy of the complex,is needed to confirm the history and to assist in the diagnosis and treatment of foot and ankle injuries. The following points are key to clinical examination of the foot and ankle: . The examination of the foot and ankle needs to be done with the patient in both weight-bearing and non-weight bearing positions. . The examination of the foot and ankle should include an evaluation of the patient's gait. . Reproduction of a patient's symptoms is the key to making a correct diagnosis. . Although anatomic variants may predispose some individuals to injury,in general, if asymptomatic, no treatment should be done.

Sports and performing arts medicine. 4. traumatic injuries in sports11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated

This self-directed learning module focuses on injuries often seen in contact sports. It includes information on trauma to the cervical spine, wrist, shoulder, knee, ankle, foot, and chest and also discusses concussion in sport. It is part of the study guide on sports and performing arts medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the etiology, differential diagnoses, treatment, and return-to-play criteria for traumatic sports injuries.

OVERALL ARTICLE OBJECTIVE

To summarize the approach to common traumatic sports injuries.

Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review

OBJECTIVE

To summarise the evidence on accuracy of the Ottawa ankle rules, a decision aid for excluding fractures of the ankle and mid-foot.

DESIGN

Systematic review.

DATA SOURCES

Electronic databases, reference lists of included studies, and experts.

REVIEW METHODS

Data were extracted on the study population, the type of Ottawa ankle rules used, and methods. Sensitivities, but not specificities, were pooled using the bootstrap after inspection of the receiver operating characteristics plot. Negative likelihood ratios were pooled for several subgroups, correcting for four main methodological threats to validity.

RESULTS

32 studies met the inclusion criteria and 27 studies reporting on 15 581 patients were used for meta-analysis. The pooled negative likelihood ratios for the ankle and mid-foot were 0.08 (95% confidence interval 0.03 to 0.18) and 0.08 (0.03 to 0.20), respectively. The pooled negative likelihood ratio for both regions in children was 0.07 (0.03 to 0.18). Applying these ratios to a 15% prevalence of fracture gave a less than 1.4% probability of actual fracture in these subgroups.

CONCLUSIONS

Evidence supports the Ottawa ankle rules as an accurate instrument for excluding fractures of the ankle and mid-foot. The instrument has a sensitivity of almost 100% and a modest specificity, and its use should reduce the number of unnecessary radiographs by 30-40%.

Radiography in acute ankle injuries: the Ottawa Ankle Rules versus local diagnostic decision rules

STUDY OBJECTIVE

We validate the Ottawa Ankle Rules and 2 Dutch ankle rules in distinguishing clinically significant fractures from insignificant fractures and other injuries in patients with a painful ankle presenting to the emergency department.

METHODS

This prospective comparison of 3 ankle rules was conducted in the ED of a 580-bed community teaching hospital in Amsterdam from January 1998 to April 1999. Participants included 647 consecutive patients aged 18 years or older presenting with a painful ankle after trauma. All physicians received extensive and pictorial training on how to correctly score the respective items of the rules. The physician on call recorded these items derived from history and physical examination on a standardized data sheet. All patients subsequently underwent standard radiographic assessment. A radiologist and a trauma surgeon evaluated the radiographs blinded from the results of the data sheet form and the treatment given. The diagnostic performance of the 3 rules was measured in terms of sensitivity, specificity, and the reduction of radiographs. Receiver operating characteristic (ROC) curves were constructed, and the area under the ROC curves was calculated and compared.

RESULTS

Seventy-four fractures were seen, of which 41 were clinically significant. The Ottawa Ankle Rules had a sensitivity of 98% for identifying clinically significant fractures; the local rules scored 88% and 59%, respectively. The potential savings in radiographs for the 3 decision rules were 24%, 54%, and 82%, respectively. The area under the ROC curve was better for both the local rules (0.84 and 0.83) compared with the Ottawa Ankle Rules (0.76).

CONCLUSION

Because the identification of all relevant fractures is more important than a reduction in radiographs, the higher sensitivity of the Ottawa Ankle Rules makes these most suitable for implementation in The Netherlands.

Evaluation of patient satisfaction and outcomes after assessment for acute ankle injuries

Physicians argue that patient preferences influence their test ordering and their potential for compliance with clinical practice guidelines (CPG). This study was conducted to evaluate patient satisfaction with clinical practice in emergency department (ED) settings using a validated and widely publicized set of CPGs. Patients presenting to 4 hospital EDs were eligible if they had sustained acute ankle or foot injuries. All sites were involved with the dissemination of radiography CPG, and use of radiography was determined by treating physicians. Telephone follow-up was attempted for all patients who did not receive ankle or foot radiography (Group 1). A random sample of 25% of patients who had a normal radiograph interpretation (Group 2) was also chosen for follow-up. Structured telephone interviews were administered and included information on post-encounter health care utilization, subsequent radiography, and patient satisfaction. A structured questionnaire was administered to all ED physicians (N = 60) to elicit their perspectives on the clinical practice guidelines. In Group 1, 342 (69%) of 494 non-radiographed patients were successfully contacted. In Group 2, 623 (77%) of 812 patients with normal ED radiographs, were successfully contacted. After ED discharge, 86 (25%) Group 1 and 191 (31%) Group 2 patients had visited another physician within 2 weeks of the initial ED encounter (P =.07). Subsequent ankle radiography was similar between the groups (38 [11%] in Group 1 vs. 59 [10%] in Group 2; P =.38). Patients appeared to be similarly highly satisfied with physician care (P =.58) and with discharge instructions (P =.12) in both groups. Overall, 76% of physicians supported the use of CPGs; however, 78% reported that patient expectations influenced their application of the Ottawa Ankle Rules. This study suggests that patients are equally satisfied with care, access additional health care services similarly and obtain the same percentage of radiographs irrespective of the initial ED ankle/foot radiograph ordering. These results may help physicians in re-evaluating their perceptions that patient expectation influence utilization and have important implications in guideline development.

Implementation of the Ottawa ankle rule in a university sports medicine center

PURPOSE

The Ottawa ankle rule (OAR) is a clinical decision rule used in emergency departments to identify which patients with acute ankle/midfoot injury require radiography. The purpose of this study was to implement the OAR, with a modification to improve the specificity for identifying malleolar fractures (the "Buffalo rule"), in a sports medicine center and measure impact on physician practice and cost savings.

METHODS

All pediatric and adult patients presenting to a university sports medicine walk-in clinic with acute (< or = 10 d old) ankle/midfoot injury had the rule applied by primary care providers. Exclusion criteria included pregnancy, isolated skin injury, > 10 d since injury, second evaluation for same injury, obvious deformity of ankle or foot, or altered sensorium.

RESULTS

In 217 patients (mean age, 23.3 +/- 8.5 yr; range, 10-64 yr) there were 24 clinically significant (i.e., nonavulsion) fractures (fracture rate 3.7% per year for 3 yr), all of which were identified by the rule (100% sensitivity). In 193 patients with malleolar pain, the sensitivity for malleolar fracture (with 95% confidence intervals) was 100% (78-100%) and specificity was 45% (43-46%). In 24 patients with midfoot pain, sensitivity was 100% (65-100%) and specificity was 35% (21-49%). Thirty-five percent of radiographic series (76 of 217) were foregone for a cost savings of almost $6000. One hundred percent follow-up on those patients for whom x-rays were obtained found no missed fractures and they were subjectively satisfied with their care.

CONCLUSION

The OAR reduced radiography in acute ankle/midfoot injury and saved money in relatively younger patients in the outpatient sports urgent care setting without missing any clinically significant fractures. The specificity of the Buffalo malleolar rule in the present implementation study, however, was not a significant improvement over the OAR malleolar rule. Widespread application of the OAR could save substantial resources without compromising quality of care.

Validation of the Ottawa ankle rules in a Hong Kong ED

The Ottawa ankle rules (OAR) have been validated in many Western countries. However, a recent study performed in an accident and emergency department in Singapore failed to validate the OAR. Therefore, the implementation of the use of OAR in accident and emergency departments in Hong Kong may be treated with skepticism. This prospective study was performed to validate the ordering of radiographs using OAR in Chinese patients with foot and ankle injuries in Hong Kong. Emergency physicians trained in the use of the OAR assessed 773 eligible patients and one hundred thirty-one fractures were identified. The sensitivity and specificity of the OAR for ankle injuries was 98% and 40.8%. For midfoot injuries, the sensitivity and specificity of the OAR was 100% and 43.8%. We concluded that the OAR are applicable in our population with potential advantages for reducing the number of unnecessary investigations and shortening the patients' length of stay in accident and emergency departments.

[The Ottawa ankle guidelines: analysis of their validity as clinical decision guidelines in the indication of X-rays for ankle and/or middle-foot injuries]

OBJECTIVE

To analyse the validity of the Ottawa ankle guidelines (OAG) as clinical decision guidelines in the indications of X-rays for ankle and/or middle-foot traumas in primary care.

DESIGN

Observational, with application of the OAG and prospective measurement of the results.Setting. Hospital casualty.

PATIENTS

Adults who attended casualty for ankle or middle-foot traumas between 1st June 1999 and 31th March 2000. Criteria for exclusion were: under 18, pregnancy, grave sensory and/or awareness disturbances, multi-trauma or multi-contusion patients, traumas over a week old, skin lesions as side-effects of the trauma, X-ray in other department, high inflammation or oedema hindering palpation of bone protuberances.

MEASUREMENTS

Application of the OAG and X-ray on all patients, regardless of the result of the OAG. Calculation of sensitivity, negative predictive value, specificity and positive predictive value.

RESULTS

56 of a sample of 494 patients had a fracture (11.34%), 34 in the malleolus area (6.9%) and 22 in the middle-foot area (4.44%). OAG sensitivity was 96.43% (95% CI, 94.8-98). Negative predictive value was 97.22% (95.77-98.67). Specificity was 15.98% (12.75-19.21), and positive predictive value was 12.8% (9.86-15.74).

CONCLUSIONS

The OAG are valid in primary care as guidelines to decide whether to request X-rays for patients with ankle or middle-foot traumas.

A prospective study of modified Ottawa ankle rules in a military population. Interobserver agreement between physical therapists and orthopaedic surgeons

To determine the necessity of ankle and foot radiographs, we used modified Ottawa Ankle Rules to evaluate all cadets seen with an acute ankle or midfoot injury at the United States Military Academy. This scoring system determines the need for radiographs. Each patient was independently examined and the decision rules were applied by a physical therapist and an orthopaedic surgeon. Ankle and foot radiographs were obtained for all subjects. Sensitivity, specificity, and the positive predictive value were calculated in 153 patients. There were six clinically significant ankle fractures and three midfoot fractures, for a total incidence of 5.8%. For physical therapists, the sensitivity was 100%, the specificity for ankle injuries was 40%, and the specificity for foot injuries was 79%. For orthopaedic surgeons, the sensitivity was also 100%, the specificity for ankle injuries was 46%, and the specificity for foot injuries was 79%. Interobserver agreement between the orthopaedic surgeons and physical therapists regarding the overall decision to obtain radiographs was high, with a kappa coefficient value of 0.82 for ankle injuries and 0.88 for foot injuries. There were no false-negative results. Use of the modified Ottawa Ankle Rules would have reduced the necessity for ankle and foot radiographs by 46% and 79%, respectively.

Foot and ankle injuries in dance

Acute traumatic injuries are common in ballet dancers. A careful history, thorough examination, and appropriate imaging should allow for the diagnosis of most problems. The clinician must have a high index of suspicion for occult bony injuries, especially if the patient fails to recover as expected. Aggressive treatment of the sprained ankle is essential to maintain foot and ankle mobility and prevent prolonged disability and subsequent overuse injuries. Kinetic chain dysfunctions are common in ballet dancers with overuse injuries and commonly follow ankle sprains. They may represent a secondary phenomenon that developed in response to the compensatory movement changes caused by the initial injury. It is important to remember, however, that these dysfunctions may have been long standing and a causative factor in the injury. Regardless of the time of onset of the dysfunction, residual kinetic chain dysfunction associated with incomplete rehabilitation of an injury may predispose the dancer to further injuries. Untreated dysfunctions at one site in the kinetic chain may predispose to compensatory dysfunction at other sites in the chain. Accordingly, it is essential to thoroughly examine the entire chain for functional movements when dealing with an injury, because identification and treatment of the kinetic chain dysfunction is important in the rehabilitation of the dancing athlete. Kinetic chain dysfunctions are common in injured ballet dancers and may be a cause of repeated injury. Why then are these dysfunctions left untreated? Medical personnel caring for dancers are sometimes guilty of tunnel vision, and focus solely on the injured site without considering what is happening at other sites in the kinetic chain. This oversight is compounded when the physicians or therapists are satisfied with discovering simply what injury has occurred rather than asking why the injury has occurred. The significance of kinetic chain dysfunctions is only just beginning to be recognized, and many examiners are not aware of the relationship between abnormal motion and injury. Generally, people see only what they look for, and they look only for what they know. Kinetic chain dysfunctions can easily be detected with simple tests of functional movement if the examiners include these tests in their assessment of the injured dancer. As long as clinicians are either unaware of or unwilling to perform these tests, these dysfunctions will remain untreated and may put the dancer at risk of failed rehabilitation or predispose them to further injury.

Lateral ankle sprains: a comprehensive review: part 1: etiology, pathoanatomy, histopathogenesis, and diagnosis

Ankle sprains are among the most common injuries sustained by athletes and seen by sports medicine physicians. Despite their prevalence in society, ankle sprains still remain a difficult diagnostic and therapeutic challenge in the athlete, as well as in society in general. The purpose of this section of our two-part study is to review scope of the problem, the anatomy and biomechanics of the lateral ankle ligaments, review the pathoanatomical correlates of lateral ankle sprains, the histopathogenesis of ligament healing, and define the mechanisms of injury to understand the basis of our diagnostic approach to the patient with this common acute and chronic injury. We extensively review the diagnostic evaluation including historical information and physical examination, as well as options for supplementary radiographic examination. We further discuss the differential diagnosis of the patient with recurrent instability symptoms. This will also serve as the foundation for part two of our study, which is to understand the rationale for our treatment approach for this common problem.