Diagnostic accuracy of the Ottawa ankle rule to exclude fractures in acute ankle injuries in adults: a systematic review and meta-analysis

Abstract

Background Ankle traumas are common presenting injuries to emergency departments in Australia and worldwide. The Ottawa Ankle Rules (OAR) are a clinical decision tool to exclude ankle fractures, thereby precluding the need for radiographic imaging in patients with acute ankle injury. Previous studies support the OAR as an accurate means of excluding ankle and midfoot fractures, but have included a paediatric population, report both the ankle and mid-foot, or are greater than 5 years old. This systematic review and meta-analysis aimed to update and assess the existing evidence of the diagnostic accuracy of the Ottawa Ankle Rule (OAR) acute ankle injuries in adults. Methods A systematic search and screen of was performed for relevant articles dated 1992 to 2020. Prospective and retrospective studies documenting OAR outcomes by physicians to assess ankle injuries were included. Critical appraisal of included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Outcomes related to psychometric data were pooled using random effects or fixed effects modelling to calculate diagnostic performance of the OAR. Between-study heterogeneity was assessed using the Higgins I2 test, with Spearman’s correlation test for threshold effect. Results From 254 unique studies identified in the screening process, 15 were included, involving 8560 patients from 13 countries. Sensitivity, specificity, negative likelihood ratio, positive likelihood ratio and diagnostic odds ratio were 0.91 (95% CI, 0.89 to 0.92), 0.25 (95% CI, 0.24 to 0.26), 1.47 (95% CI, 1.11 to 1.93), 0.15 (95% CI, 0.72 to 0.29) and 10.95 (95% CI, 5.14 to 23.35) respectively, with high between-study heterogeneity observed (sensitivity: I2 = 94.3%, p < 0.01; specificity: I2 = 99.2%, p < 0.01). Most studies presented with low risk of bias and concern regarding applicability following assessment against QUADAS-2 criteria. Conclusions Application of the OAR is highly sensitive and can correctly predict the likelihood of ankle fractures when present, however, lower specificity rates increase the likelihood of false positives. Overall, the use of the OAR tool is supported as a cost-effective method of reducing unnecessary radiographic referral, that should improve efficiency, lower medical costs and reduce waiting times.

The role of Ottawa ankle rules in geriatric emergency department visits

“…By minimizing unnecessary radiography, this clinical tool streamlines the diagnostic process and facilitates more efficient use of emergency department resources. [13,14] However, the limitations of the OAR must be recognized. Specifically, given the risk of overlooking certain fracture types, a holistic approach that incorporates clinical evaluation and patient history is essential.…”

Reappraisal of the Use of X-Rays in Acute Ankle and Midfoot Injuries. A Prospective Evaluation of the Ottawa Ankle Rules (OAR) in a Single Tertiary Trauma Centre

“…2 It is crucial to emphasize that the OAR is primarily applied in acute settings assessments generally conducted within 7 to 10 days of injury. 6,9,10,11 Systematic reviews reported high sensitivities ranging from 90% to 100% but with varying specificities (ranging from 10% to 80%) in the adult population. 4,6,9,15,16 Bachmann et al hypothesised that the accuracy of the OAR may vary due to differences in the assessors' clinical skills, experience in detecting and interpreting the findings, and the timing of assessments.…”

“…6,9,10,11 Systematic reviews reported high sensitivities ranging from 90% to 100% but with varying specificities (ranging from 10% to 80%) in the adult population. 4,6,9,15,16 Bachmann et al hypothesised that the accuracy of the OAR may vary due to differences in the assessors' clinical skills, experience in detecting and interpreting the findings, and the timing of assessments. 16 A delay in the assessment of the injury was also addressed as one of the influencing factors of the accuracy.…”

“…It is wellvalidated and has been included in many clinical practice guidelines worldwide. 1,6,9,10,11,12,13,14 According to the OAR, a series of ankle radiographs is necessary (OAR positive) only if there is any pain in the malleolar region or the Sharifudin MA a,b , Saleh Hussen RA b,c , Taib MNA a , Ahmed Shokri A b midfoot zone, with at least one of the specific clinical findings. 8 OAR negative is when the decision rules are not fulfilled to indicate the necessity for radiographic examination.…”

Lesões musculoesqueléticas em atletas de vôlei: uma revisão integrativa

“…Ao exame físico, a entorse de tornozelo pode apresentar edema e equimose e é importante avaliar se existem outras lesões associadas como, por exemplo, fraturas. As regras do tornozelo de Ottawa (OAR) são uma ferramenta de decisão clínica que pode ser utilizada para excluir fraturas de tornozelo durante o exame físico, afastando a necessidade de radiografias em pacientes com lesão aguda do tornozelo (GOMES et al, 2022). Além disso, é importante verificar se há dor na inversão passiva suave e na eversão do tornozelo, visto que a dor aumenta com a inversão forçada do tornozelo nos casos de entorses laterais, enquanto a dor de uma entorse medial é acentuada durante a eversão do tornozelo (RENSTRÖM et al, 1999).…”