Ottawa Knee Rules

Adult Clinical Decision Rules for Trauma William D. Hampton, DO Emergency Physician 26 March 2015 Learning Objectives

1. Explain statistical sensitivity & specificity and apply that knowledge in the evaluation of clinical decision rules (CDRs). 2. Discuss the various adult trauma clinical decision rules and how they were derived. 3. Compare and contrast the CDRs for head injury, cervical spine injury, and lower extremity injuries in adult trauma patients. 4. Explain the importance of CDRs in triage, selective diagnostic testing, and dispositioning trauma patients. Disclosure Statement

• Faculty/Presenters/Authors/Content Reviewers/Planners disclose no conflict of interest relative to this educational activity. Successful Completion

• To successfully complete this course, participants must attend the entire event and complete/submit the evaluation at the end of the session. • Society of Trauma Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

On a busy shift at a local emergency department, you are placed in triage and presented with a variety of patients… Or you work at a teaching hospital, and are particularly concerned about patient safety come every July… Or you work as a Nurse Practitioner at a critical access ED, and want to refine your telemedicine trauma referrals… Or you would simply like to become more comfortable in assessing and caring for critically injured patients…

Statistical Definitions Definitions Imagine a study evaluating a new test that screens people for a disease. Each person taking the test either has or does not have the disease. The test can be positive (predicting that the person has the disease) or negative (predicting that the person does not have the disease).

The test results for each subject may or may not match the subject's actual status.

http://en.wikipedia.org/wiki/Sensitivity_and_specificity. Accessed last 9/5/2013. Definitions True positive Sick people correctly diagnosed as sick

False positive Healthy people incorrectly identified as sick

True negative Healthy people correctly identified as healthy

False negative Sick people incorrectly identified as healthy

http://en.wikipedia.org/wiki/Sensitivity_and_specificity. Accessed last 9/5/2013. Definitions In general

Positive = identified Negative = rejected

True positive = correctly identified False positive = incorrectly identified

True negative = correctly rejected False negative = incorrectly rejected

http://en.wikipedia.org/wiki/Sensitivity_and_specificity. Accessed last 9/5/2013. Sensitivity & Specificity

Snout Spin Sensitivity Imagine that everyone in the audience came down with URI sx, and someone suggested that it might be Legionnaires’ Dz. You all have symptoms, but you want to know for certain you don’t have Legionnaire’s! A highly sensitive test would definitely catch anyone that is positive (for Legionnaires’ Dz). So if they’re not positive, you can be sure that they are negative. Negative results in a high sensitivity test are used to rule-out the disease. Snout – “Sensitivity rules it out” Specificity

Imagine that everyone in the audience felt well, but you were told that you had been exposed to the SARS Virus. The CDC is offering treatment to everyone…but it will cost you $10,000. You would like to be certain that you actually have SARS before spending $10,000 on treatment! A highly specific test would definitively show everyone that is negative for the disease. So if you test positive (for SARS), you can be sure that you are not mistakenly positive! A positive result from a test with high specificity means a high probability of the presence of disease. Spin – “Specificity rules it in” Giddy-up Case #1 – 65-y/o ♂ fell off ladder CC: 65-y/o ♂ presents to UC after falling off stepladder 3 hours ago. Lost balance while fixing the roof. Admits “head pain” at site of impact. Denies vomiting, syncope, or other injuries. PE: Normal vitals. Small bruise noted above left eye. Prefers eyes closed throughout exam. Case #2 – 24-y/o ♀ slip & fall by pool CC: 24-y/o ♀ presents after slip and fall on pool deck last night. Friend attributes fall to “the wine.” Admits headache and one episode of vomiting after fall. Denies any other injuries. PE: Normal vitals. Tender hematoma noted above left ear.  Left hemotympanum. GCS is 15. Cases #1 & 2

Which of these patients needs a CT Head? 65-y/o ♂ 24-y/o ♀ Neither Both New Orleans Criteria

Computed tomography is required for patients with minor head injury with any one of the following findings. The criteria apply only to patients who also have a Glasgow Coma Scale score of 15.

1. Headache 2. Vomiting 3. Older than 60 years 4. Drug or alcohol intoxication 5. Persistent anterograde amnesia (deficits in short-term memory) 6. Visible trauma above the clavicle 7. Seizure Adults (> 16 years) with minor head injury. 5 Criteria for High-Risk for Neurologic Injury 2 Criteria for Medium Risk for Neurologic Injury Rule does not apply if any of the following: • Non-trauma case • GCS < 13 • Age < 16 years • Coumadin or bleeding d/o • Obvious open skull fx New Orleans Criteria

Computed tomography is required for patients with minor head injury with any one of the following findings. The criteria apply only to patients who also have a Glasgow Coma Scale score of 15.

Computed tomography is required for adults > 16 years with minor head injury (a history of a GCS score of 13 to 15 with witnessed LOC, amnesia, or confusion) and any one of the following findings:

1. Glasgow Coma Scale score < 15 at 2 hours after injury 2. Suspected open or depressed skull fracture 3. Any sign of basilar skull fracture CCHR 4. Two or more episodes of vomiting 5. 65 years or older 6. Amnesia before impact of 30 or more minutes 7. Dangerous mechanism Originally published in 2001 in The Lancet. Prospective cohort study in 10 large Canadian hospital EDs. n = 3,121 (consecutive adults) from 1996 to 1999 who presented with a GCS score of 13–15 after head injury. 2,078 (67%) patients underwent CT Scan to look for clinically important injury on CT; remainder had 14-day telephone F/U.

Stiell IG, Wells GA, Vandemheen, K., et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357: 1391-1396. Canadian CT Head Rules

Computed tomography is required for adults > 16 years with minor head injury (a history of a GCS score of 13 to 15 with witnessed LOC, amnesia, or confusion) and any one of the following findings:

44 (1%) required neurological intervention. 254 (8%) patients were judged to have clinically important brain injury. 94 (4%) patients were judged to have clinically unimportant lesions— mainly localized SAH or isolated contusions < 5 mm in diameter.

Stiell IG, Wells GA, Vandemheen, K., et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357: 1391-1396. Canadian CT Head Rules

Computed tomography is required for adults > 16 years with minor head injury (a history of a GCS score of 13 to 15 with witnessed LOC, amnesia, or confusion) and any one of the following findings:

1. Glasgow Coma Scale score < 15 at 2 hours after injury 2. Suspected open or depressed skull fracture 3. Any sign of basilar skull fracture CCHR 4. Two or more episodes of vomiting 5. 65 years or older 6. Amnesia before impact of 30 or more minutes 7. Dangerous mechanism Results: The high-risk factors were 100% sensitive for predicting need for neurological intervention and would require only 32% of patients to undergo CT. The medium-risk factors were 98.4% sensitive and 49.6% specific for predicting clinically important brain injury, and would require only 54% of patients to undergo CT.

Stiell IG, Wells GA, Vandemheen, K., et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357: 1391-1396.

New Orleans Criteria

Computed tomography is required for patients with minor head injury with any one of the following findings. The criteria apply only to patients who also have a GCS score of 15. NOC 1. Headache 2. Vomiting 3. Older than 60 years Originally published in 4. Drug or alcohol intoxication 5. Persistent anterograde amnesia (deficits in short-term memory) 2000 in NEJM. 6. Visible trauma above the clavicle 7. Seizure

Single center study at a large, inner-city, level 1 trauma center from 1997 to 1999. Recursive Partitioning Analysis - Phase I: n = 520 consecutive patients (ages 3 – 97 years, mean age 36) with a GCS score 15 after minor head injury. Prosective Validation - Phase II: n = 909 consecutive patients (ages 3 – 94 years, mean age 36) with a GCS score 15 after minor head injury. Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PMC. Indications for computed tomography in patients with minor head injury. New England Journal of Medicine. 2000; 343: 100-105. New Orleans Criteria

Computed tomography is required for patients with minor head injury with any one of the following findings. The criteria apply only to patients who also have a GCS score of 15. NOC 1. Headache 2. Vomiting 3. Older than 60 years 4. Drug or alcohol intoxication 5. Persistent anterograde amnesia (deficits in short-term memory) 6. Visible trauma above the clavicle Results: 7. Seizure

Of 520 patients in Phase I, 36 (6.9 percent) had positive scans. Among the 909 patients in Phase II, 57 (6.3 percent) had positive scans. All patients with positive CT scans had one or more of the seven criteria: headache, vomiting, age > 60 years, drug / alcohol intoxication, short-term memory deficits, physical evidence of trauma above the clavicles, and/or seizure.

Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PMC. Indications for computed tomography in patients with minor head injury. New England Journal of Medicine. 2000; 343: 100-105.

Canadian CT Head Rules New Orleans Criteria

Prospective cohort study (2000-2002) that included 9 EDs in large Canadian community and university hospitals. N = 2,707 adults with blunt head trauma and a GCS of 13 to 15. The CCHR and NOC were compared in a subgroup of 1,822 adults with minor head injury and GCS score of 15.

Stiell IG, Clement C, et. al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA - 28-SEP-2005; 294(12): 1511-1518. Canadian CT Head Rules New Orleans Criteria

Computed tomography is required for patients with minor head Computed tomography is required for patients with minor head injury and any 1 of the following findings: a Glasgow Coma injury with any one of the following findings. The criteria apply Scale score of 13 to 15 after witnessed loss of consciousness, only to patients who also have a GCS score of 15. amnesia, or confusion. 1. Headache 1. Glasgow Coma Scale score < 15 at 2 hours after injury 2. Vomiting 2. Suspected open or depressed skull fracture 3. Older than 60 years 3. Any sign of basilar skull fracture 4. Drug or alcohol intoxication 4. Two or more episodes of vomiting 5. Persistent anterograde amnesia 5. 65 years or older 6. Visible trauma above the clavicle 6. Amnesia before impact of 30 or more minutes 7. Seizure 7. Dangerous mechanism Results: The NOC and the CCHR both had 100% sensitivity. CCHR was more specific (76.3% vs 12.1%, P < .001) for predicting need for neurosurgical intervention. For patients with minor head injury and GCS score of 15, the CCHR and the NOC have equivalent high sensitivities, but the CCHR has higher specificity for important clinical outcomes than does the NOC, and its use may result in reduced imaging rates.

Stiell IG, Clement C, et. al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA - 28-SEP-2005; 294(12): 1511-1518. Redux: Cases #1 & 2 CC: 65 -y/o ♂ presents to UC CC: 24-y/o ♀ presents after slip after fall off stepladder 3 hours and fall on pool deck last ago. Lost balance while fixing night. Friend attributes fall to the roof. Admits “head pain” “the wine.” Admits headache at site of impact. Denies and one episode of vomiting vomiting, syncope, or other after fall. Denies any other injuries. injuries. PE: Normal vitals. Small bruise PE: Normal vitals. Tender noted above left eye. Prefers hematoma noted above left eyes closed throughout exam. ear.  Left hemotympanum. GCS is 15. Which of these patients needs a CT Scan? 65-y/o ♂ 24-y/o ♀ Neither Both

Case #3 – 86-y/o ♀ s/p MVC CC: 86-y/o ♀ presents after low- speed MVC. Was stopped at light and was struck from behind. +SB. AB. Initially ambulatory on scene, but now arrives boarded & collared via EMS. Doesn’t know the date. PE: Normal vitals. No midline C-spine tenderness. No distracting injuries on exam. Case #4 – 29-y/o ♂ s/p bike accident CC: 29-y/o ♂ presents to triage after bicycle accident. Was wearing a helmet and fell face first on the ground. Has an obviously deformed right wrist and also reports neck pain. PE: Normal vitals. Right wrist appears to be a closed fracture. Arrives ambulatory. Cases #3 & 4

Which of these patients needs C-spine imaging? Bicyclist Driver Neither Both NEXUS Criteria

The NEXUS criteria state that a patient with suspected C-spine injury can be clinically cleared provided that all the following criteria are met:

1. No posterior midline cervical spine tenderness is present. 2. No evidence of intoxication is present. 3. The patient has a normal level of alertness / consciousness. 4. No focal neurologic deficit is present. 5. The patient does not have a painful distracting injury.

Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med. 1998;32(4):461-9 Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26):2510-8. One easy mnemonic for these criteria is NSAID: Neurologic Deficit Spinal Tenderness (Midline) Altered Mental Status Intoxication Distracting Injury

The NEXUS criteria state that a patient with suspected C-spine injury can be cleared provided that all the following criteria are met: NEXUS 1. No posterior midline cervical spine tenderness is present. Prospective, observational 2. No evidence of intoxication is present. study published in 2000 in 3. The patient has a normal level of alertness. 4. No focal neurologic deficit is present. NEJM. 5. The patient does not have a painful distracting injury. Multi-center study (twenty-one) across the United States. n = 34,069 patients who underwent radiography of the cervical spine after blunt trauma. NEXUS identified all but 8 of the 818 patients who had cervical- spine injury (sensitivity, 99.0%). Two of the patients classified as unlikely to have an injury met the definition of a clinically significant injury.

Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. Jul 13 2000;343(2):94-9.

Canadian C-Spine Rules For alert (GCS score=15) and stable trauma patients when cervical spine injury is a concern.

1. Any high-risk factor that mandates radiography? • Age ≥ 65 years • Dangerous mechanism • Paresthesias in extremities CCR

2. Any low-risk factor that allows safe assessment of range of motion? Originally published in • Simple rear-end MVC • Sitting position in ED JAMA in 2001. • Ambulatory at any time • Delayed onset of neck pain • Absence of midline C-spine tenderness

3. Able to actively rotate neck 45° left and right? Prospective cohort study from 1996-1999 involving 10 large Canadian community and university hospitals. n = 8,924 adults who presented following blunt trauma to the head / neck, with stable vital signs, and a GCS of 15.

Stiell IG, Wells GA, Vandemheen K, et al. The Canadian Cervical Spine Radiography rule for alert and stable trauma patients. JAMA. 2001;286:1841-1848. Canadian C-Spine Rules For alert (GCS score=15) and stable trauma patients when cervical spine injury is a concern.

1. Any high-risk factor that mandates radiography? • Age ≥ 65 years • Dangerous mechanism • Paresthesias in extremities CCR

2. Any low-risk factor that allows safe assessment of range of motion? • Simple rear-end MVC • Sitting position in ED • Ambulatory at any time • Delayed onset of neck pain Results: • Absence of midline C-spine tenderness

3. Able to actively rotate neck 45° left and right?

151 (1.7%) had an important C-spine injury. CCR demonstrated 100% sensitivity and 42.5% specificity for identifying 151 clinically important C-spine injuries.

Stiell IG, Wells GA, Vandemheen K, et al. The Canadian Cervical Spine Radiography rule for alert and stable trauma patients. JAMA. 2001;286:1841-1848. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26):2510-8. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26):2510-8.

Canadian C-Spine Rules NEXUS Criteria For alert (GCS score=15) and stable trauma patients when cervical spine injury is a concern. The NEXUS criteria state that a patient with

1. Any high-risk factor that mandates radiography? suspected C-spine injury can be cleared • Age ≥ 65 years provided that all the following criteria are met: • Dangerous mechanism • Paresthesias in extremities 1. No posterior midline cervical spine 2. Any low-risk factor that allows safe assessment tenderness is present. of range of motion? 2. No evidence of intoxication is present. • Simple rear-end MVC • Sitting position in ED 3. The patient has a normal level of alertness. Ambulatory at any time • 4. No focal neurologic deficit is present. • Delayed onset of neck pain • Absence of midline C-spine tenderness 5. The patient does not have a painful

3. Able to actively rotate neck 45° left and right? distracting injury. Originally published in NEJM in 2003.

Prospective cohort study in 9 Canadian Emergency Departments. N = 8,283 patients, 169 (2.0%) of which had clinically important cervical-spine injuries.

Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. New England Journal of Medicine. 2003 Dec 25;349(26):2510-2518. Canadian C-Spine Rules NEXUS Criteria For alert (GCS score=15) and stable trauma patients when cervical spine injury is a concern. The NEXUS criteria state that a patient with

3. Able to actively rotate neck 45° left and right? distracting injury. Results: CCR was more sensitive than the NEXUS (99.4 percent vs. 90.7 percent, P<0.001) and more specific (45.1 percent vs. 36.8 percent, P<0.001) for injury. The CCR would have missed 1 patient and NEXUS would have missed 16 patients with important injuries.

Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. New England Journal of Medicine. 2003 Dec 25;349(26):2510-2518. Redux: Cases #3 & 4 CC: 29-y/o ♂ presents to triage CC: 86 -y/o ♀ presents after low- after bicycle accident. Was speed MVC. Was stopped at wearing a helmet and fell light and was struck from face first on the ground. Has behind. +SB. AB. Initially an obviously deformed right ambulatory on scene, but now wrist and also reports neck arrives boarded & collared via pain. EMS. Doesn’t know the date. PE: Normal vitals. Right wrist PE: Normal vitals. No midline appears to be a closed C-spine tenderness. No fracture. Arrives ambulatory. distracting injuries on exam.

Which of these patients needs C-spine imaging? Bicyclist Driver Neither Both

Gestalt Psychology term meaning "unified whole"

Refers to theories of visual perception

Developed by German psychologists in the 1920s

More statistical definitions… Negative Predictive Value

NPV is the probability that a disease is absent when the test is negative.

The NPV of a test is the proportion of people that don’t have disease out of everyone who tests negative for the disease.

True Negatives Total Healthy NPV = = True Negatives + False Negatives Total Rejected

Negative predictive value describes how likely patients with a negative screening test truly don't have disease.

http://sphweb.bumc.bu.edu/otlt/MPH-Modules/EP/EP713_Screening/EP713_Screening5.html Last accessed 8/5/2014.

Positive Predictive Value

PPV is the probability that a disease is present when the test is positive.

The PPV of a test is the proportion of people that have a disease out of everyone who tests positive for the disease. True Positives True Disease PPV = = True Positives + False Positives Total Identified

Positive predictive value describes how likely patients with a positive screening test truly have disease.

http://sphweb.bumc.bu.edu/otlt/MPH-Modules/EP/EP713_Screening/EP713_Screening5.html Last accessed 8/5/2014.

Case #5 – 26-y/o ♀ c/o Rt knee injury

CC: 26-y/o ♀ c/o right knee injury from a soccer match. Patient was “clipped” by another player and fell. She was helped off the field and sat out the remainder of the game. PE: Normal vitals. Knee is swollen, but she is able to take 4 steps. No pain over patella or fibular head. She is able to flex to 90° on exam.

Does this patient need radiographic imaging? Ottawa Knee Rules

Knee X-rays are indicated after acute knee injury if any of the following are present: 1. Age 55 years or over 2. Tenderness at the head of the fibula OKR 3. Isolated tenderness of the patella 4. Inability to flex knee to 90 degrees Originally published in 5. Inability to bear weight (defined as an inability Annals of Emergency to take four steps, i.e. two steps on each leg, regardless of limping) immediately and at Medicine in 1995. presentation • Derived from a convenience sample of 1,047 adults with acute knee injuries. • Validated from a convenience sample of 1,096 adults. • 100% sensitive for clinically important fractures. • 49% specific for patients who had no injury. Stiell IG, Greenberg GH, Wells GA, et al. Derivation of a decision rule for the use of radiograph in acute knee injuries. Ann Emerg Med 1995;26:405–13. Stiell IG, Greenberg GH, Wells GA, et al. Prospective validation of a decision rule for the use of radiography in acute knee injuries. JAMA 1996;275:611–5.

Pittsburgh Decision Rule

PDR Radiography is indicated for knee injury with blunt trauma or a fall as mechanism of injury plus either of the following:

American Journal of 1. Age < 12 years or > 50 years Emergency Medicine,1994. 2. Inability to walk four weight-bearing steps in the emergency department

Phase I – Retrospective chart analysis (n = 201) via logistic regression. Phase II – Validation of the CDR (n = 133) with independent radiographic findings. Primary outcome measure was correct identification of fractures. 12 fractures (9%) were radiologically determined in phase II. Pittsburgh Decision Rule was 100% sensitive and 79% specific for correctly identifying fractures.

Seaberg DC, Jackson R. Clinical decision rule for knee radiographs. American Journal of Emergency Medicine, 1994;12:541-3. Ottawa Knee Rules Pittsburgh Decision Rule

Knee X-rays are indicated after acute knee Radiography is indicated for knee injury injury if any of the following are present: with blunt trauma or a fall as mechanism 1. Age 55 years or over of injury plus either of the following: 2. Tenderness at the head of the fibula 3. Isolated tenderness of the patella 1. Age < 12 years or > 50 years 4. Inability to flex knee to 90 degrees 5. Inability to bear weight (defined as an 2. Inability to walk four weight-bearing inability to take four steps, i.e. two steps on steps in the emergency department each leg, regardless of limping) immediately and at presentation Comparison study from American Journal of EM in April 2013. • Cross-sectional, interobserver study at an urban teaching hospital ED from 2008 to 2009 of isolated knee injuries. • 90 adult patients with isolated knee injuries; 7 fractures (7.8%). • OKR pooled sensitivity 86% and specificity 27%. • PDR pooled sensitivity 86% and specificity 51%. • PDR more specific than OKR; equal sensitivity. • Interobserver agreement: moderate for OKR, substantial for PDR Cheung TC, Tank, Y, Breederveld RS, et. al., Diagnostic accuracy and reproducibility of the Ottawa Knee Rule vs the Pittsburgh Decision Rule, American Journal of Emergency Medicine; April 2013, Vol. 31, Issue 4, 641-645. Ottawa Knee Rules Cases #10 – 26-y/o ♀ c/o Rt. knee injury Knee X-rays are indicated after acute knee injury if any of the following are present: CC: 26 -y/o ♀ c/o right knee 1. Age 55 years or over injury from a soccer match. 2. Tenderness at the head of the fibula Patient was “clipped” by 3. Isolated tenderness of the patella another player and fell. She 4. Inability to flex knee to 90 degrees was helped off the field and 5. Inability to bear weight (defined as an inability to take four steps, i.e. two steps sat out the remainder of the on each leg, regardless of limping) game. immediately and at presentation PE: Normal vitals. Knee is swollen, but she is able to Pittsburgh Decision Rule take 4 steps. No pain over Radiography is indicated for knee injury with patella or fibular head. She is blunt trauma or a fall as mechanism of injury able to flex to 90 on exam. plus either of the following: °

1. Age < 12 years or > 50 years Does this patients need 2. Inability to walk four weight-bearing steps No X-rays needed. in the emergency department radiographic imaging?

Case #6 – 28-y/o ♂ c/o Lt. ankle injury CC: 28-y/o ♂ presents for a left ankle injury. “Rolled” his ankle while playing basketball. He was briefly weight-bearing initially, but has been non-weight bearing for the last hour. PE: Normal vitals. Left ankle is swollen with bruising. Bony tenderness along lateral malleolus. Arrives via wheelchair. Does this patients need radiographic imaging? Ottawa Foot & Ankle Rules

Ankle X-ray is only required if there is any pain in the malleolar zone and any one of the following: OAR 1. Bony tenderness along the distal 6 cm of the posterior edge of the medial malleolus JAMA, 1993 2. Bony tenderness along the distal 6 cm of the posterior edge of the lateral malleolus 3. An inability to bear weight both immediately Convenience samples of and in the emergency department for 4 steps. 1,032 adults (Stage 1)

Foot x-ray is indicated if there is any pain in the and 453 adults (Stage 2) midfoot zone and any one of the following: with acute ankle injuries. 1. Bony tenderness at the base of the 5th metatarsal Stage 2 population had 50 2. Bony tenderness at the navicular bone 3. An inability to bear weight both immediately ankle fractures (11%) and and in the emergency department for 4 steps. 19 midfoot fractures (4%)

Ottawa Ankle/Foot Rules were 100% sensitive for fractures in both ankle and midfoot. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, Stewart JP, Maloney J. Decision Rules for the Use of Radiography in Acute Ankle Injuries. Journal of the American Medical Association 1993; 269:1127-1132. Stiell I, Wells G, Laupacis A, Brison R, Verbeek R, Vandemheen K, Naylor D. A multicentre trial to introduce clinical decision rules for the use of radiography in acute ankle injuries. British Medical Journal 1995; 311:594-597. Ottawa Foot & Ankle Rules

Ankle X-ray is only required if there is any pain in the malleolar zone and any one of the following: OAR 1. Bony tenderness along the distal 6 cm of the posterior edge of the medial malleolus 2. Bony tenderness along the distal 6 cm of the posterior edge of the lateral malleolus British Medical Journal, 3. An inability to bear weight both immediately 2003 and in the emergency department for 4 steps.

Foot x-ray is indicated if there is any pain in the midfoot zone and any one of the following:

1. Bony tenderness at the base of the 5th Meta-Analysis of 27 metatarsal studies reporting on 2. Bony tenderness at the navicular bone 15,581 patients. 3. An inability to bear weight both immediately and in the emergency department for 4 steps.

Ottawa ankle rules have a sensitivity of almost 100% and a modest specificity for excluding fractures of the ankle and midfoot.

Bachmann LM, Kolb E, Michael KT, et. al., Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review, BMJ 2003; 326. Ottawa Foot & Ankle Rules Case #6 28-y/o c/o Lt. ankle injury – ♂Ankle X-ray is only required if there is any pain in CC: 28-y/o ♂ presents for a left the malleolar zone and any one of the following:

ankle injury. “Rolled” his 1. Bony tenderness along the distal 6 cm of ankle while playing the posterior edge of the medial malleolus 2. Bone tenderness along the distal 6 cm of basketball. He was briefly the posterior edge of the lateral malleolus weight-bearing initially, but 3. An inability to bear weight both has been non-weight immediately and in the emergency department for 4 steps. bearing since. Foot x-ray is indicated if there is any pain in the midfoot zone and any one of the following: PE: Normal vitals. Left ankle 1. Bony tenderness at the base of the 5th is swollen with bruising. metatarsal Bony tenderness along 2. Bony tenderness at the navicular bone lateral malleolus. Arrives via 3. An inability to bear weight both immediately and in the emergency wheelchair. department for 4 steps. Does this patients need radiographic imaging? Yes.

Summary – Adult & Pediatric CDRs Summary: Adult CDRs

Canadian CT Head Rules New Orleans Criteria

Computed tomography is required for adults > 16 years with Computedminor head injurytomography is required for patients with minor head Canadian(a history of a GCS score C-Spine of 13 to 15 with witnessed Rule LOC, amnesia,injury with or any one of the followingNEXUS findings. The Criteriacriteria apply confusion) and any one of the following findings: For alert (GCS score=15) and stable trauma patientsonly to patients when who also have a GCS score of 15. Ottawa1. Glasgow Comacervical Knee Scale spine scoreRules injury < 15is a at concern. 2 hoursPittsburgh1. after HeadacheThe injury NEXUS criteria Decision state that a patient Rule with

2. Suspected open or depressed skull fracture 2. Vomitingsuspected C-spine injury can be cleared 1.Knee Any X-rayshigh-risk are factorindicated that after mandates acute Radiographyknee radiography? injury if isany indicated of the following for knee areinjury present: with blunt trauma or 3. Any sign of basilar skull fracture provided that all the following criteria are met: • Age ≥ 65 years Ottawa Foota fall as3. mechanism Older& Ankle than 60of injuryyears Rules plus either of the following: 1. Age 55 years or over 4. Two Dangerous or more episodes mechanism of vomiting 4. Drug or alcohol intoxication Ankle• X-ray is only required if there is any1. Age pain < in12 the 1.years malleolarNo or posterior > 50 zone years midline and any cervical one of spine the following: 5.2. Tenderness65 years Paresthesias or olderat the in head extremities of the fibula • 5. Persistenttenderness anterograde is present. amnesia 1. Bony tenderness along the distal2. 6 Inability cm of theto walk posterior four weight-bearing edge of the stepsmedial in themalleolus 3.6.2. AmnesiaIsolated Any low-risk tenderness before factor impact of that the of 30allowspatella or more safe minutes assessment6. Visible oftrauma above the clavicle 2. Bony tenderness along the distalemergency 6 cm of the department2. posteriorNo evidence edge of intoxicationof the lateral is present. malleolus 4.7.range InabilityDangerous of motion? to flex mechanism knee to 90 degrees 7. Seizure 3. An inability to bear weight both immediately3. andThe in patientthe emergency has a normal department level of alertness. for 4 5. Inability• Simple to bear rear-end weight MVC (defined as an inability to take four steps, i.e. two steps on steps.• Sitting position in ED 4. No focal neurologic deficit is present. each leg, regardless of limping) immediately and at presentation. Foot •x-ray Ambulatory is indicated at any if timethere is any pain in the midfoot 5. Th zonee patient and anydoes one not ofhave the afollowing: painful • Delayed onset of neck pain distracting injury. 1. Bony• Absence tenderness of midline at the C-spine base tenderness of the 5th metatarsal 2. Bony tenderness at the navicular bone 3. Able to actively rotate neck 45 left and right? 3. An inability to bear weight both° immediately and in the emergency department for 4 steps.

How am I supposed to remember all this $#!+? www.mdcalc.com www.mdcalc.com Adult Trauma Clinical Decision Rules:

Let’s play the quiz! Quiz – Adult Trauma CDRs

1. In evaluating a screening test’s ability to “rule out” a disease, what statistical characteristic is desirable? A. High specificity B. High sensitivity C. Low specificity D. Low sensitivity

B. High Sensitivity (Snout “Sensitivity Rules it Out”) Quiz – Adult Trauma CDRs

2. In evaluating a test’s ability to confirm or “rule in” a given disease, what statistical characteristic is desirable? A. High specificity B. Low specificity C. High sensitivity D. Low sensitivity

A. High specificity (Spin “Specificity Rules it In”) Quiz – Adult Trauma CDRs

3. The Canadian CT Head Rule (CCHR) and the New Orleans Criteria (NOC) are used to determine which group of patients does not need a CT Head? A. Adults with a complaint of headache B. Adults with severe head injuries C. Children with a complaint of headache D. Children with severe head injuries E. Adults with minor head injuries

E. Adults with minor head injuries Quiz – Adult Trauma CDRs

4. The Canadian C-Spine Rule (CCR) and the Nexus Criteria (NEXUS) are useful to determine no C-spine imaging in which group of patients? A. Adults with non-traumatic neck pain B. Children with suspected C-spine injury C. Adults with paresthesias of hands or feet D. Children with croup E. Adults with suspected C-spine injury

E. Adults with suspected C-spine injury Quiz – Adult Trauma CDRs 5. A test with a high negative predictive value (NPV) can be best be characterized by which of the following? A. NPV is the probability that a disease is absent when the test is negative. B. NPV describes how likely patients with a negative screening test truly don't have disease. C. The NPV of a test is the proportion of people that don’t have disease out of everyone who tests negative for the disease. D. None of the above E. All of the above

E. All of the above Quiz – Adult Trauma CDRs 6. A test with a high positive predictive value (PPV) can be best be characterized by which of the following? A. PPV is the probability that a disease is present when the test is positive. B. PPV describes how likely patients with a positive screening test truly have the disease. C. The PPV of a test is the proportion of people that have disease out of everyone who tests positive for the disease. D. None of the above E. All of the above

E. All of the above Quiz – Adult Trauma CDRs

7. The Ottawa Knee Rules (OKR), Pittsburg Decision Rules (PDR), and the Ottawa Foot & Ankle Rules (OAR) are used to determine the need for what in the injured patient? A. X-rays B. CT scans C. EKG D. Ultrasound for DVT E. Splinting and/or crutches

A. X-rays Quiz – Adult Trauma CDRs

8. In today’s lecture, what was the important take-home point in the discussion of Gestalt? A. Gestalt is a psychology term meaning unified whole. B. Gestalt refers to theories of visual perception. C. It was described by psychologists in the 1920s. D. Relying exclusively on Clinical Decision Rules is a “best practice” strategy. E. If your clinical intuition tells you to more aggressively work-up or treat your patient, go with your instinct.

E. If your clinical intuition tells you to more aggressively work-up or treat your patient, go with your instinct.

References

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