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Validation of the Ottawa Ankle Rules in Children with Ankle Injuries

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Validation of the Ottawa Ankle Rules in Children with Ankle Injuries ACADEMIC EMERGENCY MEDICINE • October 1999, Volume 6, Number 10 1005 Validation of the Ottawa Ankle Rules in Children with Ankle Injuries AMY C. PLINT, MD, BLAKE BULLOCH, MD, MARTIN H. OSMOND, MD, IAN STIELL, MD, HAL DUNLAP, MD, MARTIN REED, MD, MILTON TENENBEIN, MD, TERRY P. K LASSEN, MD Abstract. Objectives: The Ottawa Ankle Rules (95% CI = 95% to 100%) for significant ankle frac- (OAR) have been found to be 100% sensitive in adult tures, with a specificity of 24% (95% CI = 20% to patients with ankle injuries, and application of the 28%). The OAR were 100% sensitive (95% CI = 82% OAR has resulted in a 28% reduction in the number to 100%) for the midfoot, with a specificity of 36% of x-rays ordered. The objectives of this study were to (95% CI = 29% to 43%). If the OAR had been followed, determine the sensitivity and specificity of the OAR there would have been a reduction of ankle x-rays by in children and to determine the potential change in 16% and foot x-rays by 29% without missing any clin- x-ray utilization. Methods: Children, aged 2–16 ically significant fracture. However, analysis of the years, presenting to the EDs of two children’s hospi- two hospitals showed that if the rules had been ap- tals, with an ankle injury in the previous 48 hours, plied, one would have a reduction in x-rays, while the were enrolled. All patients were assessed by either other center would have an increase. Conclusions: staff physicians or fellows. X-rays were ordered ac- This study demonstrates the OAR to be sensitive for cording to standard clinical practice. Prior to review- detecting clinically significant (Ն3 mm) ankle and ing x-rays, the physical examination was recorded on midfoot fractures in children. The application of these a standardized form. Positive outcomes (clinically sig- rules may reduce the number of x-rays ordered. A fur- nificant) were defined as fractures with fragments Ն3 ther study is required to determine the effect of using mm. Patients not x-rayed and asymptomatic at five the OAR in clinical practice. Key words: child; ankle; to seven days postinjury were considered to have no injury; Ottawa Ankle Rules; guidelines; x-rays; radi- significant fracture. Results: Six hundred seventy pa- ology. ACADEMIC EMERGENCY MEDICINE 1999; tients were enrolled. The OAR were 100% sensitive 6:1005–1009 XTREMITY injury is a common cause for vis- radiographic studies.2 Clinical rules that are sen- E its to EDs.1 At the Children’s Hospital of sitive for fracture detection, but reduce the number Eastern Ontario (CHEO), more than 1,000 chil- of radiographs ordered, would be useful in reduc- dren present each year with ankle injuries. Pa- ing radiation exposure, health care costs, and wait- tients with extremity injuries frequently have ra- ing time in the ED. diographic studies. In one study, 97% of children Studies in adult populations (aged 18–55 years) presenting with extremity injuries to the ED had have found that the Ottawa Ankle Rules (OAR) ap- proached 100% sensitivity for detecting clinically significant fractures in adult patients with ankle From the Pediatric Emergency Medicine Section, Department injuries,3,4 and application of these rules resulted of Pediatrics, and the Pediatric Radiology Section, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, in a 28% reduction in the number of x-rays or- 5,6 Ontario, Canada (ACP, MHO, HD, TPK); Department of Med- dered. The OAR state that ankle x-rays are nec- icine and Department of Epidemiology and Community Medi- essary only if there is pain near the malleoli and cine, University of Ottawa, Ottawa, Ontario, Canada (IS); and one of the following: 1) inability to bear weight im- the Pediatric Emergency Medicine Section, Department of Pe- diatrics, Children’s Hospital, University of Manitoba, Winni- mediately after the injury and in the ED (four peg, Manitoba, Canada (BB, MR, MT). steps) or 2) bone tenderness at the posterior edge Received March 15, 1999; revision received May 27, 1999; ac- or tip of either malleolus. Foot x-rays are necessary cepted June 18, 1999. Presented at the Pediatric Academic So- only if there is pain in the midfoot and one of the ciety annual meeting, Washington, DC, May 1997; and the following: 1) inability to bear weight as defined SAEM annual meeting, Washington, DC, May 1997 (Best Fel- low’s presentation 1997). above and 2) bone tenderness over the navicular Supported by Children’s Hospital of Eastern Ontario Research or base of the fifth metatarsal (Fig. 1). Clinically Institution, Grant (96/02R/S (E)). significant fractures are defined as those with bone Address for correspondence and reprints: Dr. Amy C. Plint, fragments Ն3 mm in width. MD, Division of Emergency Medicine, Children’s Hospital of Eastern Ontario, 401 Smyth Avenue, Ottawa, Ontario, Canada Ankle injuries in children have several unique K1H 8L1. Fax: 613-738-4852; e-mail: [email protected] factors. Children have growth plates and may sus- 1006 OTTAWA ANKLE RULES Plint et al. • OTTAWAANKLE RULES IN CHILDREN Figure 1. The Ottawa Ankle Rules. Reproduced with permission from: Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries: refinement and prospective validation. JAMA. 1993; 269:1127–32. tain Salter-Harris fractures. Assessment of pain at both centers and since the study included only and weight bearing may also be difficult in chil- collection of data normally obtained during a visit, dren. Given these issues, prior to the utilization of written informed consent was not required. the OAR in children, one must determine the sen- sitivity and specificity of the rules in this popula- Study Setting and Population. Patients aged 2 tion. One prospective study has applied the OAR to 16 years presenting to the ED at the CHEO or to children with ankle injuries; however, the sam- the Children’s Hospital, Winnipeg, Manitoba, with ple size (n = 71) was small and, hence, the 95% an ankle injury sustained in the preceding 48 confidence interval was large. This study found the hours were eligible. Both of these hospitals are ter- OAR to be 100% sensitive (95% CI = 77% to 100%).7 tiary care centers staffed primarily with pediatric Application of the rule in children would have re- emergency physicians (EPs). There are 50,000 ED sulted in a reduction of x-rays ordered by 25% visits per year at CHEO and 34,000 ED visits per without missing any fractures. year in Winnipeg. The centers are similar in pa- We proposed that the adult-derived OAR would tient acuity and admission rates. Ankle injury was be sensitive in the pediatric population with ankle defined as any acute soft-tissue or bony injury to injuries and developed a prospective study to test the distal tibia, distal fibula, talus, malleoli, or this hypothesis. midfoot zone. All ankle injury patients, whether or not x-rays were taken, were eligible. Children less METHODS than 2 years old were excluded to reduce diffi- culties in cooperation. All children with multiple Study Design. This was a prospective evaluation injuries, obvious open fractures, evidence of neu- of the OAR when applied to a pediatric population. rovascular compromise, underlying disease predis- This study was approved by the ethics committee posing to fractures (e.g., osteogenesis imperfecta), ACADEMIC EMERGENCY MEDICINE • October 1999, Volume 6, Number 10 1007 or underlying disease with sensory abnormalities TABLE 1. Characteristics of the Patient Population (spina bifida), patients with isolated injuries of the Ottawa Winnipeg skin, patients returning for reassessment of the same injury, patients referred to the ED with No. patients en- rolled 520 150 x-rays, and clinically intoxicated patients were ex- cluded. No. patients eligible, not enrolled 287 18 Study Protocol. All patients were assessed by ED staff and fellows oriented and trained in the Age—median (25–75%) 12.5 (9.7–14.5) yr 12.9 (10.3–14.7) yr application of the OAR. The physical examination was recorded on a clinical data form prior to view- Gender—male 288 (56%) 71 (48%) ing the x-ray. This form included information re- garding age of the patient, mechanism of injury, Method of outcome location of tenderness, ability to bear weight, EP assessment X-ray studies 517 (>99%) 126 (84%)* interpretation of the x-ray, diagnosis, and treat- Telephone follow- ment. The examining physicians were not asked to up 3 (<1%) 24 (16%) interpret whether the OAR were positive or nega- tive on the data form. The principal investigator Mechanism of injury reviewed all data forms and determined whether Twisting 382 (73.5%) 102 (68%) Free fall >4 ft 34 (6.5%) 12 (8%) the rules were positive or negative. X-rays were Direct blow 43 (8.3%) 12 (8%) ordered by each center’s current practice. In Win- Motor vehicle col- nipeg, physicians ordered all x-rays. This is con- lision 0 1 (0.7%) trasted to Ottawa, where extremity x-rays are usu- Other 61 (11.8%) 14 (15.3%) ally ordered by the triage nurse based on the *Percentage difference of x-ray rate = 15% (CI = 10% to 21%). Brand protocol.8 The Brand protocol uses signs such as bone deformity, instability, crepitation, and point tenderness to determine the need for x-ray and the clinical data form. A negative outcome was of ankle and foot. The x-ray was reviewed by the defined as no fracture or a fracture fragment less staff physician for immediate clinical manage- than 3 mm or ability to return to normal physi- ment. The staff physicians were also asked to an- cal activity with no pain when followed five to swer questions regarding mechanism of injury, and seven days after injury.
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