This Article  • References  • Full text PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Contact me when this article is cited  Related Content  • Similar articles in JAMA  Social Bookmarking   What's this?

Refinement and Prospective Validation

Ian G. Shell, MD, MSc, FRCPC; Gary H. Greenberg, MD, FRCPC; R. Douglas McKnight, MD, FRCPC; Rama C. Nair, MStat, PhD; Ian McDowell, PhD; Mark Reardon, MD, FRCPC; J. Patrick Stewart, MD, CCFP(EM); Justin Maloney, MD, FRCPC

JAMA. 1993;269(9):1127-1132.

Abstract
Objective.
—To validate and refine previously derived clinical decision rules that aid the efficient use of radiography in acute ankle injuries.

Design.
—Survey prospectively administered in two stages: validation and refinement of the original rules (first stage) and validation of the refined rules (second stage).

Setting.
—Emergency departments of two university hospitals.

Patients.
—Convenience sample of adults with acute ankle injuries: 1032 of 1130 eligible patients in the first stage and 453 of 530 eligible patients in the second stage.

Main Outcome Measures.
—Attending emergency physicians assessed each patient for standardized clinical variables and classified the need for radiography according to the original (first stage) and the refined (second stage) decision rules. The decision rules were assessed for their ability to correctly identify the criterion standard of fractures on ankle and foot radiographic series. The original decision rules were refined by univariate and recursive partitioning analyses.

Main Results.
—In the first stage, the original decision rules were found to have sensitivities of 1.0 (95% confidence interval [CI], 0.97 to 1.0) for detecting 121 malleolar zone fractures, and 0.98 (95% CI, 0.88 to 1.0) for detecting 49 midfoot zone fractures. For interpretation of the rules in 116 patients, values were 0.56 for the ankle series rule and 0.69 for the foot series rule. Recursive partitioning of 20 predictor variables yielded refined decision rules for ankle and foot radiographic series. In the second stage, the refined rules proved to have sensitivities of 1.0 (95% CI, 0.93 to 1.0) for 50 malleolar zone fractures, and 1.0 (95% CI, 0.83 to 1.0) for 19 midfoot zone fractures. The potential reduction in radiography is estimated to be 34% for the ankle series and 30% for the foot series. The probability of fracture, if the corresponding decision rule were "negative," is estimated to be 0% (95% CI, 0% to 0.8%) in the ankle series, and 0% (95% CI, 0% to 0.4%) in the foot series.

Conclusion.
—Refinement and validation have shown the Ottawa ankle rules to be 100% sensitive for fractures, to be reliable, and to have the potential to allow physicians to safely reduce the number of radiographs ordered in patients with ankle injuries by one third. Field trials will assess the feasibility of implementing these rules into clinical practice.

(JAMA. 1993;269:1127-1132)

Author Affiliations
From the Division of Emergency Medicine (Drs Stiell, Greenberg, McKnight, Reardon, Stewart, and Maloney), and the Department of Epidemiology and Community Medicine (Drs Nair and McDowell), University of Ottawa (Ontario) Faculty of Medicine. Dr Stiell is a career scientist of the Ontario Ministry of Health, Health Research Personnel Development Program, Toronto,

Footnotes
Reprint requests to Clinical Epidemiology Unit, Loeb Medical Research Institute, Ottawa Civic Hospital, 1053 Carling Ave, Ottawa, Ontario, Canada K1Y 4E9 (Dr Stiell).

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial
Stiell et al.
BMJ 2009;339:b4146-b4146.
ABSTRACT | FULL TEXT  

A multifaceted strategy for implementation of the Ottawa ankle rules in two emergency departments
Bessen et al.
BMJ 2009;339:b3056-b3056.
ABSTRACT | FULL TEXT  

The rational clinical examination in emergency care
Mackway-Jones
BMJ 2008;337:a2374-a2374.
FULL TEXT  

Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children
Appelboam et al.
BMJ 2008;337:a2428-a2428.
ABSTRACT | FULL TEXT  

Management of Acute and Chronic Ankle Instability
Maffulli and Ferran
J Am Acad Orthop Surg 2008;16:608-615.
ABSTRACT | FULL TEXT  

A Clinical Decision Rule for Cranial Computed Tomography in Minor Pediatric Head Trauma
Atabaki et al.
Arch Pediatr Adolesc Med 2008;162:439-445.
ABSTRACT | FULL TEXT  

Ankle fractures in adults: an overview
Westerman and Porter
Trauma 2007;9:267-272.
ABSTRACT  

Calcaneal avulsion fracture
Platts-Mills et al.
Emerg. Med. J. 2007;24:231-231.
FULL TEXT  

Can a normal range of elbow movement predict a normal elbow x ray?
Lennon et al.
Emerg. Med. J. 2007;24:86-88.
ABSTRACT | FULL TEXT  

Improving Ambulatory Prescribing Safety with a Handheld Decision Support System: A Randomized Controlled Trial
Berner et al.
J. Am. Med. Inform. Assoc. 2006;13:171-179.
ABSTRACT | FULL TEXT  

Comparison of the Canadian CT Head Rule and the New Orleans Criteria in Patients With Minor Head Injury
Stiell et al.
JAMA 2005;294:1511-1518.
ABSTRACT | FULL TEXT  

Clinical Prediction Rules in Trauma Imaging: Who, How, and Why?
Blackmore
Radiology 2005;235:371-374.
ABSTRACT | FULL TEXT  

Acute Ankle Trauma: Value of a Short Dedicated Extremity MR Imaging Examination in Prediction of Need for Treatment
Nikken et al.
Radiology 2005;234:134-142.
ABSTRACT | FULL TEXT  

Which Patients With Knee Problems Are Likely to Benefit From Nonarthroplasty Surgery?: Development of a Clinical Prediction Rule
Solomon et al.
Arch Intern Med 2004;164:509-513.
ABSTRACT | FULL TEXT  

Physicians, Information Technology, and Health Care Systems: A Journey, Not a Destination
McDonald et al.
J. Am. Med. Inform. Assoc. 2004;11:121-124.
FULL TEXT  

The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma
Stiell et al.
NEJM 2003;349:2510-2518.
ABSTRACT | FULL TEXT  

Ottawa ankle rules for the injured ankle
Heyworth
Br. J. Sports. Med. 2003;37:194-194.
FULL TEXT  

A Decision Rule for Diagnostic Testing in Obstructive Sleep Apnea
Tsai et al.
Am. J. Respir. Crit. Care Med. 2003;167:1427-1432.
ABSTRACT | FULL TEXT  

Ottawa ankle rules for the injured ankle
Heyworth
BMJ 2003;326:405-406.
FULL TEXT  

Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review
Bachmann et al.
BMJ 2003;326:417-417.
ABSTRACT | FULL TEXT  

Management of Acute Soft Tissue Injuries
McGriff-Lee
Journal of Pharmacy Practice 2003;16:51-58.
ABSTRACT  

Effect of Arthroscopic Débridement for Osteoarthritis of the Knee on Health-Related Quality of Life
Dervin et al.
JBJS 2003;85:10-19.
ABSTRACT | FULL TEXT  

Comparison of diagnostic decision rules and structured data collection in assessment of acute ankle injury
Glas et al.
CMAJ 2002;166:727-733.
ABSTRACT | FULL TEXT  

Validation of Ottawa ankle rules protocol in Greek athletes: study in the emergency departments of a district general hospital and a sports injuries clinic
Papacostas et al.
Br. J. Sports. Med. 2001;35:445-447.
ABSTRACT | FULL TEXT  

The Ottawa Ankle Rules and missed fractures of the talus
Warren and Knottenbelt
Emerg. Med. J. 2001;18:521-521.
FULL TEXT  

The Ottawa Ankle Rule
Rae et al.
Emerg. Med. J. 2001;18:147-a-147.
FULL TEXT  

Clinical decision rules in the emergency department
Stiell
CMAJ 2000;163:1465-1466.
FULL TEXT  

A Prospective Study of Modified Ottawa Ankle Rules in a Military Population: Interobserver Agreement Between Physical Therapists and Orthopaedic Surgeons
Springer et al.
Am J Sports Med 2000;28:864-868.
ABSTRACT | FULL TEXT  

Users' Guides to the Medical Literature: XXII: How to Use Articles About Clinical Decision Rules
McGinn et al.
JAMA 2000;284:79-84.
ABSTRACT | FULL TEXT  

Contribution of Individual Projections Alone and in Combination for Radiographic Detection of Ankle Fractures
Brandser et al.
Am. J. Roentgenol. 2000;174:1691-1697.
ABSTRACT | FULL TEXT  

Rules to Live By: Decision Rules
Rogers
Am. J. Roentgenol. 2000;174:595-595.
FULL TEXT  

Prospective survey to verify the Ottawa ankle rules
Mccann
Emerg. Med. J. 2000;17 :75-76.
FULL TEXT  

Toward a Comprehensive Interdisciplinary Model of Health Care Research Use
LOGAN and GRAHAM
Science Communication 1998;20:227-246.
ABSTRACT  

Prospective Evaluation of the Ottawa Ankle Rules in a University Sports Medicine Center: With a Modification to Increase Specificity for Identifying Malleolar Fractures
Leddy et al.
Am J Sports Med 1998;26:158-165.
ABSTRACT | FULL TEXT  

Implementation of the Ottawa Knee Rule for the Use of Radiography in Acute Knee Injuries
Stiell et al.
JAMA 1997;278:2075-2079.
ABSTRACT  

Current Concepts Review - Decision Analysis
BERNSTEIN
JBJS 1997;79:1404-14.
FULL TEXT  

Implementation of the Ottawa Ankle Rules in France: A Multicenter Randomized Controlled Trial
Auleley et al.
JAMA 1997;277:1935-1939.
ABSTRACT  

Clinical Prediction Rules: A Review and Suggested Modifications of Methodological Standards
Laupacis et al.
JAMA 1997;277:488-494.
ABSTRACT  

Prospective Validation of a Decision Rule for the Use of Radiography in Acute Knee Injuries
Stiell et al.
JAMA 1996;275:611-615.
ABSTRACT  

Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle injuries
Stiell et al.
BMJ 1995;311:594-597.
ABSTRACT | FULL TEXT  

Decision Rules for Roentgenography of Children With Acute Ankle Injuries
Chande
Arch Pediatr Adolesc Med 1995;149:255-258.
ABSTRACT  

Clinical Application of the Ottawa Ankle Rules
McCarter and Slawson
JAMA 1994;272:518-518.
ABSTRACT  

Emergency radiography of the ankle
Good
BMJ 1994;308:980-980.
FULL TEXT  

Implementation of the Ottawa Ankle Rules
Stiell et al.
JAMA 1994;271:827-832.
ABSTRACT  

Radiography for Ankle Injuries
Waller
JAMA 1993;270:454-454.
ABSTRACT  

Radiography for Ankle Injuries
Hatch
JAMA 1993;270:453-453.
ABSTRACT  

CLINICAL RULES REDUCE NEED FOR ANKLE AND FOOT X-RAYS
JWatch General 1993;1993:2-2.
FULL TEXT