Evaluating fracture risk in acute ankle sprains: Any news since the Ottawa Ankle Rules? A systematic review

Figures & data

Table 1. Inclusion and exclusion criteria according to the PICO framework (population, intervention, comparator, outcome).

PICO	Inclusion criteria	Exclusion criteria
Population	Adults and youngsters (16 years and over)Inversion sprain (including acute inversion sprain among patients with chronic ankle instability)	Children (age younger than 16)TendinopathyAcute and chronic non traumatic ankle painChronic ankle instabilityOther ankle trauma
Intervention	AnamnesisClinical examination: physical examination and functional assessment (including Ottawa rules)Imaging (X-ray, ultrasonography, magnetic resonance imaging, computed tomography)
Comparator	Reference diagnostic evaluation versus other diagnostic evaluation.
Outcome	Diagnostic accuracy of procedures (e.g. false positive, false negative, sensitivity, specificity, positive and negative predictive values).

Figure 1. Flow chart on study selection for diagnosis of ankle sprain.

Table 2. Description of included systematic review.

Reference	Included studies	Patient	Intervention	Comparator	Outcome	Risk of bias
[1]	27 RCTs (pooled for analysis):
	1. Aginaga, 1999	Adults and children (separated into two groups) and included if within one week after an acute ankle sprain.	Ottawa ankle rules three subgroups: Assessment of the ankle. Assessment of the mid-foot. Assessment of the ankle and the mid-foot combined.	Radiography as reference standard but not all included studies used radiography.	Sensitivity, specificity, likelihood ratios and/or standard errors.	Moderate risk of bias. Quality assessment of the primary studies not included. Publication bias not assessed
	2. Auleley, 1998
	3. Kerr, 1994
	4. Lucchesi, 1995
	5. Mann, 1998
	6. Papacostas, 2001
	7. Perry, 1999
	8. Singh-Ranger and  Marathias, 1999
	9. Stiell, 1992
	10. Stiell, 1993
	11. Stiell, 1994
	12. Yuen, 2001
	13. Chandra and Schafmayer,  2001
	14. Garces, 2001
	15. Glas, 2002
	16. Keogh, 1998
	17. Leddy, 1998
	18. McBride, 1997
	19. Pigman, 1994
	20. Salt and Clancy, 1997
	21. Tay, 1999
	22. Verma, 1996
	23. Boutis, 2001
	24. Chande, 1995
	25. Karpas, 2002
	26. Libetta, 1999
	27. Plint, 1999

Last date search: 2002

Table 3. Description of included primary studies.

Reference	Study type, Country	Patient	Intervention	Comparator	Outcome	Risk of bias
[15]	Prospective study, U.K.	>15 years old patients in an emergency department (ED) within 48 hours after an ankle injury. n = 50	Patients self-assessment with OAR	OAR by an ED(+ radiography if appropriate)	Interobserver agreement	Low risk of biasNot all patients received a radiography as gold standard.
[16]	Prospective study, Austria	Athletically active patients (18-45 years old) within 7 days after inversion ankle trauma.n = 60	MRI (0.5 T units)	Lateral stress radiography (talar tilt test)+ lesion observed during surgery repair in 15 patients	Sensitivity, specificity, agreement between MRI and stress radiography	High risk of biasSpecific population; Intraoperative findings in a subgroup of 15 patients
[17]	Prospective cohort study, Australia	≥18 years old patients in EDwithin 10 days after ankle or foot injuryn = 366	OAR by junior and senior physicians	Radiography (irrespective of OAR results)	Sensitivity specificity, predictive values	Low risk of bias
[18]	Prospective cohort study, Switzerland	≥18 years old patients in ED within 10 days after ankle trauma.n = 359	OAR by surgeons and non-surgeons	Radiography	Sensitivity and specificity	Moderate risk of biasNo registry of OAR results in 42 cases
[19]	Prospective cohort study, U.K.	>16 year old patients with positive OAR in ED n = 110	Ultrasound scan (USS)	Radiography	Sensitivity, specificity, predictive values and likelihood ratio.	Moderate risk of bias
[22]	Prospective cohort study, The Netherlands	18–65 years old patients in ED within 48 hours after injury.n = 106	OAR/OFR by both a trained emergency nurse and a junior doctor	Radiography	Sensitivity, specificity, predictive values. Interobserver agreement.	Low risk of bias
[21]	Randomized controlled trial, The Netherlands	18–65 years old patients in ED.n = 512263 patients assessed by a trained emergency nurse and 249 by a junior doctor.	OAR/OFR by emergency nurse (+ Radiography)	OAR/OFR by junior doctor (+ Radiography)	Sensitivity, specificity, positive and negative predictive values.	Low risk of biasRadiography after 1 week of all injuries not radiographed earlier.
[23]	Prospective cohort study, U.K.	>12 years old patients with positive OAR in ED n = 50	Vibrating tuning fork (C° 128 Hz) test.	Radiography	Sensitivity, specificity and likelihood.	Low risk of bias.
[24]	Prospective cohort study, Switzerland	Adults patients in ED n = 354	Bernese ankles rules (clinical examination based on 3 consecutive steps: indirect fibular stress, direct medial malleolar stress and compression stress of the mid- and hindfoot)	Radiography	Sensitivity and specificity.	Low risk of bias.Lack of information about the included population
[25]	Prospective cohort study, U.S.A.	≥18 years old patients in ED within 1 week after the injury.n = 103	OAR by nurse or by physicians	Radiography (except for 6 patients who had not radiography but a structural telephone interview)	Sensitivity, specificity, predictive values. Interobserver agreement.	Moderate risk of bias.
[26]	Prospective cohort study, The Netherlands	≥18 years old patients in ED within 5 days after ankle injuryn = 647	For each case: • history taking and physical examination • OAR • Leiden ankle rules By junior surgical and orthopedic residents	Radiography	Specificity, sensitivity and AUC.	Low risk of bias.
[27]	Prospective cohort study, France	18-55 years old patients in ED within 48 hours after ankle sprains n = 110	Ultrasonography to detect talocrural joint effusion	MRI if positive ultrasound test (within the next 8 days).No comparison if no effusion	Prevalence of joint effusion (by ultrasound) and cause of the effusion (by MRI)	Moderate risk of bias.Lack of a comparison with a golden standard. No conclusions when no effusion.
[28]	Intervention study, Denmark	All ages patients admitted to the ED with an acute blunt ankle or midfoot injury n= 882 patients control groupn = 1 014 intervention group	OAR by junior doctors (+ Radiography if required)	Clinical evaluation without OAR by the same junior doctors (+ Radiography if required)	Specificity, sensitivity	High risk of bias.Intervention and control groups were different populations;no standard reference.
[29]	Prospective cohort study, U.S.A.	All ages patients in a university sports medicine walk-in clinic within 10 days after an ankle/ mid-foot injury.n = 217	Modified OAR (Buffalo rules)	Radiography if positive OAR; telephone follow-up in the patients without radiography	Specificity and sensitivity, Cost-saving	Moderate risk of bias no golden standard in all cases;11% of the patients were children (≤ 17 years).
[30]	Randomized controlled trial, The Netherlands	All ages patients referred by traumatologist, orthopedic surgeon, or emergency physician, within 7 days after ankle injury. n = 19797 patients assessed by a combination X-ray + MRI and 100 by X-ray only.	Radiography and MRI (0.2 T) performed immediately after radiography.	Radiography	Prediction of need for treatment	High risk of bias No criteria explaining why patients needed radiography Decision to treat based on physician only
[31]	Prospective cohort study, The Netherlands	≥18 years old patients in ED within 5 days after ankle injury n = 647	OAR, Leiden Ankle Rules and Utrecht Ankle Rules	Radiography	Sensitivity, specificity, reduction of radiography, ROC curves and area under ROC curves	Low risk of bias
[32]	Case-control study, Germany	Adults patients a clinic in a clinic within 48 hours after ankle injuryn = 45Healthy control groupn = 38	Assessment of anterior drawer test using the ankle meter	Stress radiography	ATD measurement in both groupCorrelation between ATD measurement and stress radiographyInfluence of pain	Moderate risk of bias
[33]	Prospective cohort study, U.S.A.	Military academy cadets (18-25 years old) at walk-in clinic within 10 days after ankle or midfoot injuryn = 156	Modified OAR (Buffalo rule)	Radiography,	Sensitivity, specificity, predictive valuesInterobserver agreement	Moderate risk of biasSpecific population
[34]	Prospective cohort study, The Netherlands	18 - 40 years old patients in ED within 2 days after inversion injury.n = 160	Physical examination within 48h after trauma; Arthrogram within 48h after trauma Delayed examination 5 days later; Stress radiography 5 days after trauma US for 74 consecutive patients	Intraoperative findings for 135 patientsClinical diagnosis at follow up at 6 month for the non-operatively treated group (25 patients).	Specificity and sensitivity	Moderate risk of bias
[35]	Prospective cohort study,The Netherlands	≥15 year old patients in ED within 10 days after ankle trauman = 514	Leiden ankle scoring system Radiography in case Leiden score ≥8 (n = 81)	No comparison, but telephone follow-up at six weeks	Specificity, sensitivity and reduction in the amount of radiographies	High risk of biasLack of systematic golden standard test (radiography).
[36]	Prospective cohort study, New Zealand	≥18 years old in an after-hours medical centre within 10 days after ankle or midfoot injuryn = 216	Clinical examination by GP (+ radiography orphone call follow-up according to the GP management)	Retrospectively applied OAR	Survey, sensitivity , specificity, predictive value and reduction of radiography	High risk of biasLack of systematic gold standard test (radiography).

ED, emergency department.

Table 4. Diagnostic indicators performance of the OAR in identifying fracture.

Reference	Setting	n	Missed fractures	Total fractures	Sensitivity%(95%CI)	Specificity%(95%CI)	Positive predictive value %(95%CI)	Negative predictive value %(95%CI)	Risk of bias
[17]	ED (urban teaching hospital), junior or senior physicians trained to use OAR	265	0	43	100(92–100)	16(11–21)	19(14–24)	100(90–100)	Low
[18]	ED (district hospital), surgeons or physicians in training to become general practitioners or medical students, all informed about OAR	251	0	33	100(89–100)	21(16–27)	-	-	Moderate
	• Surgeons				100(77–100)	32(20–46)
	• Non-surgeons				100(82–100)	17(11–23)
[22]	ED (urban university teaching), specialized emergency nurses (SEN) trained in ankle injuries and junior emergency physicians	106^a		14					Low
	• SEN		1 (avulsion chip of the talus)		93(64–100)	49(38–60)	22(13–35)	98(87–100)
	• Junior physicians		1 (avulsion chip of the medial malleolus (deltoid) ligament		93(64–100)	39(29–50)	19(11–31)	97(84–100)
[25]	ED (suburban teaching), emergency nurses and emergency physicians, both trained in OAR	103		27					Moderate
	• Emergency nurses		1 (nondisplaced lateral malleolar fracture)		92	36	32	90
	• Emergency physicians		1 (small avulsion of the talus bone)		92	47	38	94
[28]	ED (rural hospital), junior or senior doctors with OAR training provided to new junior doctors	1014^b	2 (undislocated fracture of the 5th metatarsal; avulsion of the lateral malleolus		99	51	-	-	High
[29]	Sports medicine center, primary care sports medicine physician or nurse practitioners, all instructed about OAR	193^b^,^c	0	17	100(78–100)	45(43–46)	-	-	Moderate
[33]	Orthopaedic walk-in clinic, physical therapists and orthopaedic surgeons	157^c^,^d		6					Moderate
	• Physical therapists		0		100(93–100)	40(32–48)	6(2–10)	100(93–100)
	• Orthopaedic surgeons		0		100(93–100)	46(38–54)	7(3–11)	100(93–100)
[36]	Primary care setting(after-hours medical centre), OAR analysed retrospectively	196	0	13^e	100(75–100)	47(41–55)	12(7–19)	-	High

ED, emergency department.

^aWithin 48 h of the injury.

^bChildren included.

^cOAR modified (Buffalo rules).

^dMilitary cadets 18–25 years old.

^eAfter exclusion of four clinically insignificant fractures.

Table 5. Diagnostic indicators performance of different tests in identifying fracture.

Ref.	Tests	n	Missed fractures n	Total fractures n	Sensitivity % (95% CI)	Specificity % (95% CI)	Risk of bias
[23]	Tuning fork test applied on the tip of the lateral  malleolus in patients with positive OAR	49	0	5	100 (46–100)	61 (46–75)	Low
[23]	Tuning fork test applied on the distal fibula shaft  in patients with positive OAR	49	0	5	100 (46–100)	95 (83–99)	Low
[24]	Bernese ankle rules	354	0	28	100	91	Low
[31]	Utrecht ankle rules	647	17	41^a	59 (42–74)	84 (81–87)
[26,31]	Leiden ankle rules	647	5	41^a	88 (74–96)	57 (53–61)	Low
[35]	Leiden ankle rules	514	5	29	83 (69–94)	88 (85–91)	High
[19]	Ultrasound in patients with positive OAR	110	1	11^b	91 (66–98)	91 (88–92)	Low

^aAfter exclusion of 33 clinically insignificant fractures.

^bAfter exclusion of four clinically insignificant fractures.

Figure 2. Ottawa ankle rules: Areas of palpation. Source: Ottawa Hospital Research Institute (http://www.ohri.ca/). Reprinted with permission of Ian Stiell of the Ottawa Hospital Research Institute.

Figure 3. Ottawa ankle rules: Criteria for X-ray series requirements.

Figure 4. Ottawa ankle rules: Recommendations for use.

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