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![Page 1: Ottawa Clinical Decision Rule - A Prospective, Validation Study for use of Radiography in Acute Ankle, Mid Foot and Knee Injuries in the ED, South India.](https://reader033.fdocuments.net/reader033/viewer/2022051710/5a667c6b7f8b9ac5128b4b95/html5/thumbnails/1.jpg)
Ottawa Clinical Decision Rule - A Prospective, Validation Study for use of Radiography in Acute Ankle, Mid Foot and
Knee Injuries in the ED, South India.
SRMC&RI
Dr. Srihari. Cattamanchi., M.D. (A&EM).Sri Ramachandra Medical College & Research Institute,
Chennai . India
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Background
• The Ottawa clinical decision rules are a set of
guidelines for doctors to aid them in deciding if a
patient with ankle, foot or knee pain should be offered
x-rays to diagnose a possible bone fractures.
• Before the introduction of the rules most patients with
ankle, foot or knee injuries would have been x-rayed.
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Background
• However only about 15% of X-rays were
positive for fracture, other patients had sprains
or other injuries.
• As a result many unnecessary X-rays were
taken, which was costly, time consuming and a
possible health risk.
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Ottawa rules for x-ray of ankle
An ankle x-ray is required only if there is any pain in
Malleolar zone and any of these findings:
– age 55 or over
– bone tenderness at posterior edge or tip of lateral
malleolus
– bone tenderness at posterior edge or tip of medial
malleolus
– inability to weight bear both immediately and in ED
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Ottawa rules for x-ray of ankle & Foot
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Ottawa rules for x-ray of foot
A foot x-ray is required if there is any pain in the
Midfoot zone and any of these findings:
– age 55 or over
– bone tenderness at Base of 5th Metatarsal
– bone tenderness at Navicular
– inability to weight bear both immediately and in the
emergency department.
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Ottawa rules for x-ray of ankle & Foot
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Ottawa rules for x-ray of knee
A knee x-ray is only required for knee injury patients with any of these findings:
– age 55 or over
– isolated tenderness of the patella
– tenderness at the head of the fibula
– inability to flex to 90 degrees
– inability to weight bear both immediately and in the emergency department.
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Objectives
To determine the sensitivity and specificity of the
Ottawa clinical decision rules.
To determine whether use of the rule would reduce the
number of radiographs ordered.
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Materials & Methods
Design: A prospective, analytical, validation study
Setting: Done at an academic ED of Sri Ramachandra
Medical College & Research Institute, a tertiary care
university hospital, & Level I trauma center, in South
India.
Duration: Between June 1st 2008 and December 31st
2009.
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Materials & Methods
Inclusion Criteria:
– All patients registered in the ED,
– above 2 years of age,
– sustained Ankle, Foot or Knee injury in
preceding 7 days, and
– evidence of bony injury on physical
examination.
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Materials & Methods
Exclusion Criteria:
– Paraplegic patients,
– pregnant,
– altered sensorium,
– polytrauma or
– other major fractures.
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Sampling: A consecutive sampling technique .
Statistical analysis: Sensitivity, specificity & 95%
confidence interval done with SPSS Ver.17.0
Instrument: A preformatted proforma was used.
Materials & Methods
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Results – Age & Sex Distribution
0
50
100
150
200
250
1 - 10Years
11 - 20Years
21 - 30Years
31 - 40Years
41 - 50Years
51 - 60Years
61 - 70Years
71 - 80Years
> 80Years
No
of
Pat
ien
ts Male - 671
Female - 258
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Mechanism of Injury
277
201
451
Direct Blow
Torsion
Other indirectinjury
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Causes of Injury
74
224
502
17112
Sports Injury
Fall Related Injury
Road TrafficAccidents
Assault
IndustrialAccidents
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Injuries Sustained
205
325
399 Ankle
Foot
Knee
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History
239
43
690
656
0 100 200 300 400 500 600 700 800
Cracking / Popping Sound Heard
Lower Limb Injury in Precedingyear
Able to Bear weightImmediately
Able to continue activity beingperformed at time of Injury
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Range of Motion
612
317
Full
Restricted
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Ability to Bear Weight – 4 Steps in ED
690
239
Yes
No
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Bone Tenderness of Ankle Joint
1316
4
97
13
0
2
4
6
8
10
12
14
16
18
Lateral Malleolus Medial Malleolus
No
of
Pat
ien
ts
Anterior Edge Inferior Tip Posterior Edge
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Bone Tenderness of Foot
21
57
24
Fig. 13. Bone Tenderness of the Foot
Cuboid Navicular Base of Fifth Metatarsal
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Bone Tenderness of Knee Joint
22
36 39 4455
33
60
43
0
10
20
30
40
50
60
70
Patella IsolatedPatella
Patella &DirectBelow
MedialFemoralCondyle
LateralFemoralCondyle
Medial TibiaLateral Tibia TibialTuberosity
No
of
Pat
ien
ts
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Prospective Prediction of Ottawa Clinical Decision Rule
87113
81118
212
318
0
50
100
150
200
250
300
350
Ankle Foot Knee
No
of
Pat
ien
ts
Fracture No Fracture
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Radiographs Ordered
632
769
1224
Ankle
Foot
Knee
N = 2625
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Fracture Yield
• Fractures Detected
• 69 ankle fractures,
• 104 midfoot fractures and
• 66 knee fractures.
• Fracture Yield
• 10.9% for ankle films,
• 13.5% for foot films and
• 5.4% for knee films.
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Radiological Findings
136
221
333
69104
66
0
50
100
150
200
250
300
350
Ankle Foot Knee
No
of
Pat
ien
ts
Normal Study Signigicant Fracture
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Missed Fractures
Rule failed to predict fracture in 3 ankle injuries
and 2 midfoot injuries
Two were distal fibula fractures and one was
distal tibia fracture.
Two missed midfoot fractures were of 5th
metatarsal and calcaneus.
The examiner’s clinical impression was no
fracture.
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Disposition
333
487
2881
Discharged Admitted to Ward Admitted to ICU / Immediate Surgery DAMA
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Sensitivity, Specificity & Negative predictive
value of rule in ankle, foot & knee injuries.
Parameters1 Ankle Foot Knee
Sensitivity 95.6% 98% 100%
Specificity 86.7% 95.5% 95.7%
Negative Predictive
value
97.5% 99% 100%
Positive Predictive
Value
78.5% 91.8% 82.5%
Potential Radiographic
Savings
57.5% 65.2% 79.6%
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Limitations
Study population - convenience sample of eligible
patients.
May have introduced selection bias toward patients with
more severe injury.
This is suggested by our relatively high fracture yields for
ankle and mid-foot injuries.
Examination accuracy may have varied among
examiners.
Inter-rater reliability not assessed.
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Conclusion
Prospective validation has shown Ottawa Rules to be
100% sensitive for identifying fractures of knee.
However, their sensitivity is not 100% in ankle and foot
injuries.
Appears to be much more sensitive than clinical
impression
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Conclusion
May be used as a guideline for selectively ordering
radiographs in acute ankle, foot and knee injury.
Application of the rule would have led to a 32% relative
reduction in use of radiography in the ED.
This would inturn decrease waiting times for patients
discharged without radiography by 55 minutes in this
study.
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Thank You
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My friends & Colleagues
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My friends & Colleagues