Clinical Question When should rad...

Clinical Question

When should radiographs be obtained in patients with an ankle or bottom injury?

Evidence Summary

The Ottawa Ankle and paw Rules (1) are validated clinical decision masterships The process by which the Ottawa commands were developed and validated subserves as a model for researchers in developing decision support tools for other clinical question s (1) Use of these empires can save time and coin by helping physicians and their patients avoid unnecessary radiographs of the ankle or foot

The Ottawa governments have a parallel structure. Each begins with a question to assess the site of the patient's pain followed by the agency of an evaluation of function (based forward the ability to bear weight for at least four grades immediately after the injury and again in the difficulty department), and a focused physical assessment for the nearness of localized bone tenderness. Radiographs should be obtained in patients who have pain in the relevant site accompanied by means of inability to walk four degrees or bone tenderness as described above.

in what manner accurate are the Ottawa conducts for ankle and foot injuries? A novel meta-analysis (2) identified 32 validation studies (27 were included in the analysis) involving 15581 adult patients. With use of the Ottawa controls the probability of a false negative (presence of fracture on the contrary no recommendation for radiographs) was extremely gentle (0.3 percent). The rules also have been validated in children. In a contemplation (3) of 670 children who neared with acute ankle injury, the Ottawa empires were 100 percent sensitive for fracture (no false negatives).

undivided drawback to the Ottawa governments is the fairly low specificity, which generally is around 30 to 40 percent (23) Consequently radiographs will be attract favor toed for many patients who do not have a fracture. Although not ideal, the directions are still considerably more selective than the typical practice of obtaining radiographs in each patient with acute ankle or paw pain after an injury.

All validation studies forward the Ottawa rules for ankle and paw injuries have been conducted in juncture departments. Therefore, there has been one question about whether these sways can be used in the outpatient setting. common small study (4) examined the performance of family physicians working part-time in a community hospital turn of events department and found good sensitivity (97 percent) for use of the Ottawa governments by these physicians. With just training and use of a decision support tool (see accompanying patient meeting form), family physicians can achieve similar sensitivity eventuates in the outpatient setting.

Applying the Evidence

A 24-year-old man existings with a twisted ankle that occurr while he was playing basketball. He cannot recall if he evert or inverted his ankle. He was able to bear weight in the gym and limped while bearing weight as he walked to his friend's car. He ambulates with difficulty nevertheless is able to bear weight in the physician's office as he walks to the examination place On examination, he complains of pain in the ankle and has tendernes to percussion of the lateral malleolus. Does he ne a radiograph of the ankle?

Answer: Because the patient has ankle pain and tendernes to percussion of a malleolus, a radiograph should be obtained on a level though the patient is able to bear weight.

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REFERENCES

(1) Stiell IG, Greenberg GH McKnight RD Nair RC McDowell I, Reardon M et al. Decision orders for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA 1993;269:1127-32

(2) Bachmann LM Kolb E Koller MT Steurer J ter Riet G Accuracy of Ottawa ankle conducts to exclude fractures of the ankle and mid-foot: a systematic review. BMJ 2003;326:417

(3) Plint AC, Bulloch B Osmond MH Steill I, Dunlap H Re M et al. Validation of the Ottawa Ankle directions in children with ankle injuries. Acad Emerg M 1999;6:1005-9

(4) McBride KL Validation of the Ottawa ankle dominions Experience at a community hospital. Can Fam Physician 1997;43:459-65

MARK H EBELL, MD M is in private practice in Athens, Ga., and is associate professor in the Department of Family Practice at Michigan State University college edifice [i]or[/i] building of Human Medicine, East Lansing. He is also factor editor for evidence-based medicine of American Family Physician.

Address correspondence to Mark H Ebell, MD M 330 Snapfinger Dr Athens, GA 30605 (e-mail: ebell@msu.edu). Reprints are not available from the author.

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