Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
This shouldn't be necessary
- Lucy C Free (22 February 2003)
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Clinical decision rules and risk of litigation
- Marcello Della Corte (23 February 2003)
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Better safe than sorry
- Seemit Dhage (24 February 2003)
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Ottawa Ankle Rules, a mistake and comment
- Katrina J Gardiner (27 February 2003)
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Literary perspective
- Joanne M Shaw (6 March 2003)
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Typing Mistake
- Manoj Srivastava (6 March 2003)
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Lucy C Free, Portfolio GP BN6 9BA
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It's a shame you have to make so much of papers like this. All it says is what we all know from Medical School; take a history and do an examination! Competing interests: None declared |
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Marcello Della Corte, Dirigente Chirurgo Ospedale S. M. Incoronata dell'Olmo Cava de'Tirreni (84013) - Italy
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I agree with Mr Heyworth that the application of the Ottawa ankle rules (and other similar ones) not only constitute good medicine, but is also an excellent way to improve the cost-effectiveness of the care provided in Emergency Departments. However, one of the reasons why these rules are still not universally applied could be the fear of litigation, especially in countries where patients (and their lawyers) are more prone to file cases against doctors. In some European countries (namely Italy) a lawsuit is more than just a civil case court, as it invariably involves a criminal court investigation for malpractice. This may make some doctors reluctant to apply consistently these rules on demanding patients. Perhaps, besides doctors' education, a more comprehensive patients' education would reduce the extent of defensive medicine and make the universal application of these simple and effective rules easier. Competing interests: None declared |
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Seemit Dhage, Senior House Officer Trauma and Orthopaedics Birmingham
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I agree Ottawa Rule is an ideal way to cut down on the number of unneccessary Ankle Xrays. However they are not applicable at times. Having spent about a year in Accident and Emergency as Senior House Officer, I have come across a variety of presentations of Ankle Sprains and Fractures. I have made some observations which unfortunately cannot be quantified or put on paper. The most striking obserevation has been the Female population are more dramatic as far as Ankle injuries are concerned. Few cases that i have seen had actually used the Emergency services, like dialling 999 for ankle sprains. Imagine this situation that the patient is brought in an ambulance, and you sit there applying Ottawa rule and bluntly tell the patient that she doesnt need an Xray. There is also a fear factor among patients besides the thought that you as a Doctor might miss something by not doing an Xray. I would say though Ottawa rule has been proven, by studies as reliable, it is up to the clinician to decide whether to use his confidence and judgement or rather simply say be safe than be sorry and ask for an xray. Competing interests: None declared |
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Katrina J Gardiner, VTS SHO Stoke Mandeville hospital,Aylesbury, HP21 8AL
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Dear Sir I read, with interest, the editorial 'Ottawa ankle rules for the injured ankle'1 and the systematic review 'Accuracy of Ottawa ankle rules to exclude fractures of the ankle and midfoot'2. Having spent 12 months as a senior house officer in A+E and completing an audit on the use of the Ottawa Ankle Rules (OAR) in the department, I have several comments to make and an error in the work published, to draw your attention to. In figure 1 (page 418)2, a series of foot xray films, not ankle films, are required if there is tenderness in the midfoot zone and at 'C' - base of 5th metatarsal or 'D' - navicular, or, inability to weight bear both immediately and in the emergency department. I would like to impress upon the reader that whilst the OAR are generally objective, pain is a subjective measure and most of these patients have attended A+E with their swollen ankle is because they have pain (and this is usually within either the 'malleolar' zone or the 'midfoot' zone). On a practical basis, most will say they are unable to walk due to pain, but it is crucial to select those who were unable to weight bear immediately after the injury. It is this discriminator that the OAR chooses to determine who undergoes radiography, as fractures are more likely in this group. Of interest, I audited a 1 month series of 'Cas cards' in the department. 4.6% (a figure reflected by J Heyworth1 in his editorial) of patients presented with ankle injuries during this period. 81% were 'inversion injuries', the specific type of ankle trauma to which OAR apply. 83% of these patients underwent radiographic examination of their ankle or foot (the same figure as in the published work from Ottawa3) and 31% of those xrays demonstrated a fracture. Most importantly, only 31% had clearly documented reasoning for radiography according to OAR, and of these, 31% had fractures. My analysis showed:
However, the management of patients according to a guideline needs to be flexible in its approach. As J Heyworth1 mentioned, patient needs are also important - 'xrays provide reassurance'. Patients frequently attend 'for an xray Doc, to check I've not broken my ankle'. It is vital that the majority of A+E 'customers' leave the department happy. So it can be the placebo value of an xray, in an ankle you know is not broken, versus counselling a patient about the unnecessary risks in exposure to ionising radiation! Notably many fractures diagnosed during my audit period were flake avulsion type. These injuries are essentially managed as a 'bad sprain', that is with tubigrip and crutches, if required. Unnecessary worry and uncertainty can be caused if diagnoses are not carefully explained. In these cases xraying does not significantly alter management although one could expect a longer period of recovery. The emergence of Emergency Nurse Practitioners (ENPs) and the rate of turnover of A+E SHOs mean the OAR should be used to change the approach to managing such a common musculoskeletal injury. Systematic examination and clear documentation of findings are essential in order to utilise OAR effectively and practice defensive, evidence based medicine that is medicolegally sound. Reduction in the numbers of xrays is also likely to significantly reduce A+E waiting times (an important Government target) and improve cost effectiveness. Finally we should all remember that exposure to radiation in the form of xrays is a largely preventable morbidity. References: 1) Heyworth J. Ottawa ankle rules for the injured ankle. BMJ 2003; 326: 404-6. 2) Bachmann LM et al. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ 2003; 326: 417-9. 3) Implementation of the Ottawa Ankle Rules. JAMA 1994; 271: 827-32. Dr Katrina Gardiner
Competing interests: None declared |
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Joanne M Shaw, Director, Medicines Partnership RPSGB, 1 Lambeth High St, London EC1 7JN
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Do you suppose that Mr Willoughby applied an early version of the Ottawa ankle rules when he so confidently diagnosed Marianne Dashwood's injured ankle as unbroken in Austen's 'Sense and Sensibility?' Competing interests: None declared |
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Manoj Srivastava, SpR Radiology, N.Staffs Healthcare NHs Trust St4 6QG
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Dear Sir, I am a specailist Registrar in Radiology and was very interested in this particular article as we have lot of A&E packets with radiographs of the ankle which are certainly not required. Interestingly I picked up an editorial mistake on the pictorial representation of the Ottawa rule. The Photo on the right side shows the view of the medial malleolus but it is written lateral malleolus. This could be confusing for someone who is reading about it first time as to whether we have to consider tenderness on the medial malleolus or not while sending for the x- ray. I hope this mistake is rectified by an erratum in the next issue and care be taken for such mistake not to be repeated in future . This is a very reputable journal and high standards should be maintained while editing. thanks manoj
Competing interests: None declared |
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