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Rapid Responses: Rapid Responses published:
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Is the Ottawa ankle rules diagram incorrect?
- Edward Penman (21 February 2003)
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Re: Is the Ottawa ankle rules diagram incorrect?
- George R. Eichler, MD. (23 February 2003)
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Ottawa rules
- Dishan Singh (24 February 2003)
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Are Medicolegal aspect of ankle injuries more important than Ottawa ankle rules?
- Sanjay Sinha, Mike Thilagarajah, SpR (24 February 2003)
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Shurely some mistake?
- Jonathan M Jones (27 February 2003)
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When is a sign not a sign?
- Adrian Fogarty (3 March 2003)
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Diagram Error
- David Hillebrandt (12 March 2003)
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Is the Ottawa Rules bad English?
- David R Hadden (16 April 2003)
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Edward Penman, General Practitioner SY4 3PN
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I suspect the diagram showing the medial ankle view should indicate "B Posterior edge or tip of MEDIAL malleolus", not "B Posterior edge or tip of LATERAL malleolus" as indicated (my emphasis). Competing interests: None declared |
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George R. Eichler, MD., Retired Scottsdale,AZ 85259-2812
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He's right! Competing interests: None declared |
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Dishan Singh, Consultant Orthopaedic Surgeon Royal National Orthopaedic Hospital AL5 4QB
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In his editorial supporting the use of the Ottawa rules, Heyworth1 suggests that injured ankles should be separated into 2 groups: those with ‘simple ligamentous injury to soft tissue or a small avulsion fracture’ and those with ‘more serious fractures requiring immobilisation’. The latter statement unfortunately reflects the casual treatment given to patients with ligamentous ankle sprains in British A&E departments. Up to a third of patients with an ankle sprain may go on to develop disabling problems such as recurrent instability or chronic pain. Doctors and nurses should be aware that the Ottawa rules are simply guidelines to decide on which group of patients should have radiographs. Patients with severe ankle sprains (e.g. those who cannot weight bear) need more than a tubigrip and advice on ice and elevation – they also need protection in an ankle stirrup or cast, and they should be referred for physiotherapy for stretching, strengthening, balance and return to sports exercises. A more thorough approach to patients with severe ankle sprains should prevent long-term problems – this requires a culture change in British A&E departments to recognise that ligament sprains can be more disabling injuries than fractures. The decreased popularity of the Ottawa rules in the United States and mainland Europe could also possibly be explained by the use of stress radiographs etc in their patients with ankle sprains. Dishan Singh
1 Heyworth J. Ottawa rules for the injured ankle. BMJ 2003; 326:405- 6. (22 February) Competing interests: None declared |
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Sanjay Sinha, SHO ,Deptt.of Orthopaedics Kent&Canterbury Hospital,Kent ,CT1 3NG, Mike Thilagarajah, SpR
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Editor We read this excellent meta-analysis with great interest. When originally published, the Ottawa ankle rule was said to have 100% sensitivity & 40% specificity for detecting ankle fractures.1Therefore, all patients who truly had a fracture would still get a radiograph, but a good many who did not have fractures would be weeded out -36% by the investigators estimate1.However subsequent independent studies2 3,4reported lower sensitivity (89% to 95%) and specificity (6%-26%) than originally thought. A sensitivity of almost 100% was confirmed in this paper by Bechmann et al. and a possible overall 30-40% reduction in the number of x-rays were also estimated.Stiell’s et al1 original paper was first published in 1992 and since then these rules has been studied repeatedly and published in over hundred well established,peer reviewed journals. Despite being very popular topic for the journals, the Ottawa ankle rules are still not very popular in UK and in many other countries. Out of 50 A&E deptts. in Southeast of England,only 15 were following Ottawa rules in 19975.We fully agree with the author that despite being a well recognised decision making tool, its use and change of clinical implementation are limited. Failure to diagnose ankle fractures can have serious medicolegal consequences and we believe that perhaps,this is the main cause of poor clinical implementation of Ottawa ankle rules in UK hospitals. Apart from this, we have certain reservations against the ankle rules. 1.The most common complain of the pt. with ankle injury is the inability to bear wt. with vague tenderness around ankle. Following the Ottawa rules a significant proportions of pts will qualify for the x-ray. 2.Its difficult to follow the rules if the pt. can’t communicate properly owing to altered mental status, alcohol intoxications or other problems. 3.In grossly swollen ankle, its difficult to appreciate the bony tenderness. 4.Talar fractures is difficult to exclude by rule. 5.Many a times the patient preferences influence the test ordering. We believe that its also important to educate the pt. about the Ottawa ankle rules by providing them with booklet/leaflets. References 1.Steill IG, Greenberg GH,McKnight RD et al.A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emergency Med 1992;21(4):384-90 2.Auleley GR, Kerboull L, Durieux P, Courpied JP, Ravaud P.Validation of the Ottawa rules in France: A study in the surgical emergency departments of a teaching hospital.AnnEmergencyMed1998;32:14–18. 3.ChandraA; SchafmayerA .Dignostic value of a clinical test for exclusion of fractures after acute ankle sprains. A prospective study for evaluating the Ottowa Ankle Rules in Germany. Unfallchirurg 2001;104(7):617-21 4. Glas AS; Pijnenburg BA; Lijmer JG; Bogaard K et al. Comparison of diagnostic decision rules and structured data collection in assessment of acute ankle injury. CMAJ 2002 ;166(6):727-33 5.KeoghSP,Shafi A et al.Comparison of Ottawa ankle rules and current local guidelines for use of radiography in acute ankle injuries. J R Coll Surg Edinb 1998;43:341-343 Competing interests: None declared |
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Jonathan M Jones, SpR in A&E Medicine St James's University Hospital, Leeds LS9 7TF
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Am I the only one to notice the error in Figure 1 accompanying this article (right hand text should read foot xray series rather than ankle xray series) or just the only one sad enough to bother sending a response to point it out? Competing interests: None declared |
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Adrian Fogarty, Consultant in Accident & Emergency Medicine Royal Free Hospital, London
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The authors of this paper, when considering the wide variation in specificity, cite "subtlety of palpation technique" as a possible contributing factor. They are, of course, quite correct. If you palpate an ankle, or anything else for that matter, and ask the patient "is that sore?", you will invariably get a much higher positive response rate than if you palpate silently and simply observe for a "non-verbal" response. The moment you rely on a patient to "give you" your clinical sign, then you're no longer dealing with an objective sign, such as an enlarged liver or a heart murmur, but rather you're dealing with an extension of symptomatology, with all the subjectivity that this entails. It's no wonder then that studies which rely on the estimation of bony tenderness are frequently associated with wide variations in specificity. Competing interests: None declared |
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David Hillebrandt, GP HolsworthyMedical Centre,Devon, EX22 6GH
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Compare with exactly the same diagram in BMJ Vol 311 pp594, 2/9/1995 for correction. Competing interests: None declared |
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David R Hadden, Hon Consultant Physician Royal Victoria Hospital, Belfast BT12 6BA, UK.
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Is the Ottawa Rules bad English? Editor The paper entitled “Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review”, by Bachmann and colleagues from Zurich and Amsterdam is an excellent assessment of the evidence in regard to this sensible approach to ordering ankle x-rays in Casualty departments. But the insistence on considering the rules to be singular is not supported by the only statement of these rules in Fig 1, which clearly identifies two major rules (regarding pain in either the malleolar zone or the midfoot zone), each of which has three further sub-sections. This is an example of a “singular plurality” – but in normal English the subject of a sentence should agree with the verb (1). We are accustomed to the Queensberry Rules in boxing, or the McNaughton Rules in law. “Too much importance is attached to grammarians’ fetishes, and too little to choosing the right words” (2), but illiteracy is another thing, and Gowers adds “we cannot have grammar jettisoned altogether: that would mean chaos”. What price the readability of British or American medical prose? DAVID HADDEN
1. Albert T. Medical Journalism. The writers guide. Oxford; Radcliffe Medical Press 1992: 62. 2. Gowers E. The Complete Plain Words. 3rd ed: revised by Greenbawm S and Whitcut J: Her Majesty’s Stationery Office: 98. 3. Weeks WB, Wallace AE, Readability of British and American medical prose at the start of the 21st century. BMJ 2002: 325: 1451- 2. Competing interests: None declared |
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