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Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review

BMJ 2003; 326 doi: (Published 22 February 2003) Cite this as: BMJ 2003;326:417

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  1. Lucas M Bachmann, senior research fellow (lucas.bachmann{at},
  2. Esther Kolb, research fellowa,
  3. Michael T Koller, research fellowa,
  4. Johann Steurer, professora,
  5. Gerben ter Riet, clinical epidemiologistb
  1. a Horten Centre, Zurich University, Postfach Nord, CH-8091 Zurich, Switzerland
  2. b Academic Medical Center, Department of General Practice, Meibergdreef 15, 1105 AZ Amsterdam, Netherlands
  1. Correspondence to: L M Bachmann
  • Accepted 2 December 2002


Objective: To summarise the evidence on accuracy of the Ottawa ankle rules, a decision aid for excluding fractures of the ankle and mid-foot.

Design: Systematic review.

Data sources: Electronic databases, reference lists of included studies, and experts.

Review methods: Data were extracted on the study population, the type of Ottawa ankle rules used, and methods. Sensitivities, but not specificities, were pooled using the bootstrap after inspection of the receiver operating characteristics plot. Negative likelihood ratios were pooled for several subgroups, correcting for four main methodological threats to validity.

Results: 32 studies met the inclusion criteria and 27 studies reporting on 15 581 patients were used for meta-analysis. The pooled negative likelihood ratios for the ankle and mid-foot were 0.08 (95% confidence interval 0.03 to 0.18) and 0.08 (0.03 to 0.20), respectively. The pooled negative likelihood ratio for both regions in children was 0.07 (0.03 to 0.18). Applying these ratios to a 15% prevalence of fracture gave a less than 1.4% probability of actual fracture in these subgroups.

Conclusion: Evidence supports the Ottawa ankle rules as an accurate instrument for excluding fractures of the ankle and mid-foot. The instrument has a sensitivity of almost 100% and a modest specificity, and its use should reduce the number of unnecessary radiographs by 30-40%.

What is already known on this topic

What is already known on this topic Although most patients with ankle sprains who present to emergency departments undergo radiography, less than 15% have a fracture

The Ottawa ankle rules is a clinical decision aid designed to avoid unnecessary radiography

What this paper adds

What this paper adds The Ottawa ankle rules is highly accurate at excluding ankle fractures after sprain injury


  • Editorial by Heyworth

  • Funding None.

  • Competing interests None declared.

  • Embedded Image Examples of the search strategy and details of the included studies appear on

  • Accepted 2 December 2002
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