Diagnostic accuracy of clinical decision rules to exclude fractures in acute ankle injuries: systematic review and meta-analysis

Ingrid Barelds, Wim P Krijnen, Johannes P van de Leur, Cees P van der Schans, Robert J Goddard

Research output: Contribution to journalReview articlepeer-review


BACKGROUND: Ankle decision rules are developed to expedite patient care and reduce the number of radiographs of the ankle and foot. Currently, only three systematic reviews have been conducted on the accuracy of the Ottawa Ankle and Foot Rules (OAFR) in adults and children. However, no systematic review has been performed to determine the most accurate ankle decision rule.

OBJECTIVES: The purpose of this study is to examine which clinical decision rules are the most accurate for excluding ankle fracture after acute ankle trauma.

METHODS: A systematic search was conducted in the databases PubMed, CINAHL, PEDro, ScienceDirect, and EMBASE. The sensitivity, specificity, likelihood ratios, and diagnostic odds ratio of the included studies were calculated. A meta-analysis was conducted if the accuracy of a decision rule was available from at least three different experimental studies.

RESULTS: Eighteen studies satisfied the inclusion criteria. These included six ankle decision rules, specifically, the Ottawa Ankle Rules, Tuning Fork Test, Low Risk Ankle Rule, Malleolar and Midfoot Zone Algorithms, and the Bernese Ankle Rules. Meta-analysis of the Ottawa Ankle Rules (OAR), OAFR, Bernese Ankle Rules, and the Malleolar Zone Algorithm resulted in a negative likelihood ratio of 0.12, 0.14, 0.39, and 0.23, respectively.

CONCLUSION: The OAR and OAFR are the most accurate decision rules for excluding fractures in the event of an acute ankle injury.

Original languageEnglish
Pages (from-to)353-368
JournalThe Journal of Emergency Medicine
Issue number3
Publication statusPublished - 1 Sept 2017


  • ankle fractures
  • ankle injuries
  • decision support techniques
  • severity of illness index


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