To validate and refine previously derived clinical decision rules that aid the efficient use of radiography in acute ankle injuries.

Survey prospectively administered in two stages: validation and refinement of the original rules (first stage) and validation of the refined rules (second stage).

Emergency departments of two university hospitals.

Convenience sample of adults with acute ankle injuries: 1032 of 1130 eligible patients in the first stage and 453 of 530 eligible patients in the second stage.

Attending emergency physicians assessed each patient for standardized clinical variables and classified the need for radiography according to the original (first stage) and the refined (second stage) decision rules. The decision rules were assessed for their ability to correctly identify the criterion standard of fractures on ankle and foot radiographic series. The original decision rules were refined by univariate and recursive partitioning analyses.

In the first stage, the original decision rules were found to have sensitivities of 1.0 (95% confidence interval [CI], 0.97 to 1.0) for detecting 121 maleolar zone fractures, and 0.98 (95% CI, 0.88 to 1.0) for detecting 49 midfoot zone fractures. For interpretation of the rules in 116 patients, kappa values were 0.56 for the ankle series rule and 0.69 for the foot series rule. Recursive partitioning of 20 predictor variables yielded refined decision rules for ankle and foot radiographic series. In the second stage, the refined rules proved to have sensitivities of 1.0 (95% CI, 0.93 to 1.0) for 50 malleolar zone fractures, and 1.0 (95% CI, 0.83 to 1.0) for 19 midfoot zone fractures. The potential reduction in radiography is estimated to be 34% for the ankle series and 30% for the foot series. The probability of fracture, if the corresponding decision rule were "negative," is estimated to be 0% (95% CI, 0% to 0.8%) in the ankle series, and 0% (95% CI, 0% to 0.4%) in the foot series.

Refinement and validation have shown the Ottawa ankle rules to be 100% sensitive for fractures, to be reliable, and to have the potential to allow physicians to safely reduce the number of radiographs ordered in patients with ankle injuries by one third. Field trials will assess the feasibility of implementing these rules into clinical practice.

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