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Ottawa Knee Rules

Ottawa Knee Rules. Santosh Davies University of Pennsylvania Emergency Department 10/01/2002. Introduction. Knee Injury common complaint in ED 1 million acute knee injury visits a year Most injuries are ligamentous Not picked up on routine radiographs Less than 15% of radiographs pick up

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Ottawa Knee Rules

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  1. Ottawa Knee Rules Santosh Davies University of Pennsylvania Emergency Department 10/01/2002

  2. Introduction • Knee Injury common complaint in ED • 1 million acute knee injury visits a year • Most injuries are ligamentous • Not picked up on routine radiographs • Less than 15% of radiographs pick up • Use of decision rule may help decrease ED wait times and decrease cost

  3. Ottawa Knee Rules

  4. Ottawa Knee Rules • Age 55 or older

  5. Ottawa Knee Rules • Age 55 or older • Tenderness at head of fibula

  6. Ottawa Knee Rules • Age 55 or older • Tenderness at head of fibula • Isolated tenderness at patella

  7. Ottawa Knee Rules • Age 55 or older • Tenderness at head of fibula • Isolated tenderness at patella • Inability to flex to 90 degrees

  8. Ottawa Knee Rules • Age 55 or older • Tenderness at head of fibula • Isolated tenderness at patella • Inability to flex to 90 degrees • Inability to complete 4 steps immediately • and in the emergency department

  9. Included patients • > 18 years of age • Acute blunt “knee” injury • Patella, head and neck of fibula, proximal 8 cm of tibia and distal 8 of femur

  10. Exclusion Criteria • Pregnant • Isolated skin injury • Outside hospital with radiographs • Injury 1 week prior • Return assessment • Altered sensorium • Paraplegic • Multiple Injuries

  11. Method • 33 physicians were trained • Goniometer was used • Radiographs were read by blinded (blind) radiologists • 23 separate variables analyzed • Those variables with good interobserver variability and negatively correlated with fracture were used for the decision rule

  12. Comments • Only 69% of the population was radiographed • Phone follow up provided with rest • Clinically insignificant fracture was defined as an avulsion fragment < 5mm in size NOT associated with complete tendon or ligament disruption

  13. Statistical analysis

  14. Decision Rule • Sensitivity of 1.0(95% CI, .95 to 1.0) • Specificity of .54(95% CI, .51 to .57) • Use of the rule allowed for a theoretical 28% reduction of xray use

  15. Validation • Multiple EDs in Spain • 1522 patients studied (65% of Knee Injured • Everyone was radiographed • Read by ED or traumatologist

  16. Validation

  17. Validation • Sensitivity was 1.0 (95% CI 0.96 to 1.0) • Specificity was 0.52 (95% CI 0.49 to 0.55) • Negative predictive value was 1.0 (95% CI 0.99 to 1.0) • Positive predictive value was 0.11 (95% CI 0.09 to 0.14).

  18. Discussion • Simple rules with good interobserver correlation • 100% sensitive • Cost reduction ( 31-34 dollars per pt) • Prospectively validated with similar results

  19. Discussion • Not everyone was radiographed • Low specificity

  20. Bibliography • Nichol G, Stiell IG, Wells GA, et al. An economic analysis of the OttawaKneeRule. Ann Emerg Med. 1999;34:438-447. • Stiell IG, Wells GA. Methodologic standards for the development of clinical decision rules in emergency medicine. Ann Emerg Med. 1999;33:437-447 • Stiell IG, Greenberg GH, Wells GA, et al. Derivation of a decision rule for the use of radiography in acute knee injuries. Ann Emerg Med. 1995;26:405-412

  21. Do we use it

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