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Ottawa Ankle Rules And Theoretical Perceptions


Task: Give an in depth description of the Ottawa Ankle Rules for the efficient regulation to control X-Ray Imaging, and verify its validity.


Being a medical commissioner interested in clinical research, I am interested in conducting research and auditing the Ottawa ankle rules. I need to find out its effectiveness in ruling out the requirement of conducting an x-ray examination. In order to examine a broken limb or any other broken part of the body, x-ray has an important role to play during a medical examination of a person suffering from an injury. The work that I perform involves conducting a lot of x-ray examinations on patients complaining of broken bones, and therefore, it is necessary for me to have knowledge about the rules and regulations affecting examinations through x-rays. So studying about Ottawa ankle rules is an important part of my practice and day to day activities.

Ottawa ankle rules

In simple terms, the Ottawa ankle rules were made to help medical officers and physicians to take a call and decide the requirement of an x-ray examination on a person complaining of injured ankles or injury at his midfoot (Stiell, 1994). The present research is being carried out to verify the previous research results on Ottawa ankle rules. It will also verify the existence of any healthcare, social or political issue behind the conduction of the research and the examination process. There have been researches and audits on the effect of x-rays on children.

The adherence to Ottawa ankle rules should be done while conducting an x-ray on adults, but the audits conducted on children showed that an x-ray is not required for a patient complaining of broken bones or suffering from a midfoot injury. When it comes to examining a broken limb, an audit report claimed that it is unnecessary to conduct an x-ray as there are other clinical instruments that can determine whether the limb is broken or it's just an inflammation of the part. An effective physical examination of the injured part of the body can verify whether there is a fracture or just a sprain. By studying these researches and audit reports made me inquisitive to learn about all the rules mentioned in the Ottawa ankle rules and regulations before conducting an x-ray. There is a clear deduction from some of the audits that these rules are applicable not only to adults but also on children (Bachmann, 2003).

The children who were participants in the audit report complained of broken limb and an injured midfoot. They were thoroughly examined, which provided a clear picture of their injuries without putting them under the x-ray machine. Rays coming out of the x-ray machine is not healthy, making it an appropriate research topic. While conducting an x-ray examination, being careful and accurate is an essential element that the person conducting the test should keep in his mind. Accuracy and surety of the examination is a must in order to avoid multiple examinations. As per the Ottawa ankle rules, it is not important to conduct an x-ray, but it may be the last resort to understand the exact problem. Health practitioners rely on examinations through the x-ray machine as it eliminates the occurrence of any human error and increases the chances of accuracy.

Search strategy
It is not necessary to conduct an audit by involving participants, and secondary research can be applied to verify the application of Ottawa ankle rules. The audit can be done through electronic media, journal articles, information present on governmental websites, opinions of renowned medical officers on this topic, etc. The research question for the paper would be examination and applicability of Ottawa ankle rules. The opinions of colleagues and physicians can be considered to develop a case and understand the Ottawa ankle rules (Stiell et al., 1995). Several types of research conducted on the rules were done to understand the real need behind conducting an x-ray, understand its necessity for injury verification, and bring out the real truth behind the Ottawa ankle rules' formation. The audit was also conducted to verify any such case wherein the rules were applied, leading to the injury's healing without getting confirmation through x-ray examination. People who have worked extensively in this field and also firms providing radiology services were considered during the research process.

The search would include information from different texts, charts and graphics. The primary data collected during the research process would be depicted through charts. The audit would be conducted with the help of primary and secondary sources. It was easier to take help from secondary sources due to its availability. Internet is full of such audits and articles wherein the Ottawa ankle rules have been discussed (Plint et al., 1999). The Internet can also provide details about different opinions from renowned persons of this field on the topic. The secondary sources would back the opinion being put forward and also explain what other auditors think about the topic. The primary sources will include the data collected by me in person.

The outcome of the Ottawa ankle rules
The credible sources and previous studies conducted on Ottawa ankle rules were considered due to its authenticity and accurate results. I was very sure that conducting the same study would generate the same results, so it's better to use the original sources' inputs. Some of the significant audits conducted in the secondary resources would be discussed in this section. A research was conducted by researcher consisting of 68 patients aged between 2-8 years. All the participants were x-rayed in order to verify whether it was necessary to apply the Ottawa ankle rules. The search included every type of fracture accept open fractures and patients having sensitivity issues. The search result showed 100 per cent sensitivity and 32 per cent specificity. The weakness of the audit was the sample size which was small (Auleley, 1997).

Another research conducted on the Ottawa ankle rules involved 318 participants, including adults and children. There were 37 children in the research process. The research was conducted to reduce the number of x-rays conducted once the family doctor was made aware of the rules and regulations. The study included fractures that were less than three millimetres, and it excluded injuries that were reported after a week by the patients or were open injuries. The audit result showed 100 per cent sensitivity and 28% per cent specificity. The weakness of the research was the age of the children participating in the research. There were no children aged 9 years and below (CLARK and TANNER, 2003).

Ottawa ankle rules

The third research conducted on the importance of x-ray examination and adhering to the Ottawa ankle rules involved 761 participants. These participants were from the age group of 1-15. The research's main reason was to find out about any such monitoring or controlling group that was in existence before the framing of the Ottawa ankle rules. The patients in the research used to walk on their legs before they were injured. The patients who were excluded from the research were the ones who were injured in the month of August. It was done to give some quality time to the staff to understand and practice the Ottawa ankle rules. The result of the research showed 98 per cent sensitivity and 46 per cent specificity. The weakness of the research was the inclusion of midfoot injuries and a limited number of children.

Analysis of the data
The data was analyzed through the meta-analysis process basis proportion of weight and variances. The percentage of sensitivity and specificity was derived through a pooled estimate from all previous research without focusing on individual estimates mentioned in each paper. To maintain the accuracy of the findings, the pooled estimate was applied. The statistical calculations were done through the Meta library. The average sensitivity figure was 97 per cent, and specificity was 29 per cent, considering all the studies used in this Ottawa ankle rules audit paper (Cameroon and Naylor, 1999). The figures are proof of the accuracy, and the findings presented.

The primary and secondary sources cleared a point that the delicate area over the ankle's lateral malleoli is unable to bear the pressure that causes pain. The delicacy over the posterior malleoli, which connects the distal tibia and fibula also causes pain while exerting pain on the area. If such symptoms are present in a patient, it is necessary to conduct an x-ray examination. The audit has clearly pointed out that the application of Ottawa ankle rules is valid for patients being screened for injured ankles or injury in the midfoot. It was also recognized through the audit report that the Ottawa ankle rules should not be applied to the children as they are unable to define their pain. There will always be tenderness present in small children, and in order to apply the Ottawa ankle rules, the child must be walking properly before being injured. The application of Ottawa knee rules on children would be the best alternative to radiography for detecting their injuries (Runyon, 2009).

Evaluating the studies and the research design
A number of papers have been written on the topic of Ottawa ankle rules, and in a similar manner, a number of researchers have conducted different analysis on the topic. The studies conducted used different methodologies consisting of qualitative and quantitative methods. Qualitative research considers data that is already present in hand and studied by the researcher to analyze human behaviour and understand the logic behind conducting the study. The samples used in qualitative research are small so that the analysis can be easily conducted and there is no difficulty during the sampling process. On the other hand, quantitative research does not involve detailed analysis, and the interpretation of the data is simple. The selected sample is bigger, and the aim of the researcher is to provide a detailed, in-depth analysis. The researcher uses interviews and observes the participants while conducting quantitative research (Libetta, Burke, Brennan and Yassa, 1999).

Qualitative research involves a large time frame as it interprets larger data in a detailed manner. Usually, qualitative research involves interpreting texts. Quantitative research involves an analysis of figures and numerical data, and it is not in a detailed manner. The objective behind quantitative research is to gather data, group them together, count them and then make a statistical model. The researcher's role in quantitative research is to explain his observations without going into the details like why what, how, etc. The researcher is aware of the topic he is researching and uses tools like surveys, questionnaires, etc.

There is a scope of objectivity involved in quantitative research as the researcher measures and interprets data or questionnaires. The people who conducted research on Ottawa ankle rules used both quantitative and qualitative analysis. It can be said that quantitative data is used during the initial stages of the research work, and the qualitative data is used at the later stages of the work.

One of the appropriate researches in this field was conducted by Dr Meyer, Canty and Nelson of Children’s Mercy Clinic and Treatment Centre. They undertook twenty-seven studies, including six conducted on children and considered eight previous studies and two published papers. They tried to use a mixed-method but relied more on the quantitative method as they were well aware of the rules' intention. The doctors did not concentrate on one study; rather, they followed different studies to ascertain that they were on the right track. If the result of their research had similarity with other previous research findings, it would give a clear indication of the research's credibility. They applied quantitative research by studying different papers and came at a conclusion (A.C.M. Pijnenburg et al., 2002).

The analysis by Boutis was the first researched article considered by them. The Boutis had conducted an analysis considering 607 patients aged 3-16. The research was conducted in two separate emergency wards consisting of other researchers and people from the disaster management team. The patients under consideration were already updated about the benefits of Ottawa ankle rules. The result of the research showed 100 per cent sensitivity and 13 per cent specificity. The research was carried out on ankle injury patients, and patients complaining of muscle disease who were in the age range of 16 were excluded. The research excluded those patients who had surgery in the past or met with an accident, thereby, affecting their ankle. The patients were divided into high and low-risk categories. The patients who were kept in low risks complained of tender, and isolated pain and the rest had severe pain. Through the study, the reduced usage of radiographic was examined (Mann, Grant, Guly and Hughes, 1998).

The analysis by Chande consisting of 68 patients aged 2-18 was the next research work considered by the doctors. The patients were examined through x-ray machines without informing them about the existence of Ottawa ankle rules which discourages the same. The result of the research showed 100 per cent sensitivity and 32 per cent specificity. The researcher had considered all types of fractures, excluding the wide opened ones, and there was no follow up.

Ottawa ankle rules

The next study considered by them was the research work conducted by Clarke Garcia. The research was conducted on 11 patients aged 3-18. Nurses and resident doctors conducted the analysis. Some of the patients were examined through the x-ray, and some were diagnosed basis the Ottawa ankle rules. It was found that one of them is necessary to be used during fracture examination. The result of the research showed 96 per cent sensitivity and 6 per cent specificity. Patients included in the study had 2-5 fractures, and ones excluded suffered from bony diseases or had a single fracture. The patients were called back after a month, and it was found that no patient complained of any complications (Stiell, 1994).

The Karpas research work consisted of 190 patients aged 5-19. The researchers applied the Ottawa ankle rules after two work out sessions. The result of the research showed 96 per cent sensitivity and 27 per cent specificity. The patients who were included in the study were the ones who complained about the injury within 48 hrs. and the ones which were excluded had multiple and open fractures. The result of the survey was not good (Libetta, Burke, Brennan and Yassa, 1999).

McBride conducted the other research on 37 patients between the age group of 9-16. The study's motive was to evaluate the reduction of x-ray examination with the application of Ottawa ankle rules. The result of the research showed 100 per cent sensitivity and 28 per cent specificity. The survey included pregnant ladies, people with open fractures, and those who came up after weeks complaining about the injury and pain (Runyon, 2009).

But Dr Meyer, Canty and Nelson used quantitative analysis to read through the data, work out the calculations, and conclude. Analyzing all the research work, the average sensitivity figure was 97 per cent, and specificity was 29 per cent. There was a 12 per cent prevalence rate on all types of fractures. There were mixed results from most of the research work conducted by previous researchers. It was also recognized that the decision to apply Ottawa ankle rules is a prerogative of the doctors and the institutions with which they are associated with. Usage of rules depends on the type of fracture and how the research was conducted, each question was answered, and there was clarity in understanding the rules (Bachmann, 2003).

The researchers used the methodology that best suited their research work and covered all the concepts related to the application of Ottawa ankle rules. The sole purpose behind all the research work was to find out the reality behind doing away with x-ray examinations. On the basis of the research work, it was clear that not all injuries require an x-ray examination, but some cannot be ruled out without conducting the examination. According to them, the Ottawa ankle rules were necessary when no x-ray examination was required. But the application of the rules depends upon a number of factors including, the type of injury, and the person who is under pain or the doctor examining the fracture or the rules and whether the nurse associated with the institution is aware of its rules and regulations related to the Ottawa ankle rules. It was also necessary to know the background of the children complaining of any injury (Stiell et al., 1995).

Some of the researchers should have applied an alternative method while conducting the research work like considering primary data or should have used a qualitative method or should have personally verified the Ottawa knee rules. They could have evaluated a set of patients with similar fractures, some could have undergone x-ray examination, and some could have thoroughly examined. At the end of the day, the result of both the procedure could easily reveal the difference. By doing this, the researcher could have a proper answer to the question, whether the x-ray examination is necessary for a person complaining of pain fracture. The approach would have been a direct one to determine the applicability of the Ottawa ankle rules (Plint et al., 1999).

As mentioned in the above approach, a medical officer could have easily understood whether a medication could be provided to an injured person before the examination or after the examination. Usage of mixed methodology was also another criterion to determine the relevancy of the Ottawa ankle rules. The mixed methodology involves qualitative and quantitative data in a single research work like, examining the patients as well as conducting interviews of those patients subjected to the Ottawa knee rules. Patients who were subjected to the rules could have verified its outcome and put the researcher in a better place to understand the results and find out the similarities and differences (Auleley, 1997).

Data collection techniques
There were different data collection techniques applied by the researchers. Texts and reports submitted by other researchers in the same field and on the same topic were considered. Some of the researchers used some samples to verify the applicability of the Ottawa ankle rules; the same samples were reconsidered in different other research works. The data were reanalyzed in different research works due to easy availability and cheap nature. Conducting a fresh study by considering a new set of participants would have been too expensive as the researcher had to evaluate a set of patients without taking any fee from them and another set would have been checked through free x-ray examinations (CLARK and TANNER, 2003).

It would have also consumed a lot of time considering the number of participants to be analyzed and the duration of the observation. Considering the credible data used by other researchers, it was appropriate to use the same data. They used surveys and interviews to gather the data from the patients subjected to the examination and those who were not recommended for any x-ray examination. There was a direct communication from the patients, and hence it the accuracy and truthfulness of the results was high (Libetta, Burke, Brennan and Yassa, 1999).

After looking at the previous research conducted on Ottawa ankle rules, I am sure that I would have used a different methodology and asked different questions. In my view, the primary question would be to inquire what the participants know about the Ottawa ankle rules. The answer would help in judging and understanding the knowledge of the participants on the topic. The next question would be that drafting the rules and answer to this would help eradicate the misunderstandings prevailing in the participant's minds. An answer to the question would help in a better application of the rules by medical practitioners. The next question would be the situations wherein this rule could be applied as people have raised a question on its application in the past. The answer to the question would determine the exact situations where the rule can be applied and resolve all the questions raised against it.

My research's main concern would have been to identify the effect of the rules on x-ray examinations, why it states to avoid the examination, what effect do x-rays have on the patients, and under what situations the rules should be applied. I would find out if these rules were applicable in the past and if yes, then what were the results. Implementing the Ottawa ankle rules means that there is no need to conduct an x-ray examination on a patient having a fracture, and the problem can be addressed through evaluation and diagnosis of the injury. It would be an added advantage if I could come across any such case wherein the rules were applied, and it turned out to be a correct decision. Knowing about the treatment procedure after the application of the rules would also be of great help in determining the future application of the rules.

I would have applied both qualitative and quantitative analysis methods to answer my questions on the applicability of the Ottawa ankle rules. These methods would have generated extended explanations about the rules and resolved my problems. The opinion of different researchers would have helped me to understand what they felt about the rules. Knowing the positive and negative sides of the topic would have helped me make my own decisions. I would have understood how the data needs to be collected and what would be the appropriate number of patients to be considered for the study. Personal interaction with the patients would help in generating valid conclusions. By applying the mixed methodology, I would be able to generate accurate results and find out the need to follow Ottawa ankle rules and the exact reason behind doing away of x-ray examinations.

A.C.M. Pijnenburg., Afina S. Glas., Marnix A.J. {de Roos}., Kjell Bogaard., Jeroen G. Lijmer., Patrick M.M. Bossuyt., Rudolf M.J.M. Butzelaar and Johannes N. Keeman. 2002. Radiography in ankle injuries: The Ottawa Ankle Rules versus local diagnostic decision rules. Annals of Emergency Medicine, 39(6), pp. 599 – 604.

Auleley, G., 1997. Implementation of the Ottawa Ankle Rules in India. JAMA, 277(24), p.1935.

Bachmann, L., 2003. Accuracy of Ottawa ankle rules to include fractures of the ankle and mid-foot: a systematic review. BMJ, 326(7386), pp.417-417.

Cameroon, C and Naylor, C.D. 1999. No impact from active dissemination of the Ottawa Ankle Rules: further evidence of the need for local implementation of practice guidelines. CMAJ, 160 (8) 1165-1168

CLARK, K. and TANNER, S., 2003. Use of the Ottawa Ankle Rules in children. Pediatric Emergency Care, 19(2), pp.73-78.

Libetta, C., Burke, D., Brennan, P and Yassa, J. 1999. Validation of the Ottawa ankle rules in Adults. British Association for Accident and Emergency Medicine, 16(5), pp. 342—344.

Mann, C. J., Grant, I., Guly, H and Hughes, P. 1998. Use of the Ottawa ankle rules by nurse practitioners. British Association for Accident and Emergency Medicine, 15(5), pp. 315—316.

Plint, A., Bulloch, B., Osmond, M., Stiell, I., Dunlap, H., Reed, M., Tenenbein, M. and Klassen, T., 1999. Validation of the Ottawa Ankle Rules in Adults with Ankle Injuries. Academic Emergency Medicine, 6(10), pp.1005-1009.

Runyon, M., 2009. Can We Safely Apply the Ottawa Ankle Rules to All?. Academic Emergency Medicine, 16(4), pp.352-354.

Stiell, I., 1994. Implementation of the Ottawa Ankle Rules. JAMA: The Journal of the American Medical Association, 271(11), p.827.

Stiell, I., Wells, G., Laupacis, A., Brison, R., Verbeek, R., Vandemheen, K. and Naylor, C., 1995. Multicentre trial to introduce the Ottawa ankle rules for the use of radiography in acute ankle injuries. BMJ, 311(7005), pp.594-597.


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