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RUNNING HEADING: OTTAWA KNEE RULES

Ottawa Knee Rules- Identifying Pediatric Fractures

Critical Appraisal Topic

Britta Thiesse BSN FNP-s

University of Mary

Nursing 568

Clinical Scenario

A 9-year-old male presented to the clinic accompanied by his mother. He had collided with some one at recess yesterday; the pediatrician did not find a fracture. Returned to clinic for ongoing pain and tenderness.

Clinical Question

Are the Ottawa knee rules also useful for identifying fractures in the pediatric population?

Definition

The rules are defined to help clinicians determine who needs an x-ray with a complaint of an acute knee injury. The rules according to Seidel et al. (2011) are any of the following:

  • Greater than 55 years of age
  • Complaints of tenderness at the head of the fibula
  • Tenderness of the patella
  • Unable to flex the knee to 90 degrees

Articles:

Bachmann,L.M., Haberzeth,S., Steurer,J., & G,R.T. (2004). The accuracy of the Ottawa knee rule to rule out knee fractures: a systematic review.Annals of Medicine, (140), 121-124.

Bulloch,B., Neto,G., Plint,A., Lim,R., Reed,M., Nijssen-Jordan,C., Klassen,T.P. (2003). Validation of the Ottawa Knee Rule in Children.Evidence Based Nursing, (42), 48-55.

Summary of Key evidence:

Article 1

In this article Bulloch et al. (2003) review how accurate the Ottawa knee rules (OKR) are at identifying fractures in the pediatric population. The completed a blind comparison of the OKR versus the x-rays. The setting was five urban pediatric Emergency Departments in Canada, and adequately trained physicians completed the assessments. Whether x-rays were completed or not were based on the physician’s choice. The age range studied was 2-16 years of age. The results of the study found that OKR had a 100% sensitivity in the identified age ranges, but had variable specificity, the highest was in the age range of 2-5 years (Bulloch et al., 2003).

Article 2

The second article is not pediatric focused, but is a systematic review to identify the sensitivity and specificity of the OKR based on the review studies. Bachmann et al. (2004) determined an inclusion criterion was an article that provided information regarding a confirmed/no confirmed fracture based on x-rays or from follow up information. The data was obtained from online databases such as Medline and Cochrane library. The results from the study showed that the OKR accurately help diagnose/rule out a fracture in an adult- a sensitivity of close to 100%. The study then discusses some of the limitations to the use of the tool, such as a patient who insists on being x-rayed. Bachmann et al. (2004) discuss that additional studies need to be completed to determine the cost effectiveness, and the varying specificity of the tool.

Clinical Bottom Line:

Both studies found that the OKR is effective (near 100% sensitivity) for determining whether x-rays are necessary for an acute knee injury. The first study discusses how the tool can also be used for pediatrics, but the second study does not include pediatrics. There are many variables as discussed in the 2nd study, such as patients who are insistent on having x-rays completed, or those who cannot complete the assessment. Overall based on the studies the OKR has shown significance for being a reliable means for determining whether x-rays are needed for an acute knee injury in the pediatric and adult population.

Implications for Practice:

Knee injuries are a very common complaint for patients visiting the clinic; the majority of visits from children are orthopedic related. Having a tool available such as the OKR to practitioners who do not practice orthopedic assessments every day is very useful when trying to determine whether an x-ray is necessary. The OKR seems to have a reliable sensitivity based on the studies.

References

Bachmann,L.M., Haberzeth,S., Steurer,J., & G,R.T. (2004). The accuracy of the Ottawa knee rule to rule out knee fractures: a systematic review.Annals of Medicine, (140), 121-124.

Bulloch,B., Neto,G., Plint,A., Lim,R., Reed,M., Nijssen-Jordan,C., Klassen,T.P. (2003). Validation of the Ottawa Knee Rule in Children.Evidence Based Nursing, (42), 48-55.

Seidel,H.M., Ball,J.W., Dains,J.E., Flynn,J.A., Solomon,B.S., & Stewart,R.W. (2011).Mosby's guide to physical examination(7thed.). St. Louis, Mo: Mosby/Elsevier.