***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Abstract . Objectives : To determine whether the Ottawa ankle rules ( OAR ) can be applied in children and what the potential reduction in the use of X-ray studies might be . Methods : Prospect i ve , observational study of children attending emergency department with blunt ankle and midfoot injuries .  X-ray studies were obtained after recording of the physical assessment . A single investigator who was blinded to the emergency physician 's interpretations and to the radiologist 's interpretations of the studies then applied the OAR to each patient . Sensitivity , specificity , and positive and negative predictive values of the OAR were calculated with 95 % confidence intervals . Results : The OAR were 100 % sensitive ( 95 % CI=81–100 % ) and 30 % specific ( 95%CI=19–43 % ) . Positive and negative predictive values were 28 % ( 95%CI=17–41 % ) and 100 % ( 95 % CI=82–100 % ) respectively . The number of X-ray studies ordered would have been reduced by 24 % if the OAR had been applied . Conclusions : The Ottawa ankle rules are very sensitive and can be applied in children , result ing in a reduction in the use of X-rays studies STUDY OBJECTIVE We vali date the Ottawa Ankle Rules and 2 Dutch ankle rules in distinguishing clinical ly significant fractures from insignificant fractures and other injuries in patients with a painful ankle presenting to the emergency department . METHODS This prospect i ve comparison of 3 ankle rules was conducted in the ED of a 580-bed community teaching hospital in Amsterdam from January 1998 to April 1999 . Participants included 647 consecutive patients aged 18 years or older presenting with a painful ankle after trauma . All physicians received extensive and pictorial training on how to correctly score the respective items of the rules . The physician on call recorded these items derived from history and physical examination on a st and ardized data sheet . All patients subsequently underwent st and ard radiographic assessment . A radiologist and a trauma surgeon evaluated the radiographs blinded from the results of the data sheet form and the treatment given . The diagnostic performance of the 3 rules was measured in terms of sensitivity , specificity , and the reduction of radiographs . Receiver operating characteristic ( ROC ) curves were constructed , and the area under the ROC curves was calculated and compared . RESULTS Seventy-four fractures were seen , of which 41 were clinical ly significant . The Ottawa Ankle Rules had a sensitivity of 98 % for identifying clinical ly significant fractures ; the local rules scored 88 % and 59 % , respectively . The potential savings in radiographs for the 3 decision rules were 24 % , 54 % , and 82 % , respectively . The area under the ROC curve was better for both the local rules ( 0.84 and 0.83 ) compared with the Ottawa Ankle Rules ( 0.76 ) . CONCLUSION Because the identification of all relevant fractures is more important than a reduction in radiographs , the higher sensitivity of the Ottawa Ankle Rules makes these most suitable for implementation in The Netherl and BACKGROUND Nurse practitioners ( NPs ) in the Emergency Department ( ED ) have been trained to assess a range of clinical problems and minor complaints such as acute ankle injury . This study compared assessment of suspected ankle and foot injuries using the  Ottawa Ankle Rules ( OAR ) by NPs and ED medical doctors ( ED-Drs ) . METHODS A prospect i ve , comparative , observational study was undertaken in an Australian acute adult and paediatric urban district ED .  NPs and ED-Drs recorded information for patients with acute ankle and /or mid-foot injuries on demographic characteristics , OAR features , use of X-ray and patient management . Outcome measures included X-ray rates and identification of fracture . RESULTS 174 patients were included in this study : 51 received NP and 123 received ED-Dr care . Assessed as requiring X-ray assessment ( NP : 78.4 % , ED-Dr : 88.6 % ; p=0.081 ) , and detection of significant fracture ( NP : 17.6 % , ED-Dr : 22.8 % ; p=0.453 ) were similar . ED-based medical registrars were more likely to miss a fracture compared with NP ( NP : 0 % , ED-based Registrar : 28.6 % , p=0.013 ) . There were no significant differences in rates of OAR features for patients seen by NPs or ED-Drs . CONCLUSION This study suggests that NPs are less likely to miss significant fractures of the ankle and /or foot compared with ED-based medical registrars . Future research should focus on actual use of the OAR and accuracy of X-ray assessment by NPs Objective The Ottawa Ankle Rules ( OAR ) are criteria for predicting ankle fractures in adults allowing for insignificant fractures , defined as small avulsion fractures . Because the clinical significance of avulsion fractures and Salter-Harris type I fractures in children is unclear , we sought to prospect ively evaluate the use of the OAR in children and to determine whether different criteria should be used for predicting ankle fractures in children . Methods In this prospect i ve study , patients younger than 18 years presenting to a pediatric emergency department ( ED ) with an acute nonpenetrating ankle injury were eligible for study participation . Information on 22 clinical variables was recorded on a st and ardized data sheet . The OAR were included but not specifically identified on the data sheets . A st and ard ankle radiographic series was obtained on all subjects . All fractures were considered to be significant . Follow-up phone calls were performed to assess final diagnosis and outcome . Sensitivity and specificity of OAR and other potential criteria for predicting ankle fractures in children were calculated . Results A total of 195 patients with ankle injuries were evaluated . The mean age of patients was 12.6 years . Forty fractures ( 21 % ) were identified . The sensitivity of OAR  was 83 % ( 95 % CI , 65–94 % ) , specificity was 50 % ( 95 % CI , 41–59 % ) , positive predictive value was 28 % , and negative predictive value was 93 % . Three independent factors were significantly associated with ankle fractures : inability to walk immediately after the event , inability to bear weight for four steps in the ED , and tender deltoid ligament . If one or more of these factors were present , sensitivity for predicting ankle fractures was 93 % ( 95 % CI , 78–99 % ) , specificity was 27 % ( 95 % CI , 20–36 % ) , positive predictive value was 23 % , and negative predictive value was 95 % . Conclusion The OAR can not be applied to children with the same sensitivity as adults Background Acute ankle injuries are one of the most common reasons for presenting to emergency departments , but only a small percentage of patients – approximately 15 % – have clinical ly significant fractures . However , these patients are almost always referred for radiography . The Ottawa Ankle Rules ( OARs ) have been design ed to reduce the number of unnecessary radiographs ordered for these patients . The objective of this study was to vali date the OARs in the Iranian population . Methods This prospect i ve survey was done among 200 patients with acute ankle injury from January 2004 to April 2004 in the Akhtar Orthopedics Hospital Emergency Department . Main outcome measures of this survey were : sensitivity , specificity , positive predictive value , negative predictive value , and likelihood ratios ( positive and negative ) of the OARs . Results Sensitivity of the OARs  for detecting 37 ankle fractures  ( 23 in the malleolar zone and 14 in the midfoot zone ) was 100 % for each of the two zones , and 100 % for both zones . Specificity of the OARs  for detecting fractures was 40.50 % for both zones , 40.50 % for the malleolar zone , and 56.00 % for the midfoot zone . Implementation of the OARs had the potential for reducing radiographs by 33 % . Conclusion OARs are very accurate and highly sensitive tools for detecting ankle fractures . Implementation of these rules would lead to significant reduction in the number of radiographs , costs , radiation exposure and waiting times in emergency departments Background The Ottawa ankle rules ( OAR ) are clinical decision guidelines used to identify whether patients with ankle injuries need to undergo radiography . The OAR have been proven that their application reduces unnecessary radiography . They have nearly perfect sensitivity for identifying clinical ly significant ankle fractures . Objectives The purpose of this study was to assess the applicability of the OAR in China , to examine their accuracy for the diagnosis of fractures in patients with acute ankle sprains , and to assess their clinical utility for the detection of occult fractures . Methods In this prospect i ve study , patients with acute ankle injuries were enrolled during a 6-month period . The eligible patients were examined by emergency orthopedic specialists using the OAR , and then underwent ankle radiography . The results of examination using the OAR were compared with the radiographic results to assess the accuracy of the OAR for ankle fractures . Patients with OAR results highly suggestive of fracture , but no evidence of a fracture on radiographs , were advised to undergo 3-dimensional computed tomography ( 3D-CT ) . Results 183 patients with ankle injuries were enrolled in the study and 63 of these injuries involved fractures . The pooled sensitivity , specificity , positive predictive value and negative predictive value of the OAR  for detection of fractures of the ankle were 96.8 % , 45.8 % , 48.4 % and 96.5 % , respectively . Our results suggest that clinical application of the OAR could decrease unnecessary radiographs by 31.1 % . Of the 21 patients with positive OAR results and negative radiographic findings who underwent 3D-CT examination , five had occult fractures of the lateral malleolus . Conclusions The OAR are applicable in the Chinese population , and have high sensitivity and modest specificity for the diagnosis of fractures associated with acute ankle injury . They may detect some occult fractures of the malleoli that are not visible on radiographs AIMS The aims of this study were to measure baseline use of  Ottawa ankle rules ( OAR )  , vali date the OAR and , if appropriate , explore the impact of implementing the Rules on X-ray rates in a primary care , after hours medical centre setting . METHODS General practitioners ( GPs ) were surveyed to find their awareness of ankle injury guidelines . Data concerning diagnosis and X-ray utilisation were collected prospect ively for patients presenting with ankle injuries to two after hours medical centres . The OAR were applied retrospectively , and the sensitivity and specificity of the OAR were compared with GPs clinical judgement in ordering X-rays . The outcome measures were X-ray utilisation and diagnosis of fracture . RESULTS Awareness of the OAR  was low . The sensitivity of the OAR  for diagnosis of fractures was 100 % ( 95 % CI : 75.3 - 100 ) and the specificity was 47 % ( 95 % CI : 40.5 - 54.5 ) . The sensitivity of GPs clinical judgement was 100 % ( 95 % CI : 75.3 - 100 ) and the specificity was 37 % ( 95 % CI : 30.2 - 44.2 ) . Implementing the OAR would reduce X-ray utilisation by 16 % ( 95 % CI : approx 10.8 - 21.3 ) . CONCLUSIONS The OAR are valid in a New Zeal and primary care setting . Further implementation of the rules would result in some reduction of X-rays ordered for ankle injuries , but less than the reduction found in previous studies OBJECTIVE To test the validity of a set of defined and tested rules for decisions on use of radiography for acute ankle injuries . DESIGN Prospect i ve survey . SETTING Community hospital emergency department managing 42000 visits annually . PARTICIPANTS A non-consecutive sample of 318 adults and children presenting during 1 year was evaluated by 25 family physicians in part-time emergency practice . INTERVENTIONS Participating physicians interpreted the Ottawa ankle rules for all enrolled patients and ordered radiographs in 96 % of cases . MAIN OUTCOME MEASURES Sensitivity of the Ottawa ankle rules to predict whether radiography is required for acute ankle injuries . RESULTS Of the 318 cases , 22 incomplete records were excluded , leaving 259 records of adults and 37 records of patients younger than 16 accepted for analysis . Of 34 adult patients with identified fractures , only one was predicted by the rules not to require  radiographs . Sensitivity of the rules was 0.971 ( confidence interval [ CI ] 0.914 to 1.00 ) , specificity was 0.302 ( CI 0.242 to 0.362 ) , positive predictive value was 0.174 ( CI 0.120 to 0.228 ) , and negative predictive value was 0.986 ( CI 0.971 to 1.00 ) . Radiography could have been reduced by 26.3 % had the rules been applied . Of the 37 children , seven had fractures . All were properly identified by the rules . Radiography in this group could have been reduced by 22 % . CONCLUSIONS 
    Output:
    
Sensitivity of the Ankle Rules was higher in adults than in children , but the profession of the assessor did not appear to influence accuracy .
Specificity was higher for Midfoot than for Ankle Rules .
Studies with a low risk of bias and where all patients received radiographs provided lower accuracy estimates .
Specificity heterogeneity was not explained by assessor training , use of imaging in all patients and low risk of bias .
Conclusions Study features and the method ological quality influence estimates of the diagnostic accuracy of the Ottawa Ankle and Midfoot Rules