***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: 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 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 BACKGROUND Trauma of the midfoot and ankle joint are among the most commonly treated injuries in the emergency unit . The " Ottawa ankle rules " were introduced in 1992 to lower the amount of radiographs based on a st and ardized clinical examination . The weakness of the " rules " is the low specificity reported in several clinical studies . METHOD We introduced a new indirect stress technique to examine the ankle and the midfoot after low-energy , supination-type trauma  , avoiding direct palpation of the injured region . RESULTS In 354 prospect ively documented patients , the Bernese ankle test produced a sensitivity of 100 % and a specificity of 91 % . CONCLUSION Compared with the original Ottawa ankle rules , the number of false-positive findings could be significantly reduced , result ing in a reduction of 84 % in radiographs after low-energy , supination-type trauma ankle and midfoot trauma . Further investigations have to be performed to prove whether these findings are reproducible within other clinical setting s , which could result in major cost savings for the health care system OBJECTIVE To vali date and refine previously derived clinical decision rules that aid the efficient use of radiography in acute ankle injuries . DESIGN Survey prospect ively administered in two stages : validation and refinement of the original rules ( first stage ) and validation of the refined rules ( second stage ) . SETTING Emergency departments of two university hospitals . PATIENTS 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 . MAIN OUTCOME MEASURES Attending emergency physicians assessed each patient for st and ardized 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 st and ard of fractures on ankle and foot radiographic series . The original decision rules were refined by univariate and recursive partitioning analyses . MAIN RESULTS 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 . CONCLUSION 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 PURPOSE To assess predictive value of a short magnetic resonance ( MR ) imaging examination with or instead of radiography performed in patients with acute ankle trauma to identify those who require additional treatment versus those who do not and can be discharged without further follow-up . MATERIAL S AND METHODS Informed consent was obtained from all participating patients , and the institutional review board approved the r and omized controlled trial and use of data to create prediction models . In a prospect i ve controlled trial , 197 patients with recent ankle trauma ( 92 women , 105 men ) were r and omized into two groups : those who underwent radiography and those who underwent a combination of radiography and MR imaging . Data about side of injury , trauma mechanism , and results of radiography and MR imaging were collected . Additional treatment was necessary in 109 of 197 patients after their initial hospital visit . With univariable and multivariable regression analysis , four models were created for prediction of treatment . RESULTS In univariable analysis , age ( odds ratio [ OR ] , 1.02 ; 95 % confidence interval : 1.00 , 1.04 ) , radiographic results ( OR , 7.92 ; 95 % confidence interval : 3.17 , 19.8 ) , and positive or uncertain results in patients who underwent MR imaging versus patients who did not ( OR , 2.42 ; 95 % confidence interval : 1.25 , 4.70 ) were predictive of treatment . In the multivariable analysis , positive or uncertain MR imaging results ( OR , 2.61 ; 95 % confidence interval : 1.28 , 5.30 ) contributed significantly to prediction of subsequent treatment . Negative MR imaging results did not contribute significantly ( OR , 0.66 ; 95 % confidence interval : 0.27 , 1.61 ) . CONCLUSION A limited MR imaging examination in initial evaluation of acute ankle injury with radiography has additional predictive value in identification of patients who need treatment but does not add significant information in identification of those who can be discharged without further follow-up . A limited MR imaging examination can not replace radiography for prediction of need for additional treatment OBJECTIVE To determine whether it is possible to decrease the number of X-rays in acute ankle injury while keeping the health care constant , using a scoring system . DESIGN Prospect i ve . METHOD Patients presenting in the emergency department of the University Hospital Utrecht ( AZU ) , the Netherl and s , over a one-year period of time with acute ankle injuries were subjected to a thorough physical examination based on a scoring system developed at Leiden University Hospital . The score was calculated and X-ray examination was indicated when this score was > or = 8 points . Radiological investigation or telephone interviews six weeks after injury achieved verification of the clinical ly relevant ankle fractures . Specificity and sensitivity were calculated from every possible cut-off point and drawn in a ' receiver operating characteristics ' ( ROC ) curve . RESULTS Of the 514 patients included 81 patients had a score of 8 or higher and 24 of them had a clinical ly relevant fracture . In 34 patients an ankle X-ray was made although their score was < 8 points . The positive and negative predictive values of the system were 30 % ( 95 % confidence interval ( 95 % CI ) : 20 - 41 ) and 99 % ( 95 % CI : 97 - 100 ) respectively . The score yielded an area under the ROC curve of 91 % ( 95 % CI : 84 - 98 ) . A cut-off point of 8 led to a reduction of X-rays by 60 % ( using the ' Ottawa ankle rules ' the decrease in this population would have been 28 % ) . On the other h and , 5 clinical ly relevant fractures were missed . CONCLUSION Radiological examination in patients wit acute ankle complaints was reduced while health care remained almost constant . In the AZU , a decision was made for a major reduction in X-rays while accepting that some fractures would be missed PURPOSE Our goal was to compare the abilities of MRI and stress radiography to detect the extent of recent lateral ankle ligament inversion injuries . METHOD In this prospect i ve study , 60 athletically active patients ( aged 18 - 45 years ) with recent inversion trauma ( < or = 7 days ) underwent stress radiography and MRI . In 15 patients , the MR findings were review ed at surgery . Patients were divided into three groups according to severity of ligament injury on MRI ( no , one , or two to three ligament tears ) . Based on bilateral stress radiography , patients were classified into three groups according to the differential degree of talar tilt ( < or = 5 , 6 - 14 , or > or = 15 degrees ) and compared with patients from the MR groups . RESULTS Surgery showed MRI to have 74 % sensitivity and 100 % specificity in the evaluation of complete lateral ankle ligament tears . Agreement between MR and stress radiography groups for the severity of recent lateral ankle ligament tears was poor ( kappa = 0.030 ) . CONCLUSION MRI should be performed in young , athletically active patients if surgical intervention is contemplated , especially at 6 - 14 degrees talar tilt on stress radiography , since stress radiography tends to over- and underestimate the severity of lateral ligament trauma OBJECTIVES The ED is often confronted with long waiting periods . Because of the progressive shortage in general practitioners , further growth is expected in the number of patients visiting the ED without consulting a general practitioner first . These patients mainly present with minor injuries suitable for a st and ardized diagnostic protocol . The question was raised whether these injuries can be treated by trained ED nurses ( specialized emergency nurses [ SENs ] ) . The aim of this study was to evaluate the diagnostic accuracy and reproducibility of SENs in assessing ankle sprains by applying the Ottawa Ankle Rules ( OAR ) and Ottawa Foot Rules ( OFR ) . METHODS In a prospect i ve study , all ankle sprains presented in the ED from April to July 2004 were assessed by both a SEN and a junior doctor ( house officer [ HO ] ) r and omized for first observer . Before the study , SENs were trained in applying OAR and OFR . In all patients , radiography was performed ( gold st and ard ) . The diagnostic accuracy for the application of OAR and OFR was calculated for both groups and was compared using z statistics . Furthermore , from the paired 
    Output:
    
Vibrating tuning fork test and ultrasound could be useful in patient with OAR positive to decrease the need for radiographs .
No evidence was found in favour of the use of magnetic resonance imaging ( MRI ) or computed tomography  ( CT ) in the acute phase of ankle sprain .