Derivation of clinical prediction rules to identify children with fractures after twisting injuries of the ankle

Peter S. Dayan, Michael Vitale, Daniel J. Langsam, Carrie Ruzal-Shapiro, Michael K. Novick, Nathan Kuppermann, Steven Z. Miller

Research output: Contribution to journalArticle

12 Citations (Scopus)

Abstract

Objective The authors sought to derive maximally sensitive prediction rules for identifying children with significant fractures after acute twisting injuries to the ankle. Methods The authors prospectively enrolled a convenience sample of patients younger than 18 years of age who presented to the pediatric emergency department of an urban, tertiary care center after sustaining acute twisting injuries of the ankle. The ankle was defined in two regions: the malleolar zone and the midfoot zone. Clinical findings were documented on standardized data collection sheets by faculty physicians before completion of ankle and/or foot radiograph series. Significant fracture was defined a priori as any fracture other than an avulsion ≤3 mm. The authors conducted binary recursive partitioning with cross-validation to develop models to predict fracture. Results Data from 717 enrolled patients with a median age of 12.9 years were analyzed. Significant malleolar zone and midfoot zone fractures were diagnosed in 81 of 682 (11.9%) and 10 of 173 (5.8%) patients for whom ankle and foot radiographs were obtained. Recursive partitioning identified patients at low risk for malleolar zone fracture if 1) they had no bone tenderness at either malleolus or the region just proximal to the fibula malleolus or 2) they had bone tenderness at either malleolus but were able to walk four steps in the emergency department and had no swelling at either malleolus. The two-part malleolar zone rule had a sensitivity of 100% and specificity of 19.1% on the learning data and 95.1% (95% confidence interval [95% CI]=87.8% to 98.6%) and 20.0% (95% CI=16.8% to 23.4%) on the test data. Tenderness either at the proximal fifth metatarsal or cuboid identified midfoot zone fractures with a sensitivity of 100% and specificity of 31.9% on the learning data and 90.0% (95% CI=55.4% to 99.7%) and 35.0% (95% CI=27.7% to 42.8%) on the test sample. Conclusions A set of sensitive prediction rules was developed to identify children with significant fractures after twisting injuries to the ankle. External validation and refinement of the rules will be needed before recommendation of widespread use.

Original languageEnglish (US)
Pages (from-to)736-743
Number of pages8
JournalAcademic Emergency Medicine
Volume11
Issue number7
DOIs
StatePublished - Jul 2004

Fingerprint

Ankle Injuries
Decision Support Techniques
Ankle
Confidence Intervals
Hospital Emergency Service
Foot
Learning
Bone and Bones
Sensitivity and Specificity
Fibula
Metatarsal Bones
Tertiary Care Centers
Pediatrics
Physicians

Keywords

  • ankle
  • children
  • fracture
  • prediction

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Derivation of clinical prediction rules to identify children with fractures after twisting injuries of the ankle. / Dayan, Peter S.; Vitale, Michael; Langsam, Daniel J.; Ruzal-Shapiro, Carrie; Novick, Michael K.; Kuppermann, Nathan; Miller, Steven Z.

In: Academic Emergency Medicine, Vol. 11, No. 7, 07.2004, p. 736-743.

Research output: Contribution to journalArticle

Dayan, Peter S. ; Vitale, Michael ; Langsam, Daniel J. ; Ruzal-Shapiro, Carrie ; Novick, Michael K. ; Kuppermann, Nathan ; Miller, Steven Z. / Derivation of clinical prediction rules to identify children with fractures after twisting injuries of the ankle. In: Academic Emergency Medicine. 2004 ; Vol. 11, No. 7. pp. 736-743.
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abstract = "Objective The authors sought to derive maximally sensitive prediction rules for identifying children with significant fractures after acute twisting injuries to the ankle. Methods The authors prospectively enrolled a convenience sample of patients younger than 18 years of age who presented to the pediatric emergency department of an urban, tertiary care center after sustaining acute twisting injuries of the ankle. The ankle was defined in two regions: the malleolar zone and the midfoot zone. Clinical findings were documented on standardized data collection sheets by faculty physicians before completion of ankle and/or foot radiograph series. Significant fracture was defined a priori as any fracture other than an avulsion ≤3 mm. The authors conducted binary recursive partitioning with cross-validation to develop models to predict fracture. Results Data from 717 enrolled patients with a median age of 12.9 years were analyzed. Significant malleolar zone and midfoot zone fractures were diagnosed in 81 of 682 (11.9{\%}) and 10 of 173 (5.8{\%}) patients for whom ankle and foot radiographs were obtained. Recursive partitioning identified patients at low risk for malleolar zone fracture if 1) they had no bone tenderness at either malleolus or the region just proximal to the fibula malleolus or 2) they had bone tenderness at either malleolus but were able to walk four steps in the emergency department and had no swelling at either malleolus. The two-part malleolar zone rule had a sensitivity of 100{\%} and specificity of 19.1{\%} on the learning data and 95.1{\%} (95{\%} confidence interval [95{\%} CI]=87.8{\%} to 98.6{\%}) and 20.0{\%} (95{\%} CI=16.8{\%} to 23.4{\%}) on the test data. Tenderness either at the proximal fifth metatarsal or cuboid identified midfoot zone fractures with a sensitivity of 100{\%} and specificity of 31.9{\%} on the learning data and 90.0{\%} (95{\%} CI=55.4{\%} to 99.7{\%}) and 35.0{\%} (95{\%} CI=27.7{\%} to 42.8{\%}) on the test sample. Conclusions A set of sensitive prediction rules was developed to identify children with significant fractures after twisting injuries to the ankle. External validation and refinement of the rules will be needed before recommendation of widespread use.",
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AU - Novick, Michael K.

AU - Kuppermann, Nathan

AU - Miller, Steven Z.

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N2 - Objective The authors sought to derive maximally sensitive prediction rules for identifying children with significant fractures after acute twisting injuries to the ankle. Methods The authors prospectively enrolled a convenience sample of patients younger than 18 years of age who presented to the pediatric emergency department of an urban, tertiary care center after sustaining acute twisting injuries of the ankle. The ankle was defined in two regions: the malleolar zone and the midfoot zone. Clinical findings were documented on standardized data collection sheets by faculty physicians before completion of ankle and/or foot radiograph series. Significant fracture was defined a priori as any fracture other than an avulsion ≤3 mm. The authors conducted binary recursive partitioning with cross-validation to develop models to predict fracture. Results Data from 717 enrolled patients with a median age of 12.9 years were analyzed. Significant malleolar zone and midfoot zone fractures were diagnosed in 81 of 682 (11.9%) and 10 of 173 (5.8%) patients for whom ankle and foot radiographs were obtained. Recursive partitioning identified patients at low risk for malleolar zone fracture if 1) they had no bone tenderness at either malleolus or the region just proximal to the fibula malleolus or 2) they had bone tenderness at either malleolus but were able to walk four steps in the emergency department and had no swelling at either malleolus. The two-part malleolar zone rule had a sensitivity of 100% and specificity of 19.1% on the learning data and 95.1% (95% confidence interval [95% CI]=87.8% to 98.6%) and 20.0% (95% CI=16.8% to 23.4%) on the test data. Tenderness either at the proximal fifth metatarsal or cuboid identified midfoot zone fractures with a sensitivity of 100% and specificity of 31.9% on the learning data and 90.0% (95% CI=55.4% to 99.7%) and 35.0% (95% CI=27.7% to 42.8%) on the test sample. Conclusions A set of sensitive prediction rules was developed to identify children with significant fractures after twisting injuries to the ankle. External validation and refinement of the rules will be needed before recommendation of widespread use.

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