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Applicability of Ottawa knee rule for knee injury in children
H Khine1, D H Dorfman, J R Avner
1Division of Pediatric Emergency Medicine, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, USA. Hnin007@aol.com
Insights
The Ottawa knee rule (OKR) showed 92% sensitivity in identifying pediatric knee fractures but missed one case. Modifying the rule may improve its use in children with acute knee trauma.
Area of Science:
- Pediatric Emergency Medicine
- Orthopedic Surgery
- Radiology
Background:
- The Ottawa knee rule (OKR) is established for reducing unnecessary knee radiographs in adults with acute knee injuries.
- Validation of the OKR in pediatric populations is needed to assess its applicability and effectiveness in children.
Purpose of the Study:
- To determine the epidemiology and incidence of knee injuries in children presenting with acute traumatic knee injuries.
- To validate the diagnostic accuracy of the Ottawa knee rule (OKR) in a pediatric cohort.
Main Methods:
- A prospective study enrolled 234 children (age 2-18) with acute knee trauma (<1 week duration) across two urban pediatric emergency departments.
- Physicians assessed 22 standardized clinical findings and applied the OKR before radiography.
- All enrolled patients underwent knee radiography.
Main Results:
- The study identified 13 fractures among 234 pediatric patients, with the OKR achieving 92% sensitivity (95% CI= 64-99).
- One case of a nondisplaced proximal tibia fracture was missed by the OKR.
- Applying the OKR could have reduced radiography needs by 46% in this pediatric cohort.
Conclusions:
- The Ottawa knee rule (OKR) did not identify all knee fractures in the studied pediatric population.
- Modifications to the OKR may be necessary to enhance sensitivity for pediatric patients while maintaining specificity.
- Further research is recommended before routine clinical application of the OKR in children with acute knee injuries.
Objective:
Previous studies have shown that the application of the Ottawa knee rule (OKR) reduces the need for radiographs in adults with acute knee injuries. Our objectives were to describe the epidemiology and incidence of knee injuries in children with acute knee trauma and to validate the OKR in a pediatric population.
Design:
A prospective, consecutive study.
Settings:
Two urban pediatric emergency departments.
Methods:
All children 18 years of age and under who presented with acute traumatic knee injury of less than 1 week's duration, excluding patients with a normal knee examination, superficial skin injuries, prior history of knee injury, underlying bone disease, serious injuries involving two or more organ systems, or altered mental status were enrolled. Physicians assessed each patient for 22 standardized clinical findings prior to radiography. The OKR was applied to each patient by the investigating physician.
Results:
All 234 patients eligible for the study had radiographs of the affected knee. The median age was 13 years with a range of 2 to 18 years. Using the OKR criteria for obtaining knee radiographs, 12 of 13 patients with fractures were identified (sensitivity 92%; 95% CI= 64-99). The missed case was an 8-year-old male who had sustained a nondisplaced fracture of the proximal tibia after a fall. If the OKR were applied to the pediatric population, it would have reduced the need for radiography in 46% of children.
Conclusions:
In the pediatric population studied, the OKR did not identify all patients with knee fractures. Future studies may consider modifying the OKR to accommodate the differences between pediatric and adult patients to improve the sensitivity of the rule while maintaining its specificity, before it can be applied routinely in clinical practice.
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