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Can the Ottawa knee rule be applied to children? A systematic review and meta-analysis of observational studies
D Vijayasankar1, A A Boyle, P Atkinson
1Peterborough District Hospital, Peterborough, UK.
Insights
The Ottawa knee rule (OKR) effectively rules out knee fractures in children over 5 years old, reducing unnecessary X-rays. Its use in younger children requires more research.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Decision Support Systems
- Diagnostic Accuracy Studies
Background:
- The Ottawa knee rule (OKR) is a validated clinical decision aid designed to minimize unnecessary radiography in adults.
- Its applicability and diagnostic performance in pediatric populations remain uncertain.
Purpose of the Study:
- To systematically evaluate the sensitivity and specificity of the Ottawa knee rule (OKR) in children.
- To determine if the OKR is suitable for widespread adoption in pediatric knee injury assessment.
Main Methods:
- A systematic review and meta-analysis of observational studies were conducted.
- Studies included children diagnosed with knee injuries, assessing the OKR's performance in ruling out fractures.
- Data were sourced from multiple databases including Medline, EMBASE, CINAHL, Cochrane Library, and Google Scholar.
Main Results:
- Four studies involving 1130 children were analyzed; three contributed to the meta-analysis.
- The pooled sensitivity was 99% (95% CI 94.4 to 99.8), indicating high accuracy in identifying true negatives.
- Pooled specificity was 46% (95% CI 43.0 to 49.1), with likelihood ratios suggesting moderate accuracy in identifying true positives.
- Radiography reduction ranged from 30% to 40% in included studies.
Conclusions:
- The Ottawa knee rule demonstrates high sensitivity and adequate specificity for diagnosing knee fractures in children aged 5 years and older.
- Insufficient data currently support the use of the OKR in children under 5 years of age.
- Further research is needed to validate the OKR's efficacy in younger pediatric populations.
Background:
The Ottawa knee rule (OKR), a clinical decision aid is used to reduce unnecessary radiography. It is not clear whether this rule can be applied to children.
Objective:
To establish whether the OKR had adequate sensitivity and acceptable specificity in children to advocate widespread use.
Methods:
A systematic review and meta-analysis was conducted of observational studies that examined the diagnostic characteristics of the OKR in children.
Data Sources:
Relevant English language articles were identified from Medline (1950 to date), EMBASE (1974 to date), CINAHL (1982 to date), the Cochrane Library, Google Scholar and a hand search of bibliographies.
Study Selection:
Observational studies that included children and have used the OKR for ruling out fractures in children either radiologically or in combination with follow-up.
Results:
Four relevant studies were identified. Three studies were suitable for inclusion in the meta-analysis, representing 1130 children. The pooled negative likelihood ratio was 0.07 (95% CI 0.02 to 0.29), the pooled positive likelihood ratio was 1.94 (95% CI 1.60 to 2.36), the pooled sensitivity was 99% (CI 94.4 to 99.8) and the pooled specificity was 46% (CI 43.0 to 49.1). The reduction in radiography was between 30% and 40%.
Conclusion:
The OKR has high sensitivity and adequate specificity for children over the age of 5 years. There are not enough good data to advocate application of the OKR in children less than 5 years.