Priority Topic: Fractures

Key Feature 8: Use clinical decision rules (ex: Ottawa ankle rules, C-spine rules, and knee rules) to guide the use of X-ray examinations. 
Skill: Clinical Reasoning, Selectivity
Phase: Investigation

When a patient provides a history of trauma and sudden onset of bony pain, the clinician must be suspicious of a fracture. But sometimes, the mechanism of injury is low-impact, the pain is not all that severe, and there are limited signs suggestive of fracture on physical exam, leading to a low pretest probability of fracture. When the risk of fracture is not all that high, there can be much uncertainty in deciding who does and does not warrant an xray. To be thorough and try not to miss any fractures, all patients with trauma and subsequent acute pain could be x-rayed, but this would certainly lead to an overabundance of unnecessary x-rays, with associated unnecessary harm to patients through excess radiation exposure and harm to the system through unnecessary costs and increase in emergency room wait times. Enter The Ottawa Rules. As described on the associated website, "​The Ottawa Rules are a set of clinical decision rules developed by Dr. Ian Stiell and his research team at The Ottawa Hospital Research Institute and the University of Ottawa. The rules have been demonstrated to decrease unnecessary diagnostic imaging and emergency room wait times which enhances patient comfort and reduces health care costs."

There are 3 rules or algorithms that have been developed to help the clinician decide whether x-rays are warranted. These are as follows:

1. The Ottawa Ankle Rules: "A clinical decision rule to determine the need for diagnostic imaging for ankle and/or foot trauma"
2. The Canadian C-Spine Rule: "A clinical decision rule to determine the need for diagnostic imaging for alert and stable trauma patients (GCS 15) with neck pain"
3. The Ottawa Knee Rule: "A clinical decision rule to determine the need for diagnostic imaging for knee trauma"

Rather than go through these here, you can see the link to the website that provides more detail. OR, you can download Calculate by QxMD app, which contains all of these and pretty much all of the other medical rules and things to calculate you may need as a physician. I mean, there may be some things that are not on there, but Well's criteria, due date according to LMP or  US, Parkland formula, CIWA, you name it. It's all on this wonderful app.