BACKGROUND: Ankle decision rules are developed to expedite patient care and 
reduce the number of radiographs of the ankle and foot. Currently, only three 
systematic reviews have been conducted on the accuracy of the Ottawa Ankle and 
Foot Rules (OAFR) in adults and children. However, no systematic review has been 
performed to determine the most accurate ankle decision rule.
OBJECTIVES: The purpose of this study is to examine which clinical decision 
rules are the most accurate for excluding ankle fracture after acute ankle 
trauma.
METHODS: A systematic search was conducted in the databases PubMed, CINAHL, 
PEDro, ScienceDirect, and EMBASE. The sensitivity, specificity, likelihood 
ratios, and diagnostic odds ratio of the included studies were calculated. A 
meta-analysis was conducted if the accuracy of a decision rule was available 
from at least three different experimental studies.
RESULTS: Eighteen studies satisfied the inclusion criteria. These included six 
ankle decision rules, specifically, the Ottawa Ankle Rules, Tuning Fork Test, 
Low Risk Ankle Rule, Malleolar and Midfoot Zone Algorithms, and the Bernese 
Ankle Rules. Meta-analysis of the Ottawa Ankle Rules (OAR), OAFR, Bernese Ankle 
Rules, and the Malleolar Zone Algorithm resulted in a negative likelihood ratio 
of 0.12, 0.14, 0.39, and 0.23, respectively.
CONCLUSION: The OAR and OAFR are the most accurate decision rules for excluding 
fractures in the event of an acute ankle injury.