Comparison of the Shetty Test and Ottawa Ankle Rules for the Exclusion of Ankle Fractures in the Emergency Department: A Prospective Study

Comparison of the Shetty Test and Ottawa Ankle Rules for the Exclusion of Ankle Fractures in the Emergency Department: A Prospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of the Shetty Test and Ottawa Ankle Rules for the Exclusion of Ankle Fractures in the Emergency Department: A Prospective Study Ihsan Gumustas¹, Ertugrul Altinbilek², Hatice Topcu², Abdullah Avlac², and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9356939/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective Foot and ankle injuries are common in emergency department visits. Various screening tools have been developed to reduce the use of radiography, aiming to minimize radiation exposure, save resources, and optimize time. The objective of this study is to assess the efficacy of the Shetty test in distinguishing patients without ankle fractures, in comparison to the commonly employed Ottawa Ankle Rules (OARs). Materials and Methods The scheduled dates for performing this prospective clinical trial were January 26, 2023, and April 26, 2023, at the Seyrantepe Hamidiye Etfal campus. A total of 100 patients presenting with ankle sprain to the emergency and orthopedic emergency departments were included if a decision for imaging was made by the clinician. Results 58% of total patients were male. The overall mean age was 29.9 ± 16 years. Ankle sprain was the most common reason for presentation. A total of 26 patients were diagnosed with fractures after radiological evaluation. The sensitivity of the Shetty test was found to be 76.92%, with a specificity of 67.57%. The sensitivity of the OARs was 92.31%, with a specificity of 18.92%. There was a significant correlation between the Shetty test and the OARs (p = 0.006). Conclusion The results of this investigation indicate that the Shetty test can safely reduce waiting times, radiation exposure, and patient costs in ankle trauma cases presenting to emergency departments. Ottawa ankle rules Shetty test ankle fracture emergency department clinical decision rule Figures Figure 1 Figure 2 BACKGROUND Ankle and foot injuries are among the most common extremity traumas and have an important place among emergency department admissions [ 1 ]. Clinically significant fractures occur in 15–30% of foot and ankle injuries. Ankle sprain is one of the most common musculoskeletal injuries among physically active individuals [ 2 ]. In a study conducted in the United States of America (USA) in 2010, there were 1,016,282 emergency room visits due to ankle sprains. The average application cost was calculated as $ 1,029 [ 3 ]. In an epidemiological summary evaluating several studies, a higher incidence of ankle sprains was observed in men than in women in two studies, while three other studies found no gender difference. In a study including 125 high schools and universities in New Jersey, ankle sprains were more frequent in women at the high school level, while no incidence difference was observed at the university level. Injuries were mostly observed in individuals between the ages of 18–34 [ 4 ]. The incidence of ankle sprain was observed to be 9 times higher in the 15–19 age group than in the 55–59 age group [ 5 ]. It has been found that half of all ankle sprains treated in US emergency rooms are not related to sports participation, indicating that these injuries can affect a broad population beyond those who engage in sports or high levels of physical activity [ 6 ]. The most common injury mechanisms are falls (54.83%) and sports activities (20.76%). Eighty-two percent of patients who arrived at the emergency room were treated and released, while sixteen percent were admitted to the hospital [ 7 ]. The primary purpose of plain radiographs is to exclude fracture in ankle sprains. Anteroposterior, lateral, and oblique projections should be obtained under weight-bearing conditions [ 8 ]. The use of CT is not at the forefront in routine evaluation; it is used in the detection of clinically suspicious but radiologically challenging fractures, in the evaluation of fracture-dislocations, and as an aid in surgical planning [ 9 ]. Multidetector CT can be used as the primary modality for complex foot and ankle fractures in high-energy or polytrauma patients [ 10 ]. Many clinical studies have shown that the indication for radiography can be significantly reduced by using screening tools, thereby reducing ionizing radiation exposure for patients while saving economic resources and time [ 11 , 12 ]. The most widely used of these tools is the Ottawa Ankle Rules (OAR), developed in 1992 [ 13 ]. The OAR can be challenging to apply in the emergency department because they involve evaluation of multiple anatomical regions and may require the patient to attempt walking. In 2013, Shetty and coworkers described a simpler method of evaluation that they reported could effectively exclude fractures in ankle trauma. According to their findings, this test proved highly effective in ruling out bone damage in cases of ankle trauma [ 1 ]. Since the Shetty test does not require mastery of anatomical localizations, it can be used safely in triage areas by non-clinician personnel [ 14 ]. Our study aims to assess the utility of the Shetty test in distinguishing patients without fractures in ankle injuries prior to radiography and to compare it with the OAR. METHODS This study was conducted after receiving approval from the institutional clinical research board as a prospective clinical study. Patients presenting with ankle complaints to the orthopedic emergency department at the Seyrantepe Hamidiye Etfal campus between January 26, 2023, and April 26, 2023, for whom imaging was ordered by the clinician, were included. Patients who were unconscious, uncooperative, had serious trauma other than to the ankle, were under the age of 7, or were over the age of 80 were excluded. After reading and signing the informed consent form, patients were taken to the examination room. History and anamnesis were recorded in the patient file. The Ottawa Ankle Rules and the Shetty test were applied and documented on the patient examination form. For the Ottawa Ankle Rules score, the following criteria were each evaluated and scored as one point: tenderness in the region 6 cm from the lower end of the medial malleolus; tenderness in the region 6 cm from the lower end of the lateral malleolus; tenderness in the navicular region; tenderness in the proximal fifth metatarsal; and inability to bear weight for four steps immediately after trauma or at the initial evaluation in the emergency room. During the Shetty test, the patient is positioned on the examination stretcher and instructed to flex their knee. They are then requested to place their foot on the clinician's palm and simulate the pressure exerted by their body weight. If the patient is unable to replicate their weight due to pain, the test is deemed positive, indicating a possible fracture, and the patient is referred for radiographic evaluation. If the patient can simulate their weight, the test is considered negative and further imaging is not recommended [ 1 ]. In radiological evaluation, the results of patients who received plain radiography or advanced imaging based on clinician suspicion were examined. Treatment was divided into four groups: medical treatment only; elastic bandage in addition to medical treatment; plaster-splint in addition to medical treatment; and surgery (Fig. 1 ). STATISTICAL ANALYSIS Statistical analysis was conducted using SPSS version 28.0 for Windows. The normality of continuous data was assessed using the Kolmogorov–Smirnov test, in addition to descriptive statistics including skewness and kurtosis. Due to non-normal distribution in at least one group, all tests were conducted using non-parametric methods. Categorical variables were presented as numbers and percentages; numerical variables were described using median (minimum–maximum) values. The Mann–Whitney U test was used for difference analysis of numerical variables between two independent groups. Chi-square analysis was used to compare proportions in independent groups. ROC analysis was conducted to determine threshold values and perform predictive analysis for pathology in cases with a significant effect on dichotomous outcomes. Statistical significance was defined as p < 0.05. RESULTS The study comprised 100 individuals who sought treatment at Health Sciences University Hamidiye Etfal Training and Research Hospital following an ankle injury. Of these, 42% were women. The mean age was 29.9 ± 16 years. The youngest patient was 7 years old and the oldest was 79 years. The median age was 30 years in female patients and 25 years in male patients. Of the patients presenting with ankle injuries, 46 (46%) reported sprains and 22 (22%) reported falls as the mechanism of trauma. There were 84 (84%) patients who met the criteria for the Ottawa Ankle Rules, and 44 (44%) individuals had a positive Shetty test. Foot and ankle X-rays were taken for all patients. CT scans were performed in 26 (26%) patients when deemed necessary by the clinician after plain radiography evaluation. Fractures were observed in 18 (18%) patients on plain radiographs and in 21 (80%) patients on CT. After combined plain radiograph and CT evaluation, fractures were identified in 26 (26%) patients overall. No fracture was detected on plain radiography in 8 (38%) of the 21 (80.8%) patients with fractures detected on CT. Regarding treatment, medical treatment only was applied to 29 (29%) patients; elastic bandage to 39 (39%); cast or splint to 30 (30%); and 2 (2%) patients underwent surgery (Table 1 ). Table 1 General Characteristics of the Patients Variable Total (n = 100) Age – mean ± SD / median (min–max) 29.9 ± 16.0 / 27 (7–79) Sex Female 42 (42%) Male 58 (58%) Trauma mechanism Fall 22 (22%) Sprain 46 (46%) Object falling 6 (6%) Traffic accident 21 (21%) Impact 5 (5%) Ottawa Ankle Rules (OAR) Positive 84 (84%) Negative 16 (16%) Shetty Test Positive 44 (44%) Negative 56 (56%) Fracture on radiograph Yes 18 (18%) No 82 (82%) Fracture on CT Yes 21 (80.8%) No 5 (19.2%) Overall fracture Yes 26 (26%) No 74 (74%) Treatment Elastic bandage 39 (39%) Plaster-splint 30 (30%) Surgery 2 (2%) Medical treatment only 29 (29%) The mean age of patients with fractures was 35.7 ± 15.1 years, compared with 27.9 ± 15.9 years in those without fractures. Patients with fractures were significantly older (p = 0.007). There was no significant relationship between sex and fracture status (p = 0.618). When the relationship between fracture and trauma mechanism was examined, the most common fractures were associated with sprain (11 cases, 42.3%) and fall (8 cases, 30.8%). Fractures were detected in 20 (45.4%) of the 44 patients with a positive Shetty test, and in 24 (28.6%) of the 84 patients with a positive OAR (Table 2 ). Table 2 Fracture relationship of OAR and Shetty test Fracture Yes – N (%) Fracture No – N (%) OAR Positive 24 (92.3%) 60 (81.1%) Negative 2 (7.7%) 14 (18.9%) Shetty Positive 20 (76.9%) 24 (32.4%) Negative 6 (23.1%) 50 (67.6%) A fracture line was visible on plain radiographs in 18 (69.2%) of the 26 patients with fractures. Fractures were observed in 21 (80.7%) of 26 patients who underwent CT. Of the 26 patients diagnosed with fracture, 24 (92.3%) received plaster-splint treatment and 2 (7.7%) underwent surgery. Of the 74 patients not diagnosed with a fracture, 39 (52.7%) were treated with elastic bandage or kinesio tape in addition to medical treatment, 6 (8.1%) received plaster-splint in addition to medical treatment, and 29 (39.2%) were followed up with medical treatment only. OAR and the Shetty test showed significant clinical correlation (p = 0.006) (Table 3 ). Table 3 Clinical correlation of Shetty test and OAR score (*Chi-square test) Shetty Positive Shetty Negative Count Col % Row % Count Col % Row % OAR Positive 42 95.5% 50.0% 42 75.0% 50.0% Negative 2 4.5% 12.5% 14 25.0% 87.5% p* 0.006 Fractures were observed in 20 (47.6%) of 42 patients with both tests positive. Among the 14 patients with both tests negative, 2 (14.3%) were found to have fractures (Table 4 ). Table 4 Distribution of patients with and without fractures according to Shetty and OAR Fracture: Yes Fracture: No Shetty Positive Shetty Negative Shetty Positive Shetty Negative n % n % n % n % OAR Positive 20 100.0% 4 66.7% 22 91.7% 38 76.0% Negative 0 0.0% 2 33.3% 2 8.3% 12 24.0% The sensitivity, specificity, negative predictive value, positive predictive value, negative likelihood ratio, positive likelihood ratio, and diagnostic accuracy of the Shetty test and OAR were calculated and are presented in Table 5 . Table 5 Sensitivity, specificity, PPV, NPV, (+) LR, (−) LR, and accuracy of the tests Test Sensitivity % (95% CI) Specificity % (95% CI) PPV % (95% CI) NPV % (95% CI) (+) LR (95% CI) (−) LR (95% CI) Accuracy % (95% CI) Shetty 76.9 (56.35–91.03) 67.57 (55.68–78.00) 45.45 (30.39–61.15) 89.29 (78.12–95.97) 2.37 (1.61–3.50) 0.34 (0.17–0.70) — OAR 92.31 (74.87–99.05) 18.92 (10.75–29.70) 28.57 (25.49–31.86) 87.50 (63.02–96.64) 1.14 (0.97–1.33) 0.41 (0.10–1.67) 38.00 (28.48–48.25) After determining the positive and negative results of the OAR and Shetty tests, ROC analysis was conducted to assess the predictive accuracy of both tests in relation to fracture diagnosis (Table 6 , Fig. 2 ). Table 6 OAR and Shetty test ROC curve results (Area Under the Curve) Test variable AUC Std. Error* Asymptotic Sig.† 95% CI (Lower – Upper) OAR 0.556 0.063 0.396 0.433–0.680 Shetty 0.722 0.058 0.001 0.609–0.836 * Under the nonparametric assumption. † Null hypothesis: true area = 0.5. Note: The Shetty test result variable has at least one tie between the positive and negative actual state groups; statistics may be biased. Fractures were observed in 6 (10.7%) of the 56 patients in whom the Shetty test was negative. In 3 (50%) of these patients, the fracture was detected on plain radiography, and in the other 3 (50%), it could only be detected on CT. Treatment of patients with a negative Shetty test and radiologically detected fractures consisted of plaster-splint application and medical follow-up. DISCUSSION In our study, 42% of patients were female and the mean age was 29.9 years. A study conducted in Turkey examining the clinical evaluation and costs of patients presenting to the emergency department with ankle trauma found that, among 523 patients, 55.4% were male and 44.6% female, with a mean age of 33 years [ 15 ]. A recent study from Turkey reported a mean age of 37.2 years for patients with foot and ankle trauma, with women comprising 51.1% of the population [ 16 ]. A retrospective study in the USA found a mean age of 43.8 years among 280,933 patients with foot and ankle fractures or dislocations, with 42.6% female [ 17 ]. The age and sex ratios in our study are broadly consistent with the existing literature. Analysis of trauma mechanisms revealed that the most common reasons for presentation were sprains (46%), falls (22%), and traffic accidents (21%). In an epidemiological study of ankle fractures in the USA involving 673,214 patients, falling was the most common mechanism of injury (54.83%) [ 7 ]. Although sprain was the most common presenting complaint in our study, falls were associated with the highest fracture rate (36%). In a Turkish study, the average patient cost for ankle trauma was 123.22 ± 505.114 TL, with a mean of 3.21 ± 1.281 X-rays per patient. Bone fractures were observed in only 16% of these patients [ 15 ]. This underscores the potential value of physical examination tools such as the OAR and the Shetty test for reducing unnecessary radiography. In our study, the sensitivity of OAR was 92.31% and specificity was 18.92%. In a study from Portugal, OAR sensitivity was 100% and specificity was 26% [ 17 ]. In a Turkish study by Ak et al. involving 216 patients, sensitivity was 97.22% and specificity was 48.89% [ 18 ]. In a systematic review by Jonckheer et al. examining 21 studies, OAR sensitivity ranged from 92% to 100% and specificity from 16% to 51% [ 19 ]. Our findings are consistent with the literature, confirming high sensitivity and low specificity for OAR. In the original study by Vijay Shetty et al. involving 50 patients, fractures were observed in 3 (42.8%) of 7 (14%) patients who tested positive for the Shetty test, and no fracture was detected in any of the 43 (86%) patients with a negative result. The sensitivity was 100% (95% CI: 43.85–100%), specificity 91.49% (95% CI: 80.07–96.64%), positive predictive value 42.86% (95% CI: 15.82–74.95%), and negative predictive value 100% (95% CI: 91.8–100%) [ 1 ]. Ojeda-Jiménez et al. studied 100 patients and found fractures in 10 (71.4%) of 14 (14%) patients with a positive Shetty test, with no fractures among the 86 (86%) patients with a negative result; sensitivity and negative predictive value were both 100% [ 20 ]. In a pilot study in an emergency department, the Shetty test showed sensitivity of 92% and specificity of 40% when administered by nurses, and sensitivity of 100% with specificity of 28% when administered by medical officers and physiotherapists, with no significant difference between groups (McNemar p = 1.00) [ 14 ]. In a Turkish study by Avinca et al. involving 150 patients, sensitivity of the Shetty and Ottawa tests was close (82.86% vs 85.71%), but specificity of the Ottawa test was higher (82.61%) [ 21 ]. In another Turkish study with 207 patients, Ottawa sensitivity was 97.22% and specificity was 48.89%, while Shetty sensitivity was 51.39% and specificity was 85.93% [ 18 ]. In the present study, sensitivity of the Shetty test was 76% and specificity was 67%. In a study of 100 patients in Spain, sensitivity was 100% and specificity was 95.56% [ 20 ]. Despite these data, in a comparative study in Turkey with 150 patients in 2019, both specificity and sensitivity of the Shetty test were found to be lower than the OAR (82.86–85.71% vs 77.39–82.61%) [ 21 ]. Our study included 100 patients presenting to the emergency department with ankle sprain for whom radiographic imaging was ordered. After imaging, fractures were detected in 26 (26%) patients. The higher fracture rate compared to the literature is attributable to the study design, which included only patients for whom radiography had already been indicated. CONCLUSIONS Based on our research findings, the Ottawa Ankle Rules are suitable for screening purposes due to their high sensitivity. However, our results indicate that the Shetty test can safely reduce waiting times, radiation exposure, and costs for patients presenting with ankle trauma to emergency departments. Declarations Conflict of Interest: None declared. Ethics Approval: Obtained from the institutional clinical research board prior to study initiation. Ethics approval and consent to participate: Ethics approval was obtained from the Ethics Committee of the University of Health Sciences, Hamidiye Etfal Education and Research Hospital prior to study initiation. The study was conducted in accordance with the Declaration of Helsinki of the World Medical Association and Good Clinical Practice (GCP) guidelines. Written informed consent was obtained from all participants. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests. Funding None. Author Contribution IG conceived and designed the study. EA, HT, AA, AO, MK and NO collected data. IG performed statistical analysis. IG and EA drafted the manuscript. All authors read and approved the final manuscript. Acknowledgements: Not applicable. Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References Shetty V, Wasnik S, Hegde C, Shetty V, Kasture S, Thakur H. The Shetty test in ankle injuries: validation of a novel test to rule out ankle fractures. Eur J Orthop Surg Traumatol. 2013;23(7):831–3. Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJ. The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am. 2010;92(13):2279–84. Shah S, Thomas AC, Noone JM, Blanchette CM, Wikstrom EA. Incidence and cost of ankle sprains in United States emergency departments. Sports Health. 2016;8(6):547–52. Prakash AA. Epidemiology of high ankle sprains: a systematic review. Foot Ankle Spec. 2020;13(5):420–30. Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJ. The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am. 2010;92(13):2279–84. Roos KG, Kerr ZY, Mauntel TC, Djoko A, Dompier TP, Wikstrom EA. The epidemiology of lateral ligament complex ankle sprains in National Collegiate Athletic Association sports. Am J Sports Med. 2017;45(1):201–9. Scheer RC, Newman JM, Zhou JJ, Oommen AJ, Naziri Q, Shah NV, et al. Ankle fracture epidemiology in the United States: patient-related trends and mechanisms of injury. J Foot Ankle Surg. 2020;59(3):479–83. Chen ET, Borg-Stein J, McInnis KC. Ankle sprains: evaluation, rehabilitation, and prevention. Curr Sports Med Rep. 2019;18(6):217–23. Patel P, Russell TG. In: StatPearls, editor. Ankle radiographic evaluation. Treasure Island (FL): StatPearls Publishing; 2023. Haapamaki VV, Kiuru MJ, Koskinen SK. 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Evaluation of clinical features and cost of foot and ankle traumas in the emergency department. J Ankara Univ Fac Med. 2022;75(3):433–40. Ekinci S, Polat O, Günalp M, Demirkan A, Koca A. The accuracy of ultrasound evaluation in foot and ankle trauma. Am J Emerg Med. 2013;31(11):1551–5. Shibuya N, Davis ML, Jupiter DC. Epidemiology of foot and ankle fractures in the United States: an analysis of the National Trauma Data Bank (2007 to 2011). J Foot Ankle Surg. 2014;53(5):606–8. Ak R, Kurt E, Bahadırlı S, Çakır MS, Bilgü AS, Kurt ŞZE. The comparison of Ottawa Ankle Rules and Shetty test performances in foot-ankle trauma patients visited to the emergency department. Injury. 2022;53(6):2287–91. Jonckheer P, Willems T, De Ridder R, Paulus D, Holdt Henningsen K, San Miguel L, et al. Evaluating fracture risk in acute ankle sprains: any news since the Ottawa Ankle Rules? A systematic review. Eur J Gen Pract. 2016;22(1):31–41. Ojeda-Jiménez J, Méndez-Ojeda MM, Martín-Vélez P, Tejero-García S, Pais-Brito JL, Herrera-Pérez M. Experience using the 'Shetty test' for initial foot and ankle fracture screening in the Emergency Department. Rev Esp Cir Ortop Traumatol (Engl Ed). 2018;62(5):343–7. Avinca Ö, Taş M. Comparison of Shetty ankle test and Ottawa ankle rules in ankle injuries. Eur Rev Med Pharmacol Sci. 2023;27(5):1852–5. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9356939","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":628573752,"identity":"3dd01651-e450-42f3-9cd8-b6e3bbc7d7b8","order_by":0,"name":"Ihsan 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12:24:48","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9356939/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9356939/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108401828,"identity":"59628c67-4743-487a-9b9b-1c3adecb7ea1","added_by":"auto","created_at":"2026-05-04 09:07:18","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":35147,"visible":true,"origin":"","legend":"\u003cp\u003eStudy algorithm.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9356939/v1/d4320ecdb39ba3e7892363ff.jpeg"},{"id":108493384,"identity":"dbba2030-334f-4742-bac3-a93434c7010b","added_by":"auto","created_at":"2026-05-05 10:00:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":61543,"visible":true,"origin":"","legend":"\u003cp\u003eOAR and Shetty test ROC curve.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9356939/v1/62795820f03df6afd9c86628.png"},{"id":108495224,"identity":"aba414c7-9577-4036-890c-5ff48944e231","added_by":"auto","created_at":"2026-05-05 10:09:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":403276,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9356939/v1/ba747e1b-d75e-4281-83f9-2acebd63842b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparison of the Shetty Test and Ottawa Ankle Rules for the Exclusion of Ankle Fractures in the Emergency Department: A Prospective Study","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eAnkle and foot injuries are among the most common extremity traumas and have an important place among emergency department admissions [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Clinically significant fractures occur in 15\u0026ndash;30% of foot and ankle injuries. Ankle sprain is one of the most common musculoskeletal injuries among physically active individuals [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn a study conducted in the United States of America (USA) in 2010, there were 1,016,282 emergency room visits due to ankle sprains. The average application cost was calculated as \u003cspan\u003e$\u003c/span\u003e1,029 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In an epidemiological summary evaluating several studies, a higher incidence of ankle sprains was observed in men than in women in two studies, while three other studies found no gender difference. In a study including 125 high schools and universities in New Jersey, ankle sprains were more frequent in women at the high school level, while no incidence difference was observed at the university level. Injuries were mostly observed in individuals between the ages of 18\u0026ndash;34 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The incidence of ankle sprain was observed to be 9 times higher in the 15\u0026ndash;19 age group than in the 55\u0026ndash;59 age group [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt has been found that half of all ankle sprains treated in US emergency rooms are not related to sports participation, indicating that these injuries can affect a broad population beyond those who engage in sports or high levels of physical activity [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The most common injury mechanisms are falls (54.83%) and sports activities (20.76%). Eighty-two percent of patients who arrived at the emergency room were treated and released, while sixteen percent were admitted to the hospital [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe primary purpose of plain radiographs is to exclude fracture in ankle sprains. Anteroposterior, lateral, and oblique projections should be obtained under weight-bearing conditions [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The use of CT is not at the forefront in routine evaluation; it is used in the detection of clinically suspicious but radiologically challenging fractures, in the evaluation of fracture-dislocations, and as an aid in surgical planning [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Multidetector CT can be used as the primary modality for complex foot and ankle fractures in high-energy or polytrauma patients [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMany clinical studies have shown that the indication for radiography can be significantly reduced by using screening tools, thereby reducing ionizing radiation exposure for patients while saving economic resources and time [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The most widely used of these tools is the Ottawa Ankle Rules (OAR), developed in 1992 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The OAR can be challenging to apply in the emergency department because they involve evaluation of multiple anatomical regions and may require the patient to attempt walking. In 2013, Shetty and coworkers described a simpler method of evaluation that they reported could effectively exclude fractures in ankle trauma. According to their findings, this test proved highly effective in ruling out bone damage in cases of ankle trauma [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Since the Shetty test does not require mastery of anatomical localizations, it can be used safely in triage areas by non-clinician personnel [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study aims to assess the utility of the Shetty test in distinguishing patients without fractures in ankle injuries prior to radiography and to compare it with the OAR.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis study was conducted after receiving approval from the institutional clinical research board as a prospective clinical study. Patients presenting with ankle complaints to the orthopedic emergency department at the Seyrantepe Hamidiye Etfal campus between January 26, 2023, and April 26, 2023, for whom imaging was ordered by the clinician, were included. Patients who were unconscious, uncooperative, had serious trauma other than to the ankle, were under the age of 7, or were over the age of 80 were excluded.\u003c/p\u003e \u003cp\u003e After reading and signing the informed consent form, patients were taken to the examination room. History and anamnesis were recorded in the patient file. The Ottawa Ankle Rules and the Shetty test were applied and documented on the patient examination form.\u003c/p\u003e \u003cp\u003eFor the Ottawa Ankle Rules score, the following criteria were each evaluated and scored as one point: tenderness in the region 6 cm from the lower end of the medial malleolus; tenderness in the region 6 cm from the lower end of the lateral malleolus; tenderness in the navicular region; tenderness in the proximal fifth metatarsal; and inability to bear weight for four steps immediately after trauma or at the initial evaluation in the emergency room.\u003c/p\u003e \u003cp\u003eDuring the Shetty test, the patient is positioned on the examination stretcher and instructed to flex their knee. They are then requested to place their foot on the clinician's palm and simulate the pressure exerted by their body weight. If the patient is unable to replicate their weight due to pain, the test is deemed positive, indicating a possible fracture, and the patient is referred for radiographic evaluation. If the patient can simulate their weight, the test is considered negative and further imaging is not recommended [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn radiological evaluation, the results of patients who received plain radiography or advanced imaging based on clinician suspicion were examined. Treatment was divided into four groups: medical treatment only; elastic bandage in addition to medical treatment; plaster-splint in addition to medical treatment; and surgery (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSTATISTICAL ANALYSIS\u003c/h2\u003e \u003cp\u003eStatistical analysis was conducted using SPSS version 28.0 for Windows. The normality of continuous data was assessed using the Kolmogorov\u0026ndash;Smirnov test, in addition to descriptive statistics including skewness and kurtosis. Due to non-normal distribution in at least one group, all tests were conducted using non-parametric methods. Categorical variables were presented as numbers and percentages; numerical variables were described using median (minimum\u0026ndash;maximum) values. The Mann\u0026ndash;Whitney U test was used for difference analysis of numerical variables between two independent groups. Chi-square analysis was used to compare proportions in independent groups. ROC analysis was conducted to determine threshold values and perform predictive analysis for pathology in cases with a significant effect on dichotomous outcomes. Statistical significance was defined as p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe study comprised 100 individuals who sought treatment at Health Sciences University Hamidiye Etfal Training and Research Hospital following an ankle injury. Of these, 42% were women. The mean age was 29.9\u0026thinsp;\u0026plusmn;\u0026thinsp;16 years. The youngest patient was 7 years old and the oldest was 79 years. The median age was 30 years in female patients and 25 years in male patients.\u003c/p\u003e \u003cp\u003eOf the patients presenting with ankle injuries, 46 (46%) reported sprains and 22 (22%) reported falls as the mechanism of trauma.\u003c/p\u003e \u003cp\u003eThere were 84 (84%) patients who met the criteria for the Ottawa Ankle Rules, and 44 (44%) individuals had a positive Shetty test. Foot and ankle X-rays were taken for all patients. CT scans were performed in 26 (26%) patients when deemed necessary by the clinician after plain radiography evaluation. Fractures were observed in 18 (18%) patients on plain radiographs and in 21 (80%) patients on CT. After combined plain radiograph and CT evaluation, fractures were identified in 26 (26%) patients overall. No fracture was detected on plain radiography in 8 (38%) of the 21 (80.8%) patients with fractures detected on CT. Regarding treatment, medical treatment only was applied to 29 (29%) patients; elastic bandage to 39 (39%); cast or splint to 30 (30%); and 2 (2%) patients underwent surgery (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGeneral Characteristics of the Patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;100)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge \u0026ndash; mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD / median (min\u0026ndash;max)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.9\u0026thinsp;\u0026plusmn;\u0026thinsp;16.0 / 27 (7\u0026ndash;79)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (42%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (58%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTrauma mechanism\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (22%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSprain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (46%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObject falling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraffic accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (21%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImpact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOttawa Ankle Rules (OAR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84 (84%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (16%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eShetty Test\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (44%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56 (56%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFracture on radiograph\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (18%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82 (82%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFracture on CT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (80.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (19.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOverall fracture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (26%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74 (74%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTreatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eElastic bandage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (39%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePlaster-splint\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (30%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedical treatment only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (29%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe mean age of patients with fractures was 35.7\u0026thinsp;\u0026plusmn;\u0026thinsp;15.1 years, compared with 27.9\u0026thinsp;\u0026plusmn;\u0026thinsp;15.9 years in those without fractures. Patients with fractures were significantly older (p\u0026thinsp;=\u0026thinsp;0.007). There was no significant relationship between sex and fracture status (p\u0026thinsp;=\u0026thinsp;0.618).\u003c/p\u003e \u003cp\u003eWhen the relationship between fracture and trauma mechanism was examined, the most common fractures were associated with sprain (11 cases, 42.3%) and fall (8 cases, 30.8%).\u003c/p\u003e \u003cp\u003eFractures were detected in 20 (45.4%) of the 44 patients with a positive Shetty test, and in 24 (28.6%) of the 84 patients with a positive OAR (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFracture relationship of OAR and Shetty test\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eFracture Yes \u0026ndash; N (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eFracture No \u0026ndash; N (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOAR\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (92.3%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60 (81.1%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14 (18.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eShetty\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (76.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e24 (32.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (23.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e50 (67.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA fracture line was visible on plain radiographs in 18 (69.2%) of the 26 patients with fractures. Fractures were observed in 21 (80.7%) of 26 patients who underwent CT.\u003c/p\u003e \u003cp\u003eOf the 26 patients diagnosed with fracture, 24 (92.3%) received plaster-splint treatment and 2 (7.7%) underwent surgery. Of the 74 patients not diagnosed with a fracture, 39 (52.7%) were treated with elastic bandage or kinesio tape in addition to medical treatment, 6 (8.1%) received plaster-splint in addition to medical treatment, and 29 (39.2%) were followed up with medical treatment only.\u003c/p\u003e \u003cp\u003eOAR and the Shetty test showed significant clinical correlation (p\u0026thinsp;=\u0026thinsp;0.006) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical correlation of Shetty test and OAR score (*Chi-square test)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eShetty Positive\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eShetty Negative\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCol %\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRow %\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCol %\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eRow %\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOAR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e75.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e50.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e25.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e87.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ep*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFractures were observed in 20 (47.6%) of 42 patients with both tests positive. Among the 14 patients with both tests negative, 2 (14.3%) were found to have fractures (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of patients with and without fractures according to Shetty and OAR\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003eFracture: Yes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003eFracture: No\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eShetty Positive\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eShetty Negative\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eShetty Positive\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003eShetty Negative\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOAR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e66.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e91.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e76.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e33.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e8.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e24.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe sensitivity, specificity, negative predictive value, positive predictive value, negative likelihood ratio, positive likelihood ratio, and diagnostic accuracy of the Shetty test and OAR were calculated and are presented in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSensitivity, specificity, PPV, NPV, (+) LR, (\u0026minus;) LR, and accuracy of the tests\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTest\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSensitivity % (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSpecificity % (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePPV % (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNPV % (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(+) LR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(\u0026minus;) LR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAccuracy % (95% CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eShetty\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76.9 (56.35\u0026ndash;91.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67.57 (55.68\u0026ndash;78.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45.45 (30.39\u0026ndash;61.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e89.29 (78.12\u0026ndash;95.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.37 (1.61\u0026ndash;3.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.34 (0.17\u0026ndash;0.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOAR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92.31 (74.87\u0026ndash;99.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.92 (10.75\u0026ndash;29.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.57 (25.49\u0026ndash;31.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e87.50 (63.02\u0026ndash;96.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.14 (0.97\u0026ndash;1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.41 (0.10\u0026ndash;1.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e38.00 (28.48\u0026ndash;48.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAfter determining the positive and negative results of the OAR and Shetty tests, ROC analysis was conducted to assess the predictive accuracy of both tests in relation to fracture diagnosis (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOAR and Shetty test ROC curve results (Area Under the Curve)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTest variable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAUC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStd. Error*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAsymptotic Sig.\u0026dagger;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI (Lower \u0026ndash; Upper)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOAR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.556\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.063\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.396\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.433\u0026ndash;0.680\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShetty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.722\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.058\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.609\u0026ndash;0.836\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003e* Under the nonparametric assumption. \u0026dagger; Null hypothesis: true area\u0026thinsp;=\u0026thinsp;0.5. Note: The Shetty test result variable has at least one tie between the positive and negative actual state groups; statistics may be biased.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFractures were observed in 6 (10.7%) of the 56 patients in whom the Shetty test was negative. In 3 (50%) of these patients, the fracture was detected on plain radiography, and in the other 3 (50%), it could only be detected on CT. Treatment of patients with a negative Shetty test and radiologically detected fractures consisted of plaster-splint application and medical follow-up.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn our study, 42% of patients were female and the mean age was 29.9 years. A study conducted in Turkey examining the clinical evaluation and costs of patients presenting to the emergency department with ankle trauma found that, among 523 patients, 55.4% were male and 44.6% female, with a mean age of 33 years [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. A recent study from Turkey reported a mean age of 37.2 years for patients with foot and ankle trauma, with women comprising 51.1% of the population [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. A retrospective study in the USA found a mean age of 43.8 years among 280,933 patients with foot and ankle fractures or dislocations, with 42.6% female [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The age and sex ratios in our study are broadly consistent with the existing literature.\u003c/p\u003e \u003cp\u003eAnalysis of trauma mechanisms revealed that the most common reasons for presentation were sprains (46%), falls (22%), and traffic accidents (21%). In an epidemiological study of ankle fractures in the USA involving 673,214 patients, falling was the most common mechanism of injury (54.83%) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Although sprain was the most common presenting complaint in our study, falls were associated with the highest fracture rate (36%).\u003c/p\u003e \u003cp\u003eIn a Turkish study, the average patient cost for ankle trauma was 123.22\u0026thinsp;\u0026plusmn;\u0026thinsp;505.114 TL, with a mean of 3.21\u0026thinsp;\u0026plusmn;\u0026thinsp;1.281 X-rays per patient. Bone fractures were observed in only 16% of these patients [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This underscores the potential value of physical examination tools such as the OAR and the Shetty test for reducing unnecessary radiography.\u003c/p\u003e \u003cp\u003eIn our study, the sensitivity of OAR was 92.31% and specificity was 18.92%. In a study from Portugal, OAR sensitivity was 100% and specificity was 26% [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In a Turkish study by Ak et al. involving 216 patients, sensitivity was 97.22% and specificity was 48.89% [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In a systematic review by Jonckheer et al. examining 21 studies, OAR sensitivity ranged from 92% to 100% and specificity from 16% to 51% [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Our findings are consistent with the literature, confirming high sensitivity and low specificity for OAR.\u003c/p\u003e \u003cp\u003eIn the original study by Vijay Shetty et al. involving 50 patients, fractures were observed in 3 (42.8%) of 7 (14%) patients who tested positive for the Shetty test, and no fracture was detected in any of the 43 (86%) patients with a negative result. The sensitivity was 100% (95% CI: 43.85\u0026ndash;100%), specificity 91.49% (95% CI: 80.07\u0026ndash;96.64%), positive predictive value 42.86% (95% CI: 15.82\u0026ndash;74.95%), and negative predictive value 100% (95% CI: 91.8\u0026ndash;100%) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Ojeda-Jim\u0026eacute;nez et al. studied 100 patients and found fractures in 10 (71.4%) of 14 (14%) patients with a positive Shetty test, with no fractures among the 86 (86%) patients with a negative result; sensitivity and negative predictive value were both 100% [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In a pilot study in an emergency department, the Shetty test showed sensitivity of 92% and specificity of 40% when administered by nurses, and sensitivity of 100% with specificity of 28% when administered by medical officers and physiotherapists, with no significant difference between groups (McNemar p\u0026thinsp;=\u0026thinsp;1.00) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In a Turkish study by Avinca et al. involving 150 patients, sensitivity of the Shetty and Ottawa tests was close (82.86% vs 85.71%), but specificity of the Ottawa test was higher (82.61%) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In another Turkish study with 207 patients, Ottawa sensitivity was 97.22% and specificity was 48.89%, while Shetty sensitivity was 51.39% and specificity was 85.93% [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In the present study, sensitivity of the Shetty test was 76% and specificity was 67%.\u003c/p\u003e \u003cp\u003eIn a study of 100 patients in Spain, sensitivity was 100% and specificity was 95.56% [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Despite these data, in a comparative study in Turkey with 150 patients in 2019, both specificity and sensitivity of the Shetty test were found to be lower than the OAR (82.86\u0026ndash;85.71% vs 77.39\u0026ndash;82.61%) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study included 100 patients presenting to the emergency department with ankle sprain for whom radiographic imaging was ordered. After imaging, fractures were detected in 26 (26%) patients. The higher fracture rate compared to the literature is attributable to the study design, which included only patients for whom radiography had already been indicated.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eBased on our research findings, the Ottawa Ankle Rules are suitable for screening purposes due to their high sensitivity. However, our results indicate that the Shetty test can safely reduce waiting times, radiation exposure, and costs for patients presenting with ankle trauma to emergency departments.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConflict of Interest:\u003c/h2\u003e\n\u003cp\u003eNone declared.\u003c/p\u003e\n\u003ch2\u003eEthics Approval:\u003c/h2\u003e\n\u003cp\u003eObtained from the institutional clinical research board prior to study initiation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval was obtained from the Ethics Committee of the University of Health Sciences, Hamidiye Etfal Education and Research Hospital prior to study initiation. The study was conducted in accordance with the Declaration of Helsinki of the World Medical Association and Good Clinical Practice (GCP) guidelines. Written informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eCompeting interests:\u003c/h2\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eIG conceived and designed the study. EA, HT, AA, AO, MK and NO collected data. IG performed statistical analysis. IG and EA drafted the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements:\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eShetty V, Wasnik S, Hegde C, Shetty V, Kasture S, Thakur H. The Shetty test in ankle injuries: validation of a novel test to rule out ankle fractures. Eur J Orthop Surg Traumatol. 2013;23(7):831\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWaterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJ. The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am. 2010;92(13):2279\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShah S, Thomas AC, Noone JM, Blanchette CM, Wikstrom EA. Incidence and cost of ankle sprains in United States emergency departments. Sports Health. 2016;8(6):547\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrakash AA. Epidemiology of high ankle sprains: a systematic review. Foot Ankle Spec. 2020;13(5):420\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWaterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJ. The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am. 2010;92(13):2279\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoos KG, Kerr ZY, Mauntel TC, Djoko A, Dompier TP, Wikstrom EA. The epidemiology of lateral ligament complex ankle sprains in National Collegiate Athletic Association sports. Am J Sports Med. 2017;45(1):201\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScheer RC, Newman JM, Zhou JJ, Oommen AJ, Naziri Q, Shah NV, et al. Ankle fracture epidemiology in the United States: patient-related trends and mechanisms of injury. J Foot Ankle Surg. 2020;59(3):479\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen ET, Borg-Stein J, McInnis KC. Ankle sprains: evaluation, rehabilitation, and prevention. Curr Sports Med Rep. 2019;18(6):217\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel P, Russell TG. In: StatPearls, editor. Ankle radiographic evaluation. Treasure Island (FL): StatPearls Publishing; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaapamaki VV, Kiuru MJ, Koskinen SK. Ankle and foot injuries: analysis of MDCT findings. AJR Am J Roentgenol. 2004;183(3):615\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacLellan J, Smith T, Baserman J, Dowling S. Accuracy of the Ottawa Ankle Rules applied by non-physician providers in a pediatric emergency department. CJEM. 2018;20(5):746\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZia Ziabari SM, Monsef V, Asadi P, Ghodsi Khorsand SM, Homaie Rad E, Noyani A, et al. Evaluation of the accuracy and cost-effectiveness of using the Bernese and Ottawa rules in ankle sprain. Int J Burns Trauma. 2021;11(1):34\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. 1992;21(4):384\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJovic D, Johnson D, Tolmie L, Stanier P, Hutchins R. Shetty test in ankle and foot trauma: an emergency department pilot study assessing specificity and sensitivity. Emerg Med Australas. 2020;32(4):683\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGen\u0026ccedil; S, \u0026Ccedil;atal Y, Şen M, Oğuz AB, Koca A, G\u0026uuml;nalp Eneyli M, et al. Evaluation of clinical features and cost of foot and ankle traumas in the emergency department. J Ankara Univ Fac Med. 2022;75(3):433\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEkinci S, Polat O, G\u0026uuml;nalp M, Demirkan A, Koca A. The accuracy of ultrasound evaluation in foot and ankle trauma. Am J Emerg Med. 2013;31(11):1551\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShibuya N, Davis ML, Jupiter DC. Epidemiology of foot and ankle fractures in the United States: an analysis of the National Trauma Data Bank (2007 to 2011). J Foot Ankle Surg. 2014;53(5):606\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAk R, Kurt E, Bahadırlı S, \u0026Ccedil;akır MS, Bilg\u0026uuml; AS, Kurt ŞZE. The comparison of Ottawa Ankle Rules and Shetty test performances in foot-ankle trauma patients visited to the emergency department. Injury. 2022;53(6):2287\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJonckheer P, Willems T, De Ridder R, Paulus D, Holdt Henningsen K, San Miguel L, et al. Evaluating fracture risk in acute ankle sprains: any news since the Ottawa Ankle Rules? A systematic review. Eur J Gen Pract. 2016;22(1):31\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOjeda-Jim\u0026eacute;nez J, M\u0026eacute;ndez-Ojeda MM, Mart\u0026iacute;n-V\u0026eacute;lez P, Tejero-Garc\u0026iacute;a S, Pais-Brito JL, Herrera-P\u0026eacute;rez M. Experience using the 'Shetty test' for initial foot and ankle fracture screening in the Emergency Department. Rev Esp Cir Ortop Traumatol (Engl Ed). 2018;62(5):343\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAvinca \u0026Ouml;, Taş M. Comparison of Shetty ankle test and Ottawa ankle rules in ankle injuries. Eur Rev Med Pharmacol Sci. 2023;27(5):1852\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Ottawa ankle rules, Shetty test, ankle fracture, emergency department, clinical decision rule","lastPublishedDoi":"10.21203/rs.3.rs-9356939/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9356939/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eFoot and ankle injuries are common in emergency department visits. Various screening tools have been developed to reduce the use of radiography, aiming to minimize radiation exposure, save resources, and optimize time. The objective of this study is to assess the efficacy of the Shetty test in distinguishing patients without ankle fractures, in comparison to the commonly employed Ottawa Ankle Rules (OARs).\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e \u003cp\u003eThe scheduled dates for performing this prospective clinical trial were January 26, 2023, and April 26, 2023, at the Seyrantepe Hamidiye Etfal campus. A total of 100 patients presenting with ankle sprain to the emergency and orthopedic emergency departments were included if a decision for imaging was made by the clinician.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e58% of total patients were male. The overall mean age was 29.9\u0026thinsp;\u0026plusmn;\u0026thinsp;16 years. Ankle sprain was the most common reason for presentation. A total of 26 patients were diagnosed with fractures after radiological evaluation. The sensitivity of the Shetty test was found to be 76.92%, with a specificity of 67.57%. The sensitivity of the OARs was 92.31%, with a specificity of 18.92%. There was a significant correlation between the Shetty test and the OARs (p\u0026thinsp;=\u0026thinsp;0.006).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe results of this investigation indicate that the Shetty test can safely reduce waiting times, radiation exposure, and patient costs in ankle trauma cases presenting to emergency departments.\u003c/p\u003e","manuscriptTitle":"Comparison of the Shetty Test and Ottawa Ankle Rules for the Exclusion of Ankle Fractures in the Emergency Department: A Prospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-04 09:07:15","doi":"10.21203/rs.3.rs-9356939/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7153a6eb-9963-43ac-b35f-e4c75a1526d8","owner":[],"postedDate":"May 4th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-05T04:52:20+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-05T05:08:10+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-04 09:07:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9356939","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9356939","identity":"rs-9356939","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}