Purpose: The Ottawa Knee Rules were developed in order to determine the need for radiographs after acute knee injury secondary to the risk of fracture.

Stage of CPR Development: Validated.


1. Age > 55
2. Tenderness at the head of the fibula
3. Isolated tenderness of the patella during palpation
4. Inability to flex the knee to 90 degrees
5. Inability to bear weight immediately and upon ER evaluation


Study Sensitivity Specificity -LR NPV
Stiell et al., 1996 1.00 0.50 0.02 N/A
Diercks et al., 1997 1.00 0.38 0.19 N/A
Richman et al., 1997 0.85 0.45 0.34 N/A
Stiell et al., 1997 1.00 0.48 0.02 N/A
Seaberg et al., 1998 0.97 0.27 0.13 N/A
Tigges et al., 1999 0.98 0.19 0.12 N/A
Cook et al., 2001 1.00 0.42 0.24 N/A
Emparanza et al., 2001 1.00 0.52 0.01 N/A
Khine et al., 2001 0.92 0.49 0.16 N/A
Szucs et al., 2001 1.00 0.47 0.12 N/A
Ketelslegers et al., 2002 1.00 0.32 N/A 100%
Kec et al., 2003 0.70-1.00 0.25-0.33 N/A 91-100%
Bullock et al., 2003 1.00 0.43 N/A 100%
Jenny et al., 2005 1.00 0.35 N/A N/A
Jalili et al., 2010 0.95 0.44 0.09 99.1%
Konan et al., 2013 1.00 0.23 N/A 100%
Cheung et al., 2013 0.86 0.23 N/A 95%


1. Stiell IG, Greenberg GH, Wells GA, McDowell I, Cwinn AA, Smith NA, et al. Prospective validation of a decision rule for the use of radiography in acute knee injuries. JAMA. 1996;275:611-5.

2. Diercks DB, Hall KN, Hamilton CA. Validation ofthe Ottawa knee rules in an urban teaching emergency department [Abstract]. Acad Emerg Med. 1997;4: 408.

3. Richman PB, McCuskey CF, Nashed A, Fuchs S, Petrik R, Imperato M, et al. Performance of two clinical decision rules for knee radiography. J Emerg Med. 1997;15:459-63.

4. Stiell IG, Wells GA, Hoag RH, Sivilotti ML, Cacciotti TF, Verbeek PR, et al. Implementation of the Ottawa Knee Rule for the use of radiography in acute knee injuries. JAMA. 1997;278:2075-9.

5. Seaberg DC, Yealy DM, Lukens T, Auble T, Mathias S. Multicenter comparison of two clinical decision rules for the use of radiography in acute, high-risk knee injuries. Ann Emerg Med. 1998;32:8-13.

6. Tigges S, Pitts S, Mukundan S Jr, Morrison D, Olson M, Shahriara A. External validation of the Ottawa knee rules in an urban trauma center in the United States. AJR Am J Roentgenol. 1999;172:1069-71.

7. Cook SR, Lillis K, Leddy JJ. Evaluation of the Ottawa knee rule in a pediatric E.D. and university sports medicine center [Abstract]. Med Sci Sports Exerc. 2001;33:S186.

8. Emparanza JI, Aginaga JR. Validation of the Ottawa Knee Rules. Ann Emerg Med. 2001;38:364-8.

9. Khine H, Dorfman DH, Avner JR. Applicability of Ottawa knee rule for knee injury in children. Pediatr Emerg Care. 2001;17:401-4.

10. Szucs PA, Richman PB, Mandell M. Triage nurse application of the Ottawa knee rule. Acad Emerg Med. 2001;8:112-6.

11. Ketelslegers E, et al. Validation of the Ottawa knee rules in an emergency teaching centre. European Radiology. 2001;12(5):1218-1220. doi:10.1007/s00330-001-1198-9.

12. Kec RM, et al. Can emergency department triage nurses appropriately utilize the Ottawa Knee Rules to order radiographs?-An implementation trial. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2003;10(2):146-150.

13. Bullock B, et al. Validation of the Ottawa Knee Rule in children: a multicenter study. Annals of Emergency Medicine. 2003;42(1):48-55. doi:10.1067/mem.2003.196.

14. Bachmann LM, Haberzeth S, Stuerer J, ter Riet G. The accuracy of the Ottawa Knee Rule to rule out knee fractures: a systematic review. Ann Intern Med. 2004; 140: 121–124.

15. Jenny JY, et al. Should plain X-rays be routinely performed after blunt knee trauma? A prospective analysis. The Journal of Trauma. 2005; 58(6):1179-82.

16. Vijaysankar D, Boyle AA, Atkinson P. Can the Ottawa Knee Rule be applied to children? A systematic review and meta analysis of observational studies. Emerg Med J. 2009; 26: 250-253.

17. Jalili M, et al. Validation of the Ottawa Knee Rule in Iran: a prospective study. Emergency medicine journal : EMJ. 2010;27(11):849-851. doi:10.1136/emj.2009.080267.

18. Konan S, et al. Can the Ottawa and Pittsburgh rules reduce requests for radiography in patients referred to acute knee clinics? Annals of the Royal College of Surgeons of England. 2013;95(3):188-191. doi:10.1308/003588413X13511609954699.

19. Cheung TC, et al. Diagnostic accuracy and reproducibility of the Ottawa Knee Rule vs the Pittsburgh Decision Rule. The American Journal of Emergency Medicine. 2013;31(4):641-645. doi:10.1016/j.ajem.2012.11.003.

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