—We wish to draw Dr Hatch's attention to the "Data Collection" section (second paragraph), which is given entirely to the issue of clinically significant fractures:The criterion standard that the decision rules were designed to identify were clinically significant fractures seen in the ankle or foot radiographic series. These radiographic series were interpreted by qualified radiologists who were blinded to the content of the data collection sheets. We defined clinically significant fractures as bone fragments greater than 3 mm in breadth. This definition was agreed on by members of the emergency and orthopedics departments and reflects clinical management in that malleolar or midfoot avulsion fractures of 3 mm or less are not treated with plaster immobilization in our institutions.1The rules, from their inception, were not designed to detect tiny avulsion fractures, and hence sensitivity was not calculated for this outcome. In our experience, however, the vast
Stiell IG, Greenberg GH, McKnight RD. Radiography for Ankle Injuries-Reply. JAMA. 1993;270(4):454. doi:10.1001/jama.1993.03510040057027
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