Ottawa Ankle Rules
Rules our clinically significant foot and ankle fractures to reduce of x-ray imaging
Jennifer Glen
Provided by
EVAL FoundationInstructions
Indication: Patients ≥ 2 years with ankle or midfoot pain or tenderness in the setting of trauma
Precautions: Use clinical judgment if examination may be compromised for any of the following circumstances:
- Intoxication
- Distracting painful injuries
- Gross swelling which prevents palpation of tenderness
- Diminished sensation in legs
- Uncooperative patient
Anatomy
The Ottawa Ankle Rule aids in the judicious use of radiography in acute and midfoot injuries. Indicated in patients ≥ 2 years with ankle or midfoot pain or tenderness in the setting of trauma but ought to use caution in ages < 18 years. Implementation of the Ottawa Ankle Rule may reduce unnecessary radiographs and radiation exposure while improving patient flow. Additionally, patients without criteria for imaging are unlikely to have a clinically significant fracture.
.Summary
Using the Ottawa Ankle Rule can reduce the number of unnecessary radiographs, limit radiation exposure, and improve patient flow.
Notes
- Ottawa Rules are good at ruling out fracture (high sensitivity) but poor for ruling in fractures (many false positives).
- High Sensitivity (90-100%) for ruling out clinically significant ankle and midfoot fractures (fracture/avulsion > 3 mm)
- Lower Specificity (41% for ankle & 79% for Foot) for ruling in facture, and not intended for specific diagnosis.
Considerations
- Palpate the entire distal 6 cm of the fibula and tibia.
- Weight bearing counts even if the patient limps.
- Precautions: Use clinical judgment if examination may be compromised for any of the following circumstances:
- Intoxication
- Distracting painful injuries
- Gross swelling which prevents palpation of tenderness
- Diminished sensation in legs
- Uncooperative patient
Rules
- An ankle x-ray series is only required if there is pain in the malleolar zone AND any of these findings:
- Bone tenderness at the posterior edge or tip of lateral malleolus, OR
- Bone tenderness at the posterior edge or tip of medial malleolus, OR
- Inability to bear weight both immediately after injury AND in ED.
- A foot x-ray series is only required if there is pain in the midfoot zone AND any of these findings:
- Bone tenderness at the base of 5th metatarsal, OR
- Bone tenderness at the navicular, OR
- Inability to bear weight both immediately after injury AND in ED.
All questions & possible results
Anatomy
Location of pain
Select all that apply:
- Malleolar
- Midfoot
Malleolar bone tenderness at the posterior edge of the distal 6 cm or the tip of lateral malleolus
Select one option:
- No
- Yes
Malleolar bone tenderness at the posterior edge of the distal 6 cm or the top of medial malleolus
Select one option:
- No
- Yes
In the presence of malleolar bone tenderness, there is an inability to bear weight (unable to take 4 steps) both immediately after injury AND in ED
Limping counts as weight bearing.
Select one option:
- No
- Yes
Midfoot bone tenderness at the base of the 5th metatarsal
Select one option:
- No
- Yes
Midfoot bone tenderness at the navicular
Select one option:
- No
- Yes
In the presence of midfoot tenderness, there is an inability to bear weight (unable to take 4 steps) both immediately after injury AND in ED
Limping counts as weight bearing.
Select one option:
- No
- Yes
Possible results
Ruled out: Ankle x-ray series not indicated.
Sensitivity & Specificity
Ottawa Rules are good at ruling out fracture (high sensitivity) but poor for ruling in fractures (many false positives).
- High Sensitivity (90-100%) for ruling out clinically significant ankle and midfoot fractures (fracture/avulsion > 3 mm)
- Lower Specificity (41% for ankle & 79% for Foot) for ruling in facture, and not intended for specific diagnosis.
Management
- X-ray
- RICE plan (Rest, Ice, Compression, Elevation)
- Consider splinting/crutches, pain medication or specialty referral as indicated
- Follow-up in 5-7 days if pain and ability to walk are not improved.
Ruled out: Foot x-ray series not indicated.
Sensitivity & Specificity
Ottawa Rules are good at ruling out fracture (high sensitivity) but poor for ruling in fractures (many false positives).
- High Sensitivity (90-100%) for ruling out clinically significant ankle and midfoot fractures (fracture/avulsion > 3 mm)
- Lower Specificity (41% for ankle & 79% for Foot) for ruling in facture, and not intended for specific diagnosis.
Management
- X-ray
- RICE plan (Rest, Ice, Compression, Elevation)
- Consider splinting/crutches, pain medication or specialty referral as indicated
- Follow-up in 5-7 days if pain and ability to walk are not improved.
Cannot rule out: Foot x-ray series indicated.
Sensitivity & Specificity
Ottawa Rules are good at ruling out fracture (high sensitivity) but poor for ruling in fractures (many false positives).
- High Sensitivity (90-100%) for ruling out clinically significant ankle and midfoot fractures (fracture/avulsion > 3 mm)
- Lower Specificity (41% for ankle & 79% for Foot) for ruling in facture, and not intended for specific diagnosis.
Management
- X-ray
- RICE plan (Rest, Ice, Compression, Elevation)
- Consider splinting/crutches, pain medication or specialty referral as indicated
- Follow-up in 5-7 days if pain and ability to walk are not improved.
Cannot rule out: Ankle x-ray series indicated.
Sensitivity & Specificity
Ottawa Rules are good at ruling out fracture (high sensitivity) but poor for ruling in fractures (many false positives).
- High Sensitivity (90-100%) for ruling out clinically significant ankle and midfoot fractures (fracture/avulsion > 3 mm)
- Lower Specificity (41% for ankle & 79% for Foot) for ruling in facture, and not intended for specific diagnosis.
Management
- X-ray
- RICE plan (Rest, Ice, Compression, Elevation)
- Consider splinting/crutches, pain medication or specialty referral as indicated
- Follow-up in 5-7 days if pain and ability to walk are not improved.
Literature
- A study to develop clinical decision rules for the use of radiography in acute ankle injuries — Stiell IG, Greenberg GH, McKnight RD, et al
- Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation — Stiell IG, Greenberg GH, McKnight RD, et al
- Implementation of the Ottawa ankle rules — Stiell IG, McKnight RD, Greenberg GH, et al
