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Ottawa Ankle Rules

Rules out clinically significant foot and ankle fractures to reduce x-ray imaging

CreadorDr. Ian Stiell, MD, MSc, FRCPC
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Instrucciones

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

RoshReview (Wolf Y, 2018)

Introduction

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.

Using the Ottawa Ankle Rule can reduce the number of unnecessary radiographs, limit radiation exposure, and improve patient flow.

Considerations

  • 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.

  • 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.

Todas las preguntas y los resultados posibles

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
Resultados posibles
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.

 

Cómo citar

Stiell 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 Apr;21(4):384-90. doi: 10.1016/s0196-0644(05)82656-3. PMID: 1554175.

Bibliografía

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