HWN Suggests

Ottawa Ankle Rules

The Ottawa Ankle Rules are simple guidelines... First, while inspecting the medial ankle, palpating along the posterior edge of the medial malleoli as well as proximally 6 cm along the tibia. Then, palpate over the navicular bone. Now, on the lateral ankle, again palpate along the posterior edge of the malleoli including superior 6 cm along the fibula. Finally, palpate the base of the 5th metatarsal. If the patient is unable to walk 4 steps and has malleoli pain and tenderness an ankle x-ray series is indicated, while inability to walk 4 steps and mid-foot pain with navicular or 5th metatarsal pain indicates need for a foot x-ray series.

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 A 20-year perspective on the Ottawa Ankle Rules Are we still on solid footing?

The OARs remain the de facto standard of care for clinical decision-making and for using or deferring radiographic imaging in patients with traumatic ankle and foot injuries. Other protocols and technologies may approach or equal the OARs, but none supplants them for simplicity, reproducibility, and reliability. Research supports the broad adoption beyond North America and to other practice settings such as urgent care and family practice. Research also supports the full adoption and implementation by other healthcare providers, including ED triage nurses. After more than 20 years, the OARs remain on solid footing.

Articles of Interest

Can We Safely Apply the Ottawa Ankle Rules to Children?

The validated rules state that an ankle x-ray series is only indicated after an acute blunt injury when there is pain in the malleolar zone and bony tenderness to palpation over the posterior edge or tip of either the medial or lateral malleolus or if the patient is unable to bear weight both immediately and in the ED. Likewise, a foot x-ray series is indicated only when there is pain in the midfoot and bony tenderness to palpation of either the navicular or the base of the fifth metatarsal or if the patient is unable to bear weight both immediately and in the ED.

Clinician's Corner: Mastering the Ottawa Ankle Rule: What is it?

The Ottawa Ankle Rule (OAR) carries a 100% sensitivity for ankle or foot fractures (Stiell et al., 1992) and has been validated for use in multiple studies (Sperry et al., 1999; Stiell et al., 1993). Subsequent studies have found that the OAR can be applied to children aged 2–16 years presenting to the emergency department (ED) with similarly high sensitivity (Plint et al., 1999).

Diagnostic accuracy of the Ottawa ankle rule to exclude fractures in acute ankle injuries in adults: a systematic review and meta-analysis

Application of the OAR is highly sensitive and can correctly predict the likelihood of ankle fractures when present, however, lower specificity rates increase the likelihood of false positives. Overall, the use of the OAR tool is supported as a cost-effective method of reducing unnecessary radiographic referral, that should improve efficiency, lower medical costs and reduce waiting times.

Revisiting the humble ankle sprain

Ankle injuries are one of the most common presentations to the Emergency Department (ED), but few emergency physicians would consider them to represent a diagnostic challenge. In our armoury, we already have the Ottawa ankle rules (which are highly sensitive for bony injury) and access to plain radiographs. However, Deutekom et al present a systematic review of studies evaluating the diagnostic accuracy of ultrasound for ankle injuries. Why should we consider another diagnostic modality for such a straightforward injury? There are three good reasons.

The Challenges of Implementing and Documenting Ottawa Ankle Rules in the Pediatric Emergency Department

Implementing the highly sensitive OAR yielded zero missed fractures. Their poor specificity results in unnecessary radiation exposure, which also increases expense and wait time. Excess imaging may be attributed to ambiguous OAR criteria, their dependence on pediatric cooperation, and parental expectations for imaging studies.

The Stiell Sessions: Clinical Decision Rules and Risk Scales

There are hundreds of clinical decision rules and risk scales published in the medical literature, some more widely adopted than others. Dr. Ian Stiell, the father of clinical decision rules, shares with us his views and experiences gained from co-creating some of the most influential CDRs and risk scales to date.

Resources

Ottawa Ankle Rule

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

Radiopaedia

There are two components, assessing for ankle and midfoot fractures. A patient with traumatic ankle pain qualifies for ankle radiographs if they have any of the following - point tenderness at posterior edge (of distal 6 cm) or tip lateral malleolus. point tenderness at posterior edge (of distal 6 cm) or tip medial malleolus. inability to weight bear (four steps) immediately after the injury and in emergency department.