Ottawa Ankle Rules

Purpose[edit | edit source]

Ankle sprains are a common occurrence in athletes as well as the general population. Traditionally, physicians would order radiographs for all ankle injuries, although less than 15% would have a clinically significant fracture,[1] and add to healthcare costs. The Ottawa Ankle Rules were established to help physicians decide which patients should have an x-ray following an acute ankle injury.[2]

Variables[3][edit | edit source]

OAR













Figure 1. Palpation locations within the malleolar and midfoot zones. (Image from CDR Ankle Poster)[4]


A. Bony tenderness along distal 6 cm of posterior edge of fibula or tip of lateral malleolus

B. Bony tenderness along distal 6 cm of posterior edge of tibia/tip of medial malleolus

C. Bony tenderness at the base of 5th metatarsal

D. Bony tenderness at the navicular

E. Inability to bear weight both immediately after injury and for 4 steps during intial evaluation

Method of Use[3][edit | edit source]

An ankle x-ray series is only required if there is pain in the malleolar zone AND any of variables A or B or E.

A foot x-ray series is only required if there is pain in the midfoot zone AND any of variables C or D or E.

Recommendations[3][edit | edit source]

Ensure to apply the Ottawa Ankle Rules accurately by...

  1. Palpating the entire distal 6cm of the tibia and fibula
  2. Not neglecting the importance of medial malleolar tenderness
  3. Using the rules only on those over the age of 18

Be sure to give written instructions and encourage follow-up in 5-7 days if pain and walking ability have not improved.

Evidence[edit | edit source]

A systematic review of 27 studies by Bachmann et al found the pooled sensitivity of the Ottawa Ankle Rules to be 97.6%, with a median specificity of 31.5%.[5] The pooled negative likelihood ratio for the ankle and midfoot were 0.08 and 0.08 respectively whereas in children it was 0.07. The authors applied these ratios to the reported 15% fracture prevalence and determined the probability of a fracture after negative testing following implementation of the Ottowa Ankle Rules to be less than 1.4%. The authors concluded the instrument should reduce the number of unneccessary radiographs by 30-40%.[5]

Reliability[edit | edit source]

The Ottawa Ankle Rules have been found to have sensitivities of 1.0 (95% confidence interval (CI), .95-1.0) for detecting malleolar fractures and 1.0 (95% CI, .82-1.0) for detecting midfoot fractures.[6]

Accuracy[edit | edit source]

A systematic review of 27 studies found a 1.73% (95% CI, 1.05-2.75) probability of a fracture after negative testing when implementing the Ottawa Ankle Rules. When implemented less than 48 hours after injury, the fracture probability went to 1.05 (95% CI .35-3.24).[5]

Validity[edit | edit source]

In children aged 2-16, the Ottawa Ankle Rules were found to have a sensitivity of 1.0 (95% CI, .95-1.0) for malleolar fractures and 1.0 (95% CI, .82-1.0) for midfoot fractures.[7]

Clinical Significance[edit | edit source]

When implementing the Ottawa Ankle Rules in the emergency or clinic setting, the relative reduction in ankle radiography was reduced by 28% compared to a 2% increase in a control setting not using the rules (P<.001). Foot radiography was reduced by 14% at an intervention hospital and increased by 13% at the control hospital (P<.05). Significant differences in time spent in emergency department (P<.0001) and a lower estimated total medical costs for physician visits and radiography (P<.001) were also found.[6]

Resources[edit | edit source]

http://www.ohri.ca/emerg/cdr/ankle_rule_flash.html

Recent Related Research (from Pubmed)[edit | edit source]

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References:[edit | edit source]

  1. Brooks SC, Potter BT, Rainey JB. Inversion injuries of the ankle: clinical assessment and radiographic review. BMJ 1981; 282: 607-608
  2. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, Stewart JP, Maloney J. Decision rules for the use of radiography in acute ankle injuries. JAMA 1993;269:1127-32.
  3. 3.0 3.1 3.2 Stiell IG, McKnight RD, Greenberg GH, McDowell I, Nair RC, Wells GA, Johns C, Worthington JR. Implementation of the Ottawa Ankle Rules. JAMA 1994;271:827-32.
  4. http://www.ohri.ca/emerg/cdr/docs/cdr_ankle_poster.pdf
  5. 5.0 5.1 5.2 Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: Systematic review. BMJ 2003;326:417-23.
  6. 6.0 6.1 Stiell IG, McKnight RD, Greenberg GH, McDowell I, Nair RC, Wells GA, et al. Implementation of the Ottawa ankle rules. JAMA 1994; 271: 827-832
  7. Plint AC, Bulloch B, Osmond MH, et al. Validation of the Ottawa Ankle Rules in children with ankle injuries. Acad Emerg Med. 1999 Oct;6(10):1005-9