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Ottawa Ankle Rule in the Evaluation for Fractures in Blunt Ankle Injuries

Summary:

The Ottawa Ankle Rule can be used in the evaluation of ankle injuries to identify patients who have a low likelihood of fracture. This obviates the need for obtaining ankle radiographs in certain patients, reducing cost, resource utilization, radiation exposure, and potentially, emergency department length of stay.

Interpretation:

A patient presenting with ankle injury needs ankle radiographs only if there is pain near the malleoli and any of the following findings are true:

  • Inability to bear weight both immediately and in the emergency department (four steps)
  • Bone tenderness at the posterior edge or tip of either malleolus

A patient presenting with ankle injury needs foot radiographs only if there is pain in the midfoot and any of the following findings are true:

  • Inability to bear weight both immediately and in the emergency department (four steps)
  • Bone tenderness at the navicular or the base of the fifth metatarsal

Additional Clinical Considerations:

The Ottawa ankle rule is an excellent screening tool for patients with ankle injuries. It has very high sensitivity (100% in initial studies and 97.6% in subsequent meta-analysis), and is therefore unlikely to miss clinically significant ankle and midfoot injuries. It has been studied in both adult and pediatric patients.

The Ottawa ankle rule is well validated and has been shown to limit the number of radiographs obtained for ankle injuries. However, there is some reluctance to use it due to ease and speed of obtaining radiographs, patient expectations, and clinician fears over missed fractures and possible litigation.


Author: Dylan Kellogg, MD
Editors: Anthony J. Busti, MD, PharmD, FNLA, FAHA
Last Updated:  August 2015

Landmark or Original Studies

  • 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 April;21:384-90. PubMed
  • 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: refinement and prospective validation. JAMA. 1993 Mar 3;269(9):1127-32. PubMed

Supporting Studies

  • 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 Feb 22;326(7386):417. PubMed
  • Plint AC, Bulloch B, Osmond MH, Stiell I, Dunlap H, Reed M, Tenenbein M, Klassen TP. Validation of the Ottawa ankle rules in children with ankle injuries. Acad Emerg Med. 1999 Oct;6(10):1005-9. PubMed

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MESH Terms or Keywords

  • Ottawa Ankle Rule, Ankle Injuries Ottawa, Ankle Xrays Ottawa Rule