CanadiEM MVP Infographic Series – A Study to Develop Clinical Decision Rules for the Use of Radiography in Acute Ankle Injuries

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This post will highlight a study by Stiell et. al (1992) in which the authors successfully developed highly sensitive clinical decision rules to detect significant ankle and foot fractures on radiography.1  

At the time of this study, the authors noted that there were no widely accepted guidelines for the use of radiography in ankle injuries.2,3 Ankle radiographic series were the second most commonly performed musculoskeletal exam in the emergency department despite the incidence of significant fractures being less than 15%.4-8 The annual cost of these radiographs exceeded those of low volume but high-technology procedures such as coronary catherization (Ontario Ministry of Health, March 1991). The unnecessary radiographs also led to unwarranted radiation exposures in patients. 9-11 

This prospective study was conducted in emergency departments of the Ottawa Civic and Ottawa General Hospitals over a five month period. The inclusion and exclusion criteria for the study are listed in the infographic above. Staff emergency physicians noted 32 clinical variables, such as specific points of bone tenderness, on a data form and estimated the probability that the patient had a significant fracture. Physicians then ordered an ankle x-ray if the patient had any pain or tenderness in the malleolar zone and a foot x-ray if there was any pain or tenderness in the midfoot zone.

The results showed that an ankle x-ray should be ordered if there is pain near the malleoli AND at least one of:

  • age 55 or greater
  • unable to bear weight immediately after injury AND in the ED (4 steps)
  • or bone tenderness at the posterior edge or tip of either malleolus.

Results also found that a foot x-ray should be ordered if there is pain in the midfoot AND:

  • bone tenderness at the navicular, cuboid or base of the fifth metatarsal

These rules were found to be 100% sensitive and 40.1% specific. The authors believed that these rules would reduce 1/3 of the ankle and foot x-rays ordered in the emergency department leading to a significant reduction in annual healthcare costs.

Further studies have been conducted since 1992 which have led to a modification in these clinical decision rules. To learn more about the updated rules, please visit


  1. Stiell I, Greenberg G, McKnight R, Nair R, McDowell I, Worthington J. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. 1992;21(4):384-390.
  2. Bell R, Loop J. The utility and futility of radiographic skull examination for trauma. N Engl J Med. 1971;284(5):236-239.
  3. Masters S, McClean P, Arcarese J, et al. Skull x-ray examinations after head trauma. Recommendations by a multidisciplinary panel and validation study. N Engl J Med. 1987;316(2):84-91.
  4. Brooks S, Potter B, Rainey J. Inversion injuries of the ankle: clinical assessment and radiographic review. Br Med J (Clin Res Ed). 1981;282(6264):607-608.
  5. Vargish T, Clarke W, Young R, Jensen A. The ankle injury–indications for the selective use of X-rays. Injury. 1983;14(6):507-512.
  6. Montague A, McQuillan R. Clinical assessment of apparently sprained ankle and detection of fracture. Injury. 1985;16(8):545-546.
  7. Sujitkumar P, Hadfield J, Yates D. Sprain or fracture? An analysis of 2000 ankle injuries. Arch Emerg Med. 1986;3(2):101-106.
  8. Diehr P, Highley R, Dehkordi F, et al. Prediction of fracture in patients with acute musculoskeletal ankle trauma. Med Decis Making. 1988;8(1):40-47.
  9. Matthews M. Guidelines for selective radiological assessment of inversion ankle injuries. Br Med J (Clin Res Ed). 1986;293(6552):957.
  10. Abrams HL. The Overutilization of X-Rays. N Engl J Med. May 1979:1213-1216. doi:10.1056/nejm197905243002110
  11. Cockshott W, Jenkin J, Pui M. Limiting the use of routine radiography for acute ankle injuries. Can Med Assoc J. 1983;129(2):129-131.
  12. Gleadhill D, Thomson J, Simms P. Can more efficient use be made of x ray examinations in the accident and emergency department? Br Med J (Clin Res Ed). 1987;294(6577):943-947.

This post was peer reviewed by Alvin Chin and uploaded by Anuja Bhalerao.

Anuja Bhalerao

Anuja is a third year medical student at the University of Toronto. She is a CanadiEM Junior Editor and is interested in medical education.
Alvin is currently a PGY5 in the FRCP EM program at McMaster University. He serves as Director of Design for CanadiEM and has interests in knowledge translation and health innovation.