Ottawa Ankle and Foot Rules

Tiny Tip: The Ottawa Ankle and Foot Rules – To Image or Not to Image

In Medical Concepts, Tiny Tips by Maeghan FuLeave a Comment

Ankle and foot injuries are common presentations to the Emergency Department, and it can often be difficult to know whether imaging is required. In 1992, Dr. Ian Stiell and his colleagues developed The Ottawa Ankle Rules1,2 to facilitate this decision. The Ottawa ankle and foot rules are highly sensitive and widely used as a tool to reduce unnecessary imaging in Emergency Departments.

Ottawa Ankle and Foot Rules

 

Ottawa Ankle and Foot Rules

The rules are as follows:
An ankle radiographic series is only required if there is any pain in the malleolar zone and any of these findings:

  1. Bone tenderness at A
  2. Bone tenderness at B
  3. Inability to bear weight both immediately and in the emergency department

A foot radiographic series is only required if there is any pain in the midfoot zone and any of these findings:

  1. Bone tenderness at C
  2. Bone tenderness at D
  3. Inability to bear weight both immediately and in the emergency department

For those who have difficulty remembering the rules, here is a poem to help:

Tiny Tip for the Ottawa Ankle Rule

Ankle X-ray series required if:

“Resting pain in the malleolar zones, AND
Tenderness over malleolar bones,
Don’t forget the distal six,
The posterior edge or the tips.
They may not walk four steps or more,
When injured AND through ED door”

 *Note: “distal six, posterior edge, or the tips”, is in reference to the distal 6cm of the fibula and tibia, and the posterior edge and tip of the malleolus, which must be palpated for tenderness.

Tiny Tip for the Ottawa Foot Rule

Foot X-ray series required if:

“Resting pain in the mid-foot zone, AND
Tender base of 5th metatarsal bone.
Show them how slick you are,
When you check the navicular.
They may not walk four steps or more,
When injured AND through ED door”

This post was copyedited by Eve Purdy (@purdy_eve) and uploaded by Sean Nugent (@sfnugent)

References

1.
Stiell I, McKnight R, Greenberg G, et al. Implementation of the Ottawa ankle rules. JAMA. 1994;271(11):827-832.
[PubMed]
2.
Ottawa Hospital Research Institute T. Ottawa ankle rules for ankle injury radiography. ohri.ca. //www.ohri.ca/emerg/cdr/docs/cdr_ankle_poster.pdf. Published 1994. Accessed June 2, 2016.
3.
Plint A, Bulloch B, Osmond M, et al. Validation of the Ottawa Ankle Rules in children with ankle injuries. Acad Emerg Med. 1999;6(10):1005-1009.
[PubMed]
4.
Crocco A. Review: the Ottawa Ankle Rules are accurate for excluding fractures in acute blunt ankle/midfoot injury in children. Evid Based Med. 2009;14(6):184.
[PubMed]
5.
Gravel J, Hedrei P, Grimard G, Gouin S. Prospective validation and head-to-head comparison of 3 ankle rules in a pediatric population. Ann Emerg Med. 2009;54(4):534-540.e1.
[PubMed]

Reviewing with the Staff

This Tiny Tips piece on how to remember the Ottawa Ankle rules is super helpful and very accurate. It is a fun way to remember this very important rule for determining who might need an ankle x-ray - I just hope I only have to remember it and not have to actually sing it - that would be bad!

One other clinical tip is that the Ottawa Ankle Rules have been validated in children[3,4,5] and it is completely okay to use it in these little adults. Not everyone remembers that.

Dr. Lisa Thurgur
Dr. Thurgur is an Emergency Physician at The Ottawa Hospital, and an Assistant Professor at University of Toronto.

Maeghan Fu

Maeghan Fu is a medical student at the University of Ottawa