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Ottawa Ankle Rules

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Ottawa Ankle Rules

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The Ottawa Ankle Rules were developed to reduce unnecessary radiographs for patients presenting to emergency rooms after traumatic foot and ankle injuries

They were developed to help predict fractures in patients with ankle injuries.

They are a number of guidelines to help the clinical to decide if the patient with foot or ankle trauma should be offered X-rays to diagnose a possible fracture.

These rules were first introduced by by a team of doctors in the emergency department of the Ottawa Civic Hospital in Ottawa, Canada, in 1992.

See Also: Ankle Anatomy

What are the 5 Ottawa Ankle Rules?

Using only the clinical findings of the ability to bear weight and areas of point tenderness, this simple diagnostic protocol results in fewer radiographs, lower costs, decreased time in the emergency room, increased patient satisfaction, and (most importantly) no undetected fractures (100% sensitivity).

After trauma, ankle and foot radiography is indicated if any of the following are present:

  1. Bone tenderness at the posterior edge or tip of the lateral malleolus.
  2. Bone tenderness at the posterior edge or tip of the medial malleolus.
  3. Inability to bear weight both immediately and in the emergency department.
  4. Bone tenderness at the base of the 5th metatarsal.
  5. Bone tenderness at the navicular bone.
Ottawa Ankle Rules positions

Ankle Standard Views

Standard views of the ankle include the A-P, mortise, and lateral views:

  1. A-P view: This view provides the clinician with information about the shape, position, and texture of the bones, and helps determine whether there is any fractured or new subperiosteal bone.
  2. Mortise view: This view provides information about the ankle mortise and the distal tibiofibular joint.
  3. Lateral view: This view provides the clinician with information about the shape, position, and texture of bones, including the tibial tubercle, talus, and calcaneus.

Other nonroutine views include the following:

  1. Dorsoplantar view of the foot: This view provides information with regard to the forefoot.
  2. Medial oblique view of the foot: This view provides information about the tarsal bones and joints and the metatarsal shafts and bases. In addition this view can highlight any pathology in the calcaneocuboid joint.

Stress views of the ankles are routinely utilized for assessment of instability and injury to the lateral collateral ligament of structures.

The stress views include inversion to assess talar tilt and the anterior drawer stress. The accuracy of these tests increases with the use of local anesthesia and a comparison with the uninvolved ankle.

Ankle Joint X-Ray Positions

X-Ray ViewPatient PositionPurpose and Structures Imaged
A-P ViewThe patient is positioned in supine with the foot vertical. The central ray perpendicular to a point midway between the malleoliFrontal projection of the ankle joint, the distal end of the tibia and fibula, and the proximal portion of the talus.
Neither the syndesmosis nor the inferior portion of the lateral malleoli is well demonstrated in this projection
Mortise View Supine with the leg and foot rotated internally approximately 15 degrees.
The central ray perpendicular to the ankle joint
The syndesmosis is well seen without overlap of the anterior process of the distal tibia; best view of mortise and distal aspect of the lateral malleolus
Lateral
Lateral side of the ankle down; the patient is supine and turned toward the affected side. The central ray is perpendicular to the lateral malleolusA lateral view of the distal third of the tibia and fibula, the ankle joint, talus, calcaneus, and the hind foot.
Impingement
The ankle is positioned in extreme plantar flexion to detect posterior impingement, and weight-bearing and maximum dorsiflexion to detect and anterior impingement.To assess bony contribution to posterior or anterior impingement.
Oblique tarsal The ankle is positioned to provide an oblique view of the footBest view to detect a fracture of the anterior process of the calcaneus, but can also demonstrate fractures of the base of the fifth metatarsal
Inversion stress Best performed with a calibrated standardized device needed to position and stress the ankleCheck for lateral instability
Eversion stress Best performed with a calibrated standardized device needed to position and stress the ankleCheck for medial instability

Foot X-Ray Positions

X-Ray ViewPatient PositionPurpose and Structures Imaged
Dorsoplantar Patient supine with the knee flexed and the sole of the foot resting on the X-ray cassette. Central ray is perpendicular to the base of the third metatarsalA frontal projection of the tarsals, metatarsals, and phalanges; tarsometatarsal, metatarsophalangeal, and interphalangeal joints.
Lateral Lateral side down with the patient supine. The central ray is perpendicular to the midfootA true lateral projection of the talocrural, subtalar, transverse, and tarsometatarsal joint; hind foot, midfoot, and forefoot relationships
Medial oblique Supine with the knee flexed and the leg rotated medially until the sole of the foot forms an angle of 30 degrees to the plane of the film.The central ray is perpendicular to the midfoot.
The calcaneocuboid, cuboid-fourth and fifth metatarsal, cuboid cuneiform, and talonavicular articulations
Less overlap of tarsals than anteroposterior
Good view of sinus tarsi
Harris Beath (axial) view of the hind footThe patient is positioned in sitting on the X-ray table, leg extended, and the heel resting on the cassette. The ankle is extended and held in this position by the patient applying traction to the forefoot with a bandage or strap. A 45 degrees cranial tube angle is used with the primary beam entering the sole of the foot at the level of the base of the fifth metatarsalBest shows the articular surfaces of both the posterior and medial subtalar joints, coalition at the medial facet, and avulsions fractures at the medial or lateral aspects of the calcaneal tuberosity
Harris view

Accuracy

Statistically pooled data from 27 high-quality studies involving 15,581 adults and children to analyze the the Ottawa Ankle Rules sensitivity and specificity:

  • Sensitivity: 98%
  • Specificity: 20%

Designed to have a high sensitivity so that fractures are not missed, the Ottawa Ankle Rules have a high negative predictive value when applied to a skeletally mature population. The rules have also been validated in children. If the rules are followed, it is highly likely that a fracture will not be missed.

The conservative nature of the rules results in a relatively low specificity (0.26–0.48), indicating that many patients are still referred for radiographs who do not have a fracture. With the modification relating to the location of the malleolar pain, the specificity is improved to 0.42–0.59.

Ottawa Foot Rules

Radiographic series of the foot is only required if one of the following are present:

  1. Bone tenderness is at navicular
  2. Bone tenderness at the base of 5th MT
  3. Totally unable to bear weight both immediately after injury & (for 4 steps) in the emergency department.

The accuracy of Ottawa Foot Rules the were:

  • Adults: Sensitivity = 93-100% & specificity = 12-21%
  • Children: Sensitivity = 100% & specificity = 36%

References

  1. Stiell IG, Greenberg GH, McKnight RD, Wells GA. Ottawa ankle rules for radiography of acute injuries. N Z Med J. 1995 Mar 22;108(996):111. PMID: 7715880.
  2. Stiell I, Wells G, Laupacis A, Brison R, Verbeek R, Vandemheen K, Naylor CD. Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle injuries. Multicentre Ankle Rule Study Group. BMJ. 1995 Sep 2;311(7005):594-7. doi: 10.1136/bmj.311.7005.594. PMID: 7663253; PMCID: PMC2550661.
  3. 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. doi: 10.1136/bmj.326.7386.417. PMID: 12595378; PMCID: PMC149439.
  4. Vela, L, Tourville, TW, and Hertel, J: Physical examination of acutely injured ankles: an evidence-based approach. AthlTher Today, 8:13, 2003.
  5. Nugent, PJ: Ottawa ankle rules accurately assess injuries and reduce reliance on radiographs. J Fam Pract, 53:785, 2004.
  6. Gravel, J, et al: Prospective validation and head-to-head comparison of 3 ankle rules in a pediatric population. Ann Emerg Med, 54:534, 2009.
  7. Leddy, JJ, et al: Prospective evaluation of the Ottawa ankle rules in a university sports medicine center. With a modification to increase specificity for identifying malleolar fractures. Am J Sports Med, 26:158, 1998.
  8. Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.
  9. Netter’s Orthopaedic Clinical Examination An Evidence-Based Approach 3rd Edition Book.
  10. Millers Review of Orthopaedics -7th Edition Book.
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