GPAC: Guidelines and Protocols Advisory Committee

Ankle Injury - X-Ray for Acute Injury of the Ankle or Mid-Foot

Effective Date: January 30, 2009

Summary | Flow Sheet | Patient Guide | Full Guideline in PDF

Recommendations and Topics

Scope

Diagnosis/Investigation

Figure 1: Zones of the Ankle and Mid-Foot

Rationale

References

Scope

The purpose of the guideline is to avoid unnecessary x-rays in non-pregnant adults (age 19+) with acute ankle and mid-foot injuries when they present for the first time in an ambulatory setting and have no sensory or cognitive impairment.

Diagnostic Codes

845 sprains and strains of ankle and foot; 824 ankle fracture; or 825 fracture of metatarsal bones

Diagnosis/Investigation

This guideline update is consistent with the Ottawa Ankle Rules (OAR)¹ which have been validated in national and international studies.^3-11

Ankle x-rays are only required if there is pain in the malleolar zone as well as any one of:

• Bone tenderness at A; or
• Bone tenderness at B; or
• Inability to bear weight both immediately and in the emergency department (four steps taken independently, even if limping).

Foot x-rays are only required if there is pain in the mid-foot zone as well as any one of:

• Bone tenderness at C; or
• Bone tenderness at D; or
• Inability to bear weight both immediately and in the emergency department (four steps taken independently, even if limping).

Whether or not an x-ray is ordered, it is recommended that patients be advised to seek follow-up care if their pain or ability to bear weight has not improved in seven days.

Figure 1: Zones of the ankle and mid-foot according to the Ottawa Ankle Rules¹

Rationale

Acute ankle injuries are one of the most common reasons for patients presenting to emergency departments. Historically most patients have then been subjected to x-rays of the ankle and/or mid-foot although only about 15% have clinically significant fractures.^1,2

This guideline is consistent with the Ottawa Ankle Rules (OAR), which were developed by researchers at the University of Ottawa and the Ontario Ministry of Health, for adult patients (19+ years) in an attempt to limit x-rays of the foot and ankle to those most likely to have suffered fractures. The OAR were proven effective when applied by over 200 physicians of varying experience on almost 6500 patients at eight hospitals in Ontario¹ and have since been validated in international studies. ^3-11

The OAR are a highly sensitive tool for detecting ankle and mid-foot fractures. A 2003 European systematic review of 27 studies, enrolling over 15,500 patients, reported a sensitivity of almost 100% and projected a reduction in x-rays of 30% to 40% if the OAR were consistently applied. Specificity varied from 28% to 48% due to variability in clinical skill, setting, and patient recall.¹²

A fracture that can be found using plain x-rays is the only criterion that has been considered in this guideline. Some of the fractures detected by plain x-rays may not require treatment, while plain x-rays do not detect some uncommon but significant fractures. In the original study, "Ten (0.5%) of the 2033 patients in the follow up group had a fracture diagnosed after discharge from the emergency department... all were contacted after six months and all had healed without delay or long term effects."¹

References

1. Stiell I, Wells G, Laupacis A, et al. Multicentre trial to introduce the Ottawa Ankle Rules for use of radiography in acute ankle injuries. BMJ 1995;311:594-7.
2. Nugent PJ. Ottawa Ankle Rules accurately assess injuries and reduce reliance on radiographs. J Fam Pract. 2004 Oct;53(10):785-8.
3. Auleley GR, Kerboull L, Durieux P, et al. Validation of the Ottawa Ankle Rules in France: a study in the surgical emergency department of a teaching hospital. Ann Emerg Med 1998;32:14-8.
4. Broomhead A, Stuart P. Validation of the Ottawa Ankle Rules in Australia. Emerg Med (Fremantle). 2003 Apr;15(2):126-32.
5. Graham ID, Stiell IG, Laupacis A, et al. Awareness and use of the Ottawa Ankle and Knee Rules in 5 countries: Can publication alone be enough to change practice? Ann Emerg Med 2001; 37:259-66.
6. Leddy JJ, Kesari A, Smolinski RJ. Implementation of the Ottawa ankle rule in a university sports medicine center. Med Sci Sports Exerc 2002;34:57-62.
7. Leisey J. Prospective validation of the Ottawa Ankle Rules in a deployed military population. Mil Med. 2004 Oct;169(10):804-6.
8. Papacostas E, Malliaropoulos N, Papadopoulos A, Liouliakis C. Validation of Ottawa Ankle Rules protocol in Greek athletes: a study in the emergency departments of a district general hospital and a sports injuries clinic. Br J Sports Med 2001;35:445-7.
9. Wynn-Thomas S, Love T, McLeod D, et al. The Ottawa ankle rules for the use of diagnostic X-ray in after hours medical centres in New Zealand. N Z Med J. 2002 Sep 27;115(1162):U184.
10. Yazdani S, Jahandideh H, Ghofrani H. Validation of the Ottawa Ankle Rules in Iran: a prospective survey. BMC Emerg Med. 2006 Feb 16;6:1-7.
11. Yuen MC, Sim SW, Lam HS, Tung WK. Validation of the Ottawa ankle rules in a Hong Kong ED. Am J Emerg Med. 2001 Sep;19(5):429-32.
12. 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.

This guideline is based on scientific evidence current as of the Effective Date.

This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association and adopted by the Medical Services Commission.

Disclaimer

The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems.

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