medicine Medicine is the science and practice of caring for a patient, managing the diagnosis, prognosis, prevention, treatment, palliation of their injury or disease, and promoting their health. Medicine encompasses a variety of health care pr ...

, the Ottawa ankle rules are a set of guidelines for clinicians to help decide if a patient with foot or

ankle The ankle, or the talocrural region, or the jumping bone (informal) is the area where the foot and the leg meet. The ankle includes three joints: the ankle joint proper or talocrural joint, the subtalar joint, and the inferior tibiofibular joi ...

pain should be offered

X-ray An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10 picometers to 10 nanometers, corresponding to frequencies in the range 30&nb ...

s to diagnose a possible

bone fracture A bone fracture (abbreviated FRX or Fx, Fx, or #) is a medical condition in which there is a partial or complete break in the continuity of any bone in the body. In more severe cases, the bone may be broken into several fragments, known as a '' ...

. Before the introduction of the rules most patients with ankle injuries would have been imaged. However the vast majority of patients with unclear ankle injuries do not have bone fractures. As a result, many unnecessary X-rays were taken, which was costly, time-consuming and a slight health risk due to radiation exposure.

The Ottawa ankle rules

Ankle X-ray

Ankle X-ray is only required if: * There is any

pain Pain is a distressing feeling often caused by intense or damaging stimuli. The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, ...

in the malleolar zone; and, * Any one of the following: ** Bone tenderness along the

distal Standard anatomical terms of location are used to unambiguously describe the anatomy of animals, including humans. The terms, typically derived from Latin or Greek roots, describe something in its standard anatomical position. This position pro ...

6 cm of the posterior edge of the

tibia The tibia (; ), also known as the shinbone or shankbone, is the larger, stronger, and anterior (frontal) of the two bones in the leg below the knee in vertebrates (the other being the fibula, behind and to the outside of the tibia); it conn ...

or tip of the

medial malleolus A malleolus is the bony prominence on each side of the human ankle. Each leg is supported by two bones, the tibia on the inner side (medial) of the leg and the fibula on the outer side (lateral) of the leg. The medial malleolus is the promi ...

, OR ** Bone tenderness along the distal 6 cm of the posterior edge of the

fibula The fibula or calf bone is a leg bone on the lateral side of the tibia, to which it is connected above and below. It is the smaller of the two bones and, in proportion to its length, the most slender of all the long bones. Its upper extremity ...

or tip of the

lateral malleolus A malleolus is the bony prominence on each side of the human ankle. Each leg is supported by two bones, the tibia on the inner side (medial) of the leg and the fibula on the outer side (lateral) of the leg. The medial malleolus is the promine ...

, OR ** An inability to bear weight both immediately and in the emergency department for four steps.

Foot X-ray series

Additionally, the Ottawa ankle rules indicate whether a foot X-ray series is required. It states that it is indicated if: * There is any pain in the midfoot zone; and, * Any one of the following: ** Bone tenderness at the base of the fifth

metatarsal The metatarsal bones, or metatarsus, are a group of five long bones in the foot, located between the tarsal bones of the hind- and mid-foot and the phalanges of the toes. Lacking individual names, the metatarsal bones are numbered from the me ...

(for foot injuries), OR ** Bone tenderness at the navicular bone (for foot injuries), OR ** An inability to bear weight both immediately and in the emergency department for four steps. Certain groups are excluded, in particular

pregnant Pregnancy is the time during which one or more offspring develops ( gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins. Pregnancy usually occurs by sexual intercourse, but ca ...

women, and those with diminished ability to follow the test (for example due to

head injury A head injury is any injury that results in trauma to the skull or brain. The terms ''traumatic brain injury'' and ''head injury'' are often used interchangeably in the medical literature. Because head injuries cover such a broad scope of inju ...

intoxication Intoxication — or poisoning, especially by an alcoholic or narcotic substance — may refer to: * Substance intoxication: ** Alcohol intoxication ** LSD intoxication ** Toxidrome ** Tobacco intoxication ** Cannabis intoxication ** Cocaine in ...

). Several studies strongly support the use of the Ottawa Ankle Rules in children over 6 (98.5% sensitivity); however, their usefulness in younger children has not yet been thoroughly examined.

Usefulness

The rules have been found to have a very high sensitivity, moderate specificity, and therefore a very low rate of

false negative A false positive is an error in binary classification in which a test result incorrectly indicates the presence of a condition (such as a disease when the disease is not present), while a false negative is the opposite error, where the test resul ...

s. Evidence supports the rules as an accurate instrument for excluding fractures of the ankle and mid-foot, reducing the number of unnecessary investigations and length of stay in emergency departments. The original study reported that the test was 100% sensitive and reduced the number of ankle X-rays by 36%. A second trial with a larger number of patients replicated these findings. Subsequently, a multi-centre study explored the feasibility of implementing the rules on a wider scale. Unfortunately, teaching the rules to patients does not appear to help reduce presentation to hospital.

History

This list of rules was published in 1992 by a team of doctors in the emergency department of the Ottawa Civic Hospital in

Ottawa Ottawa (, ; Canadian French: ) is the capital city of Canada. It is located at the confluence of the Ottawa River and the Rideau River in the southern portion of the province of Ontario. Ottawa borders Gatineau, Quebec, and forms the c ...

Canada Canada is a country in North America. Its ten provinces and three territories extend from the Atlantic Ocean to the Pacific Ocean and northward into the Arctic Ocean, covering over , making it the world's second-largest country by to ...

. Since the rules were formulated in Ottawa they were dubbed the ''Ottawa ankle rules'' by their creators a few years after their development, a title that has stuck. In this respect, the naming of the rules is similar to that of the Bristol stool scale or the

Glasgow Coma Scale The Glasgow Coma Scale (GCS) is a clinical scale used to reliably measure a person's level of consciousness after a brain injury. The GCS assesses a person based on their ability to perform eye movements, speak, and move their body. These thr ...

(GCS), which also take their names from the cities in which they were formulated.

Related rules

The original rules were developed for ankle and foot injuries only, but similar guidelines have been developed for other injuries such as the

Ottawa knee rules The Ottawa knee rules are a set of rules used to help physicians determine whether an x-ray of the knee is needed. They state that an X-ray is required only in patients who have an acute knee injury with one or more of the following: * Age 55 years ...

References

External links

* * — an independent journal about

evidence-based medicine Evidence-based medicine (EBM) is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients". The aim of EBM is to integrate the experience of the clinician, the values of t ...

. * (graphical explanation). {{Bone, cartilage, and joint procedures Emergency medicine Orthopedic clinical prediction rules