GPAC: Guidelines and Protocols Advisory Committee

Ankle Injury - X-ray for Acute Ankle Injury

Effective Date: December 1, 2002

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

Recommendations and Topics

Scope

1. Ankle X-ray

2. Foot X-ray

Rationale

References

Sponsors

Scope

This guideline provides recommendations to physicians regarding whether or not to request ankle and/or foot x-rays when a careful clinical assessment shows a twisted ankle:

• in a nonpregnant patient,19 years or older;
• presenting for the first time in the ambulatory setting;
• the patient has no cognitive or sensory impairment.

The radiographic options include: plain x-ray or no x-ray of the ankle and/or midfoot.

RECOMMENDATION 1: Ankle X-ray

Ankle x-rays are only required if there is any pain in the malleolar zone, and any one of these findings:

1. bone tenderness at A; or
2. bone tenderness at B; or
3. inability to bear weight both immediately and in the emergency department (four steps).*

RECOMMENDATION 2: Foot X-ray

Foot x-rays are only required if there is any pain in the midfoot zone, and any one of these findings:

1. bone tenderness at C; or
2. bone tenderness at D; or
3. inability to bear weight both immediately and in the emergency department (four steps).*

* Whether or not radiography is ordered, patients should be advised to seek follow-up care if their pain or ability to bear weight has not improved in seven days.

Rationale

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. Patients with fractures that are missed by using the rules are expected to return soon for reassessment and treatment. The occurrence of long-term disability after missing a fracture is very rare.¹

This guideline is consistent with the Ottawa Ankle Rules (OAR), which have been validated for adult patients 19 years of age and older, in many international studies.^1-7 Both this guideline and OAR have been validated to be highly sensitive for detecting ankle and midfoot fractures.^1-7 Application of the guideline reduces patient waiting time, avoids inappropriate x-ray exposure, improves accuracy of the clinical examination, and reduces health care expenditures on unnecessary x-rays of the ankle and foot without compromising quality of care.^1,3,4 This guideline is useful as an aid and should be used along with sound clinical judgment and experience.^8-9

References

1. Stiell I, Wells G, Laupacis A, Brison R, Verbeek R, Vandemheen K, et al. Multicentre trial to introduce the Ottawa Ankle Rules for use of radiography in acute ankle injuries. BMJ 1995;311:594-7.
2. Graham ID, Stiell IG, Laupacis A, McAuley L, Howell M, Simon N, 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.
3. Anis AH, Stiell IG, Stewart DG, Laupacis A. Cost-effectiveness analysis of the Ottawa Ankle Rules. Ann Emerg Med 1995;26:422-8.
4. 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.
5. Auleley GR, Kerboull L, Durieux P, Cosquer M, Courpied JP, Ravaud P. 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.
6. 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.
7. Yuen MC, Sim SW, Lam HS, Tung WK. Validation of the Ottawa Ankle Rules in a Hong Kong ED. Am J Emerg Med 2001;19:429-32.
8. Perry S, Raby N, Grant PT. Prospective survey to verify the Ottawa Ankle Rules. J Accid Emerg Med 1999;16:258-60.
9. Glas AS, Pijnenburg BA, Lijmer JG, Bogaard K, de Roos M, Keeman JN, et al. Comparison of diagnostic decision rules and structured data collection in assessment of acute ankle injury. CMAJ 2002;166:727-33.

Sponsors

This guideline was developed in 1995, revised in 1998 and 2002 by the Guidelines and Protocols Advisory Committee, under the auspices of the British Columbia Medical Association, the Medical Services Commission and the Government of British Columbia. This revision was approved by the British Columbia Medical Association and adopted by the Medical Services Commission.

Funding for this guideline was provided in full or part through the Primary Health Care Transition Fund.

Revised Date: April 1, 2007

This guideline is based on scientific evidence current as of the effective date.

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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