Less than a decade ago, clinical epidemiologist ian stiell, working with emergency department physicians, formulated the ottawa ankle rules. They have nearly perfect sensitivity for identifying clinically significant ankle fractures. Ottawa ankle rules the ottawa hospital research institute. In medicine, the ottawa ankle rules are a set of guidelines for clinicians to help decide if a patient with foot or ankle pain should be offered xrays to diagnose a possible bone fracture. Since the publication of this study, the ottawa ankle rule have been well validated and have been shown to limit the number of radiographs obtained for ankle injuries, decreased patient wait times and cost. Bachmann lm, kolb e, koller mt, steurer j, ter riet g. The ottawa ankle rules oar are a clinical decision tool used to minimize unnecessary radiographs in ankle and foot injuries. Use of the ottawa ankle rule by paramedics in the outofhospital setting introduction the ottawa ankle rule oar is extensively documented in the emergency department setting and has been subjected to repeated validation. Key recommendations usethe ottawa knee rules okr to exclude fractures and reduce unnecessary imaging. Use of the ottawa ankle rule by paramedics in the outof.
An ankle xray series is only required if there is any pain in the malleolar zone and. Knowing when to order xrays, or even what to order, can be confusing. Ankle and foot injuries are common presentations to the emergency department, and it can often be difficult to know whether imaging is required. Emergency physiciansusually order radiographs for nearly all ankle injury patients, and 85% of these are negative for fracture. The ottawa ankle rule rules out clinically significant foot and ankle fractures to reduce use of xray imaging.
Background the ottawa ankle rules oar are clinical decision guidelines used to identify whether patients with ankle injuries need to undergo radiography. In a metaanalysis, the ottawa rules for xray of the ankle had a 97. Sensitivity and specificity of oar were 100% and 77% respectively. Get a printable copy pdf file of the complete article 1. Ottawa ankle rules xray for acute injury of the ankle or. Implementation of the ottawa ankle rules jama jama network. Ottawa ankle rules this guideline will aid you in determining which patients require an xray of their ankle. To open a pdf file you will need compatible software such as adobe reader. National athletic trainers association position statement. Before the introduction of the rules most patients with ankle injuries would have been imaged. Acute ankle injuries are one of the most common reasons for presenting to emergency departments, but only a small percentage of patients approximately 15% have clinically significant fractures.
The most important step in ankle fracture management is identifying stable verses unstable fractures. Racgp the ottawa knee rules a useful clinical decision tool. Ottawa ankle rules accurately assess injuries ottawa ankle rules for determining the need for radiographs indications for ankle radiographs tenderness over the inferior or posterior pole of either malleolus, including the distal 6 cm inability to bear weight 4 steps taken independently, even if limping. The ottawa knee rules okrs were first derived and validated in ottawa, canada, with the aim of reducing the number of unnecessary radiographs ordered after knee trauma without compromising patient care.
Patients who do not meet the fracture predictor of the okrs are highly unlikely to have clinically. A previous best evidence topic report examined whether these rules could be applied to children. Where indicated the nurse sent the patient for radiography. Ankle stability and movement coordination impairments. The ottawa ankle rules oars aim to determine if a patient presenting with acute ankle or foot traumarelated pain requires plain radiographs of the foot or ankle to exclude a fracture. There are two components, assessing for ankle and midfoot fractures. A knee xray series is only required for knee injury patients with any of these findings. A clinical decision rule to determine the need for diagnostic imaging for knee trauma. The ottawa ankle rule was derived to aid efficient use of radiography in acute ankle and midfoot injuries. Get a printable copy pdf file of the complete article 915k, or click on a. An ankle xray is required only if there is any pain in malleolar zone and any of these findings. Ottawa knee and ankle rules pdf ottawa ankle and foot rules. A group of ottawa emergency physicians developed two rules to identify clinically important fractures of the malleoli and the midfoot.
However, these patients are almost always referred for radiography. Limited data support its use by other health care workers in children. The ottawa ankle rule project demonstrated that more than 95% of patients with. The shockwave flash swf version is for online viewing only. Ankle injuries are extremely common but many features on history and physical examination are unreliable the combined ottawa ankle and foot rules have a sensitivity of 97. Prospective validation of a decision rule for the use of radiography in acute knee injuries. Rule out a complete tear of the ligaments by doing drawer testing of the ankle before discharging the patient or at the first followup visit ottawa knee rules a knee xray is only required for knee injury patients with any of these findings. If you do not have it you can download adobe reader free of charge. Stress radiography is an unreliable tool to detect acute ligamentous disruption after ankle.
The ottawa ankle rules calculator was designed to ease the process of remembering and then selecting the applicable rules and can automatically tell whether there is still need for further diagnosis through xrays. The ottawa ankle rules and the buffalo modification of the ottawa rules should be judiciously applied to adult patients with ankle trauma to decrease the total number of ankle radiographs obtained. Ankle sprains are a common occurrence in athletes as well as the general population. The ottawa ankle rules oars are a valid clinical tool to determine the need for radiographs of the acutely injured ankle or midfoot. This screening tool was developed because of the need for a rapid and accurate way to avoid unnecessary imaging. Multi trial to introduce the ottawa ankle rule for the use of radiography in acute ankle injuries the fifth study assessed the feasibility and impact of. Sep 24, 2015 the truth about mobile phone and wireless radiation dr devra davis duration. Stiell ig, greenberg gh, mcknight rd, nair rc, mcdowell i, reardon m, stewart jp, maloney j. Hence the role of the ottawa ankle rules in small children is not yet answered. Pdf most of the documents on the racgp website are in portable document format pdf. Comparison of ottawa ankle rules and bernese ankle rules in acute ankle and midfoot injuries article pdf available in turkish journal of emergency medicine 10 january 2010 with 3,069 reads.
Ottawa ankle rules an overview sciencedirect topics. Future studies should address the generalizability of these decision rules in a variety of hospital settings. The ottawa ankle rules can be applied in children to determine the need for radiography in ankle and midfoot injuries. The ottawa ankle rules oar are a set of guidelines to help the physician as to decision making regarding need for x ray examination after ankle and midfoot injury. A foot xray series is only required if there is any pain the midfoot zone and.
The rules appear on the front page of this document. What is the evidence for the accuracy of the ottawa ankle rules. Using the ottawa ankle rules, xray imaging can be reduced 34% for the ankle series and 30% for the foot series. Ottawa ankle rules many trials evaluate the validity of the ottawa ankle rules oar for excluding fractures of the ankle in patients with an ankle sprain.
Ottawa ankle rules to exclude fractures of ankle and midfoot. The metaanalysis of bachmann, with a moderate risk of bias, summarizes the accuracy of the oar from 1990 to 2002. The ottawa ankle rule project demonstrated that more than 95% of patients with ankle injuries had radiographic examinations but that 85% of the films showed no fractures. This study was performed during a 24month period in the suleyman. Ottawa ankle rules xray for acute injury of the ankle or midfoot figure 1. Yes no for patients with acute trauma to the ankle bone tenderness at a bone tenderness at b inability to bear weight both immediately and in the ed an ankle radiographic series is only required if there is any pain in the malleolar zone and any of these. Diagnostic accuracy of the ottawa ankle and midfoot rules. This standardized procedure uses the ottawa rules for xray of the ankle and the foot as guidelines to allow the rn to order xrays prior to clinician appointment when the patient meets the established criteria. Pdf comparison of ottawa ankle rules and bernese ankle. These files will have pdf in brackets along with the filesize of the download. The ottawa ankle rules, developed by stiell, specifies the criteria to be met before ordering xrays for a patient presenting with an acute ankle injury. Ottawa knee rule ottawa hospital research institute. Usethe ottawa ankle rules oar to exclude fractures and reduce unnecessary imaging.
Available at no cost, download the pdf files to your local printer for professional printing and laminating, or print from home or the office. Our study is a randomized, prospective clinical study. Pdf application of ottawa ankle rules researchgate. If you have persistent problems with pain, swelling, you are not able to use your ankle properly, or your ankle is not recovering at the rate you expect, please see your gp. The rules are intended to guide clinical decisions about the efficient use of radiography in the diagnosis of malleolar zone fractures and midfoot zone fractures. For most patients, fractures cannot be ruled out without radiography. Ottawa ankle rules for the injured ankle british journal. The ottawa ankle rules oars are a valid clinical tool. Safety and efficiency of the ottawa ankle rule in a swiss population.
The ottawa ankle rules are a clinical decisionmaking strategy for determining which patients require radiographic imaging for ankle and midfoot injuries. Zones of the ankle and midfoot according to the ottawa 4 ankle rules malleolar zone midfoot zone posterior edge or tip of lateral malleolus posterior edge or tip of medial malleolus base of 5th metatarsal navicular lateral view medial view a 6cm 6cm c d b. Accuracy of ottawa ankle rules to exclude fractures of the ankle and midfoot. Rules have been prospectively validated on multiple occasions in different populations and in both children and adults.
Data sources medline, embase, cinahl, sportdiscus and cochrane library. The oars were not developed to exclude ligamentous or tendon injuries in the foot and ankle. Ottowa ankle rules order form unc school of medicine. Particularly, the ottawa and bernese ankle rules should be used to. Ottawa ankle rule oar to rule out ankle and midfoot fractures in patients presenting with acute ankle sprain and. The ottawa ankle rules and missed fractures of the talus. In those presenting with acute ankle injury, the incidence of ankle fracture is low 220% amongst those who undergo evaluation with radiography 1, 2. Radiographic examinations showed 19 fractures out of 100 investigated patients table 1. However, the number of preschool children included in all these studies was small. Implementation of the ottawa ankle rules led to a decrease in use of ankle radiography, waiting times, and costs without patient dissatisfaction or missed fractures.
Diagnosis historically imaging is ordered for most patients presenting with an ankle andor midfoot injury even though only about 15%. The ottawa ankle rules are guidelines indicating that xray studies should be obtained if there is pain in the malleolar zone and a bony tenderness at the distal 6 cm of the fibula or b bony tenderness at the distal 6 cm of the tibia or inability to take 4 steps immediately after injury. Clinical value of the ottawa ankle rules for diagnosis of. Ankle and foot ottawa ankle rules guideline for the administered by the alberta medical association this guideline has been adapted by an alberta clinical practice guidelines program working group from the ottawa ankle rules developed by dr. Racgp the ottawa knee rules a useful clinical decision. This would allow a reduction in radiographs of the ankle of 16% and of the foot by 29%, without missing any clinically significant fracture. It is the dedication of healthcare workers that will lead us through this crisis. The oar are a reliable tool to exclude fractures in children over 5 years of age when applied by physicians. Ottawa ankle rules accurately assess injuries and reduce. Results the search yielded 98 citations, with 80 relating directly to the oar. The ottawa ankle rules determine the need for radiographs in acute ankle injuries. No part of this publication may be reproduced in any format without written consent of eb medicine. Ankle rules for ankle injury radiography a an ankle xray series is only required if there is any pain in malleolar zone and any of these findings. The applicability of the ottawa ankle rules in children aged 216 years has been confirmed with 100% sensitivity for significant fractures of the ankle and midfoot.
O ottawa rules for xray of knee, ottawa ankle and foot rules lateral view ankle and foot medial view posterior edge or tip of medial malleolus navicular malleolar zone midfoot zone posterior edge or tip of lateral malleolus base of 5th metatarsal 6cm an ankle xray is required only if there is any pain in malleolar zone and any of these findings. Stress radiography is an unreliable tool to detect acute ligamentous disruption after ankle sprain. Clinical usefulness of the ottawa ankle rules for detecting. Are the ottawa ankle rules helpful in ruling out the need. The ottawa ankle rule is useful in ruling out fracture high sensitivity, but does poorly at ruling in fractures many false positives. Conclusionsintroduction of the ottawa ankle rules proved to be feasible in a large variety of hospital and community settings. Soft tissue injuries are the most common diagnosis following ankle injury, with up to 85% of ankle sprains involving the lateral ligament complex lateral ankle sprain 3. Ian stiell and his colleagues developed the ottawa ankle rules 12 to facilitate this decision. The above research led to a final set of decision rules, named the ottawa ankle rules, for the use of radiography in ankle injury. Exclusions less than 18 years old intoxication multiple painful injuries pregnant head injury diminished sensation due to neurological deficit recommendations. The ottawa ankle rules can be applied in children to determine the need for radiography in ankle. The ottawa ankle rules show areas of tenderness to be evaluated in patients with ankle trauma to determine need for imaging. Oct 10, 2016 knowing when to order xrays, or even what to order, can be confusing. The ottawa ankle rules in children emergency medicine.
Comparison of ottawa ankle rules and bernese ankle rules in acute ankle and midfoot injuries injury during daily walking, and the remaining reported other reasons. There was no increase in the number of missed fractures one in each group. Implementation of the ottawa ankle rules by general practitioners in the emergency department of a turkish district hospital with a positive test. Abstract ankle injury is a common injury sustained in an outdoor activity or as a sport injury presenting to the emergency department. Ottaaw knee rule for knee injury radiography stiell ig, greenberg gh, wells ga, mcdowell i, cwinn aa, smith na, cacciotti tf, sivilotti mla. To validate and refine previously derived clinical decision rules that aid the efficient use of radiography in acute ankle injuries. The aim of this study is to consider these injured patients in the light of the ottawa ankle rules and the bernese ankle rules. Use of the ottawa ankle rules by nurse practitioners. Advise patients to seek followup care if their pain or ability to bear weight has not improved in five to seven days. Use of the rules over a prolonged period of time by many physicians of varying experience led to a decrease in ankle radiography, waiting times, and costs without an increased rate of missed fractures. It is anticipated that application of the ottawa ankle rules in preschool children is difficult as the rules rely on their ability to report tenderness. Bone tenderness at the posterior edge or tip of the lateral malleolus a. Ian stiell, professor in the department of emergency medicine at the university of ottawa, discussing the assessment of an ankle andor foot injury using the ottawa ankle.
Ottawa ankle rules summary if you are interested in learning more about clinical decision rules, the ottawa ankle rule is a simple and world famous example, which was developed in ottawa and tested in many canadian centres including queens. Ottawa ankle rules ottawa hospital research institute. Multicentre trial to introduce the ottawa ankle rules for. The ottawa ankle rules oars have been designed to reduce the number of unnecessary radiographs ordered for these patients. Comparison of ottawa ankle rules and bernese ankle rules. Ottawa ankle rules xray for acute injury of the ankle or mid. The ottawa ankle rule was derived to aid in the efficient use.
Metaanalysis of the ottawa ankle rules oar, oafr, bernese ankle rules, and the malleolar zone algorithm resulted in a negative likelihood ratio of 0. Implementation of the ottawa ankle rules by general. A knee xray is only required for knee injury patients with any of these findings. Decision rules for the use of radiography in acute ankle injuries. Ankle radiography is indicated only if a patient has pain in the malleolar zone and any of the following findings. The ottawa ankle and foot rules are highly sensitive and widely used as a tool to reduce unnecessary imaging in emergency departments. Pdf abstract ankle injury is a common injury sustained in an outdoor activity or as a sport injury presenting to the emergency department. Jan 11, 20 trauma of the foot and ankle is commonly seen in the emergency service. Specificities for the ottawa ankle rule are approximately 41% for the ankle and 79% for the foot, although the rule is not designed or intended to make a specific diagnosis. Before the introduction of the rules most patients with.
The ottawa ankle rules modified buffalo rule the buffalo rule was derived to increase the diagnostic accuracy of the ottawa ankle rules, with the point tenderness criterion directed to the crest or midportion of the malleoli distal 6 cm of the fibula and tibia, reducing the likelihood of palpating over injured ligament structures. Sensitivities range from the high 90100% range for clinically significant ankle and midfoot fractures, defined. The ottawa ankle and foot rules are highly sensitive and widely used as a tool to reduce unnecessary imaging in emergency. Specificity represents the number of patients without the condition and. Update on acute ankle sprains american family physician.
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