Ankle & Foot- Radiology

**July 2006 OIG**

**LT Karen Kilman**

**The Ottawa rule helps reduce excessive x-ray**

**TERRY PHILBIN, DO**\
Department of Orthopaedic Surgery, Cleveland Clinic\
\
**BRIAN G. DONLEY, MD**\
Department of Orthopaedic Surgery, Cleveland Clinic

**A**: In deciding whether a patient with an acute ankle injury needs
radiographs, we generally use the Ottawa rule---a set of criteria
developed using logistic regression analysis by Stiell et al^1^ in
Ottawa, Canada, to help physicians reduce the excessive use of ankle
radiographs. In brief, an ankle radiographic series is indicated only
if:

-   The patient has pain near the malleoli, and if any of the following
    are true:

-   The patient is 55 years old or older

-   The patient could not bear weight on the ankle immediately after the
    injury and currently cannot walk four steps on it

-   The patient has bone tenderness at the posterior edge or tip of
    either malleolus [(FIGURE
    1)](http://www.clevelandclinicmeded.com/ccjm/June2000/Philbin.gif).

In addition, we obtain radiographs if the patient cannot communicate
(owing to altered mental status, alcohol intoxication, or other
problems) or if pain and swelling do not resolve within 7 to 10 days
after an injury.

**MANY ARE SPRAINED,\
BUT FEW ARE FRACTURED**

Ankle trauma is one of the most common reasons for visits to an
emergency room. Approximately 27,000 ankle sprains occur every day in
the United States.^2^ Ankle sprain is the most common injury in sports.
Fractures are diagnosed in only 7% to 36% of ankle injuries, even though
most patients undergo a radiographic evaluation. Decreasing excessive
radiographs would decrease patient exposure to radiation, waiting time,
and medical costs.

**IMPORTANCE OF PHYSICAL EXAMINATION**

A thorough physical examination can help decrease the need for a high
number of radiographs obtained in patients with acute ankle injuries.
The basic ankle examination should evaluate the neurovascular status,
any gross instability, and skeletal tenderness. The joints above and
below the injury should be examined (eg, the proximal fibula and the
fifth metatarsal). Physical findings such as gross deformity,
instability, crepitation, localized bony tenderness, severe soft tissue
tenderness, moderate or severe edema, and ecchymosis can help delineate
whether radiographs are needed.^3^

**HOW RELIABLE IS THE OTTAWA RULE?**

When originally published, the Ottawa rule was said to have 100%
sensitivity and 40% specificity for detecting malleolar fractures.
Therefore, all patients who truly had a fracture would still get a
radiograph, but a good many who did not have fractures would be weeded
out---36% by the investigators' estimate.^1^ And when the rule was
implemented in eight Canadian hospitals, waiting times, medical costs,
and the need for radiographs all decreased significantly.^4^

However, subsequent independent studies^5,6^ reported that the Ottawa
rule had lower sensitivity (93% to 95%) and specificity (6% to 11%) than
originally thought.

Nevertheless, although the Ottawa rule is not perfect, it provides an
excellent guide to help determine when radiographs are necessary in
patients with acute ankle injuries.

**CARE OF ANKLE SPRAINS**

Patients with acute ankle injuries that do not require radiographs
should rest the injured ankle, ice it, elevate it, and wrap it with a
compressive bandage. If the pain and swelling do not abate in 7 to 10
days, reevaluation is necessary.

**REFERENCES**

**1. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I,
Worthington JR.** A study to develop clinical decision rules for the use
of radiography in acute ankle injuries. Ann Emerg Med 1992;
21:384--390.\
**2. Bennet WF.** Lateral ankle sprains: Part 1 Anatomy, biomechanics,
diagnosis, and natural history. Orthop Rev 1994; 23:381--387.\
**3. Auletta AG, Conway WF, Hayes WF, Guisto DF, Gervin AS.**
Indications for radiography in patients with acute ankle injuries: Role
of the physical examination. AJR 1991; 157:789--791.\
**4. Stiell I, Wells G, Laupacis A, et al for the Multicentre Ankle Rule
Study Group.** Multicentre trial to introduce the Ottawa ankle rules for
use of radiography in acute ankle injuries: BMJ 1995; 311:594--597.\
**5. Auleley GR, Kerboull L, Durieux P, Courpied JP, Ravaud P.**
Validation of the Ottawa rules in France: A study in the surgical
emergency departments of a teaching hospital. Ann Emerg Med 1998;
32:14--18.\
**6. Kerr L, Kelly AM, Grant J, et al.** Failed validation of a clinical
decision rule for the use of radiography in acute ankle injury. NZ Med J
1994; 107:294--295.

> **Evaluating the patient with an ankle or foot injury**
>
> Mark H. Ebell
>
> Clinical Question
>
> When should radiographs be obtained in patients with an ankle or foot
> injury?
>
> Evidence Summary
>
> The Ottawa Ankle and Foot Rules (1) are validated clinical decision
> rules. The process by which the Ottawa rules were developed and
> validated serves as a model for researchers in developing decision
> support tools for other clinical problems. (1) Use of these rules can
> save time and money by helping physicians and their patients avoid
> unnecessary radiographs of the ankle or foot.
>
> The Ottawa rules have a parallel structure. Each begins with a
> question to assess the site of the patient\'s pain followed by an
> evaluation of function (based on the ability to bear weight for at
> least four steps immediately after the injury and again in the
> emergency department), and a focused physical assessment for the
> presence of localized bone tenderness. Radiographs should be obtained
> in patients who have pain in the relevant site accompanied by
> inability to walk four steps or bone tenderness as described above.
>
> How accurate are the Ottawa rules for ankle and foot injuries? A
> recent meta-analysis (2) identified 32 validation studies (27 were
> included in the analysis) involving 15,581 adult patients. With use of
> the Ottawa rules, the probability of a false negative (presence of
> fracture but no recommendation for radiographs) was extremely low (0.3
> percent). The rules also have been validated in children. In a study
> (3) of 670 children who presented with acute ankle injury, the Ottawa
> rules were 100 percent sensitive for fracture (no false negatives).
>
> One drawback to the Ottawa rules is the fairly low specificity, which
> generally is around 30 to 40 percent. (2,3) Consequently, radiographs
> will be recommended for many patients who do not have a fracture.
> Although not ideal, the rules are still considerably more selective
> than the typical practice of obtaining radiographs in every patient
> with acute ankle or foot pain after an injury.
>
> All validation studies on the Ottawa rules for ankle and foot injuries
> have been conducted in emergency departments. Therefore, there has
> been some question about whether these rules can be used in the
> outpatient setting. One small study (4) examined the performance of
> family physicians working part-time in a community hospital emergency
> department and found good sensitivity (97 percent) for use of the
> Ottawa rules by these physicians. With proper training and use of a
> decision support tool (see accompanying patient encounter form),
> family physicians can achieve similar sensitivity results in the
> outpatient setting.
>
> Applying the Evidence
>
> A 24-year-old man presents with a twisted ankle that occurred while he
> was playing basketball. He cannot recall if he everted or inverted his
> ankle. He was able to bear weight in the gym and limped while bearing
> weight as he walked to his friend\'s car. He ambulates with difficulty
> but is able to bear weight in the physician\'s office as he walks to
> the examination room. On examination, he complains of pain in the
> ankle and has tenderness to percussion of the lateral malleolus. Does
> he need a radiograph of the ankle?
>
> Answer: Because the patient has ankle pain and tenderness to
> percussion of a malleolus, a radiograph should be obtained even though
> the patient is able to bear weight.
>
> \[ILLUSTRATION OMITTED\]
>
> REFERENCES
>
> (1.) Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I,
> Reardon M, et al. Decision rules for the use of radiography in acute
> ankle injuries. Refinement and prospective validation. JAMA
> 1993;269:1127-32.
>
> (2.) 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:
> a systematic review. BMJ 2003;326:417.
>
> (3.) Plint AC, Bulloch B, Osmond MH, Steill I, Dunlap H, Reed M, et
> al. Validation of the Ottawa Ankle Rules in children with ankle
> injuries. Acad Emerg Med 1999;6:1005-9.
>
> (4.) McBride KL. Validation of the Ottawa ankle rules. Experience at a
> community hospital. Can Fam Physician 1997;43:459-65.

The following is a small excerpt from:
<http://www.emedicine.com/RADIO/topic829.htm>

This provides a brief overview of the different diagnostic procedures
available.

+-------------------------------------------------+--------------------+
| ## Ankle, Fractures                             |   ---------------  |
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| **Last Updated:** July 28, 2005                 | ------------------ |
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+-------------------------------------------------+--------------------+
| **Synonyms and related keywords:** ankle        |                    |
| fracture, broken ankle, fractured ankle, broken |                    |
| ankle bone, fractured ankle bone, fractured     |                    |
| anklebone, broken anklebone, Ottawa ankle       |                    |
| rules, broken foot, fractured foot, sprained    |                    |
| ankle, twisted ankle                            |                    |
+-------------------------------------------------+--------------------+

+---+-----------------------------------+--------------------------------+
|   | **AUTHOR INFORMATION**            | **Section 1 of 11   **         |
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| - |                                   |                                |
| - |                                   |                                |
| - |                                   |                                |
| - |                                   |                                |
| - |                                   |                                |
| - |                                   |                                |
| - |                                   |                                |
| - |                                   |                                |
| - |                                   |                                |
| - |                                   |                                |
| - |                                   |                                |
| - |                                   |                                |
| - |                                   |                                |
| - |                                   |                                |
| - |                                   |                                |
| - |                                   |                                |
| - |                                   |                                |
| - |                                   |                                |
| - |                                   |                                |
| - |                                   |                                |
| - |                                   |                                |
| - |                                   |                                |
| - |                                   |                                |
| - |                                   |                                |
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| - |                                   |                                |
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| - |                                   |                                |
+---+-----------------------------------+--------------------------------+

  -----------------------------------------------------------------------------------------------------------------------
  Author: [**[Michael E Mulligan,
  MD]{.underline}**](http://www.emedicine.com/cgi-bin/foxweb.exe/screen@d:\em\ga?book=radio&authorid=4907&topicid=829),
  Chief, Division of Radiology, Kernan Hospital; Assistant Chief of Musculoskeletal Imaging, Associate Professor,
  Department of Radiology, University of Maryland School of Medicine

  Michael E Mulligan, MD, is a member of the following medical societies: [American Roentgen Ray
  Society](http://www.arrs.org/), [International Skeletal Society](http://www.intskelsoc.com/), [Radiological Society of
  North America](http://www.rsna.org/), and [Society of Skeletal Radiology](http://www.skeletalrad.org/)

  Editor(s): **Amilcare Gentili, MD**, Clinical Professor of Radiology, University of California at San Diego; Consulting
  Staff, Department of Radiology, Thornton Hospital; **Bernard D Coombs, MB, ChB, PhD**, Consulting Staff, Department of
  Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand; **Theodore E Keats, MD**,
  Professor, Departments of Radiology and Orthopedics, University of Virginia School of Medicine; **Robert M Krasny,
  MD**, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute; and **Felix S Chew, MD,
  EdM, MBA**, Professor, Department of Radiology, Vice Chairman for Radiology Informatics, Section Head of
  Musculoskeletal Radiology, University of Washington
  -----------------------------------------------------------------------------------------------------------------------

+---+------------------+------------------------------------------------+
|   | **CT SCAN**      | **Section 5 of                                 |
|   |                  | 11   **![](                                    |
|   |                  | media/image3.png){width="0.3229166666666667in" |
|   |                  | height="0.10416666666666667in"}                |
|   |                  | ![](                                           |
|   |                  | media/image4.png){width="0.3229166666666667in" |
|   |                  | height="0.10416666666666667in"}![](            |
|   |                  | media/image2.png){width="0.3229166666666667in" |
|   |                  | height="0.10416666666666667in"}                |
+---+------------------+------------------------------------------------+
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+---+------------------+------------------------------------------------+

**Findings:** CT is not needed in the evaluation of most ankle
fractures. It may be used to better define pilon fractures or triplane
fractures. Thin overlapping sections should be taken, in case coronal
and sagittal reconstructions are needed, or newer multislice isotropic
techniques should be used.

+---+---------+--------------------------------------------------------+
|   | **MRI** | **Section 6 of                                         |
|   |         | 11                                                     |
|   |         |   **![](media/image3.png){width="0.3229166666666667in" |
|   |         | height="0.10416666666666667in"}                        |
|   |         | ![](media/image4.png){width="0.3229166666666667in"     |
|   |         | height="0.10416666666666667                            |
|   |         | in"}![](media/image2.png){width="0.3229166666666667in" |
|   |         | height="0.10416666666666667in"}                        |
+---+---------+--------------------------------------------------------+
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| - |         |                                                        |
| - |         |                                                        |
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| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
| - |         |                                                        |
+---+---------+--------------------------------------------------------+

**Findings:** MRI is not needed for the evaluation of most ankle
fractures. It can show additional injuries in children with Salter
Harris fractures. MRI also may be used to check for occult injuries,
especially injuries of the talar dome or soft tissue injuries, such as
surrounding ligament or tendon abnormalities.

+---+------------------------+------------------------------------------+
|   | **ULTRASOUND**         | **Section 7 of                           |
|   |                        | 11   **![](media/                        |
|   |                        | image3.png){width="0.3229166666666667in" |
|   |                        | height="0.10416666666666667in"}          |
|   |                        | ![](media/                               |
|   |                        | image4.png){width="0.3229166666666667in" |
|   |                        | h                                        |
|   |                        | eight="0.10416666666666667in"}![](media/ |
|   |                        | image2.png){width="0.3229166666666667in" |
|   |                        | height="0.10416666666666667in"}          |
+---+------------------------+------------------------------------------+
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+---+------------------------+------------------------------------------+

**Findings:** Ultrasound usually is not employed in the United States in
the evaluation of patients with ankle fractures. It can depict fractures
and associated soft tissue injuries, especially injuries of the peroneal
tendons.

+---+------------------------------+-------------------------------------+
|   | **NUCLEAR MEDICINE**         | **Section 8 of                      |
|   |                              | 11   **![](media/image              |
|   |                              | 3.png){width="0.3229166666666667in" |
|   |                              | height="0.10416666666666667in"}     |
|   |                              | ![](media/image                     |
|   |                              | 4.png){width="0.3229166666666667in" |
|   |                              | height="0.1                         |
|   |                              | 0416666666666667in"}![](media/image |
|   |                              | 2.png){width="0.3229166666666667in" |
|   |                              | height="0.10416666666666667in"}     |
+---+------------------------------+-------------------------------------+
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+---+------------------------------+-------------------------------------+

**Findings:** Bone scintigraphy is not needed in the evaluation of most
ankle injuries. It can be used to look for occult injuries, especially
injuries of the talar dome.

Additional information and examples of radiographs and MRI photos are
available at:

[http://www.uptodateonline.com](http://www.uptodateonline.com/)

This can be accessed through the IHS website and seen under the
"Overview of Ankle Fractures" and Ankle Sprain" articles.

See Below for a Graphic Figure depicting the Ottawa Ankle / Foot Rules.

+-----------------------------------------------------------------------+
|   ------------------------------------------------------------------  |
|   ![](media/image5.png){width="5.447916666666667in"                   |
|   height="6.145833333333333in"}                                       |
|                                                                       |
|   ------------------------------------------------------------------  |
|                                                                       |
|   ------------------------------------------------------------------  |
|                                                                       |
|   ------------------------------------------------------------------  |
+-----------------------------------------------------------------------+
|   ------------------------------------------------------------------  |
|   ©2006 UpToDate^®^ • www.uptodate.com\                               |
|   Licensed to **Indian Health Service**                               |
|                                                                       |
|   ------------------------------------------------------------------  |
+-----------------------------------------------------------------------+