Ankle Fracture Guidelines

Updated: Oct 26, 2016
  • Author: Kara Iskyan, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Guidelines

Guidelines Summary

Ottawa Ankle Rules for Ankle Injury Radiography

An ankle x-ray series is only required if there is any pain in the malleolar zone and any of these findings [23] :

  • Bone tenderness at the posterior edge or tip of the lateral malleolus
  • Bone tenderness at the posterior edge or tip of the medial malleolus
  • Inability to take 4 complete steps both immediately and in the ED

A foot x-ray series is only required if there is any pain in the midfoot zone and any of these findings:

  • Bone tenderness at the base of the 5th metatarsal
  • Bone tenderness at the navicular
  • Inability to take 4 complete steps both immediately and in the ED

Apply the Ottawa Ankle Rules accurately:

  • Palpate the entire distal 6 cm of the fibula and tibia
  • Do not neglect the importance of medial malleolar tenderness
  • Do not use for patients under age 18 years

Clinical judgement should prevail over the rules in the following circumstances:

  • If the patient is intoxicated or uncooperative
  • If the patient has other distracting painful injuries
  • If the patient has diminished sensation in the legs
  • If the patient has gross swelling that prevents palpation of malleolar bone tenderness

Give written instructions and encourage follow-up in 5-7 days if pain and ability to walk are not better.