Ankle Fracture Management in the ED Guidelines

Updated: Jan 31, 2022
  • Author: Kara Iskyan, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
  • Print
Guidelines

Guidelines Summary

Ottawa Ankle Rules for Ankle Injury Radiography

An ankle x-ray series is required only if there is any pain in the malleolar zone along with any of these findings [29] :

  • 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 required only if there is any pain in the midfoot zone along with any of these findings:

  • Bone tenderness at the base of the fifth 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 younger than 18 years.

Clinical judgment should prevail over these rules in the following circumstances:

  • Patient is intoxicated or uncooperative.
  • Patient has other distracting painful injuries.
  • Patient has diminished sensation in the legs.
  • 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 improved.