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.

Medication

Ribeiro de Ávila V, Bento T, Gomes W, et al. Functional outcomes and quality of life after ankle fracture surgically treated: a systematic review. J Sport Rehabil. 2018 May 1. 27 (3):274-83. [QxMD MEDLINE Link].
Wire J, Hermena S, Slane VH. Ankle fractures. 2022 Jan. [QxMD MEDLINE Link]. [Full Text].
Hinds RM, Garner MR, Lazaro LE, et al. Ankle fracture spur sign is pathognomonic for the hyperplantarflexion variant ankle fracture. Foot Ankle Int. 2015 Feb. 36 (2):159-64. [QxMD MEDLINE Link].
Yavas S, Arslan ED, Ozkan S, et al. Accuracy of Ottawa Ankle Rules for midfoot and ankle injuries. Acta Biomed. 2021 Sep 2. 92 (4):e2021241. [QxMD MEDLINE Link].
Scheer RC, Newman JM, Zhou JJ, et al. Ankle fracture epidemiology in the United States: patient-related trends and mechanisms of injury. J Foot Ankle Surg. 2020 May - Jun. 59 (3):479-83. [QxMD MEDLINE Link].
Parikh SN, Mehlman CT. The community orthopaedic surgeon taking trauma call: pediatric ankle fracture pearls and pitfalls. J Orthop Trauma. 2017 Nov. 31 Suppl 6:S27-S31. [QxMD MEDLINE Link].
McKissack HM, Viner GC, McMurtrie JT, et al. Does insurance status affect access to care among ankle fracture patients? An institutional retrospective study. J Foot Ankle Surg. 2021 May-Jun. 60 (3):520-2. [QxMD MEDLINE Link].
Van Schie-Van der Weert EM, Van Lieshout EM, De Vries MR, et al. Determinants of outcome in operatively and non-operatively treated Weber-B ankle fractures. Arch Orthop Trauma Surg. 2012 Feb. 132(2):257-63. [QxMD MEDLINE Link]. [Full Text].
Han SM, Wu TH, Wen JX, et al. Radiographic analysis of adult ankle fractures using combined Danis-Weber and Lauge-Hansen classification systems. Sci Rep. 2020 May 6. 10 (1):7655. [QxMD MEDLINE Link].
Duchesneau S, Fallat LM. The Tillaux fracture. J Foot Ankle Surg. 1996 Mar-Apr. 35(2):127-33; discussion 189. [QxMD MEDLINE Link].
McCrory P, Bladin C. Fractures of the lateral process of the talus: a clinical review. "Snowboarder's ankle.". Clin J Sport Med. 1996 Apr. 6(2):124-8. [QxMD MEDLINE Link].
Chan GM, Yoshida D. Fracture of the lateral process of the talus associated with snowboarding. Ann Emerg Med. 2003 Jun. 41(6):854-8. [QxMD MEDLINE Link].
Ojeda-Jiménez J, Méndez-Ojeda MM, Martín-Vélez P, et al. Experience using the "Shetty test" for initial foot and ankle fracture screening in the emergency department. Rev Esp Cir Ortop Traumatol (Engl Ed). 2018 Sep-Oct. 62 (5):343-7. [QxMD MEDLINE Link].
Dowdall H, Gee M, Brison RJ, et al. Utilization of radiographs for the diagnosis of ankle fractures in Kingston, Ontario, Canada. Acad Emerg Med. 2011 May. 18(5):555-8. [QxMD MEDLINE Link].
[Guideline] Dalinka MK, Alazraki NP, Daffner RH, et al; Expert Panel on Musculoskeletal Imaging. Suspected ankle fractures. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. [Full Text].
Mosher TJ, Kransdorf MJ, Adler R, et al. ACR Appropriateness Criteria acute trauma to the ankle. J Am Coll Radiol. 2015 Mar. 12 (3):221-7. [QxMD MEDLINE Link].
Broomhead A, Stuart P. Validation of the Ottawa Ankle Rules in Australia. Emerg Med (Fremantle). 2003 Apr. 15(2):126-32. [QxMD MEDLINE Link].
David S, Gray K, Russell JA, et al. Validation of the Ottawa Ankle Rules for Acute Foot and Ankle Injuries. J Sport Rehabil. 2016 Feb. 25 (1):48-51. [QxMD MEDLINE Link].
Dowling S, Spooner CH, Liang Y, et al. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. Acad Emerg Med. 2009 Apr. 16(4):277-87. [QxMD MEDLINE Link].
Petscavage J, Baker SR, Clarkin K, et al. Overuse of concomitant foot radiographic series in patients sustaining minor ankle injuries. Emerg Radiol. 2010 Jul. 17 (4):261-5. [QxMD MEDLINE Link].
Gonzalez O, Fleming JJ, Meyr AJ. Radiographic assessment of posterior malleolar ankle fractures. J Foot Ankle Surg. 2015 May-Jun. 54 (3):365-9. [QxMD MEDLINE Link].
Fokin A Jr, Huntley SR, Summers SH, et al. Computed tomography assessment of peroneal tendon displacement and posteromedial structure entrapment in pilon fractures. J Orthop Trauma. 2016 Nov. 30 (11):627-33. [QxMD MEDLINE Link].
Tollefson B, Nichols J, Fromang S, et al. Validation of the sonographic Ottawa Foot and Ankle Rules (SOFAR) study in a large urban trauma center. J Miss State Med Assoc. 2016 Feb. 57 (2):35-8. [QxMD MEDLINE Link].
Alioto RJ, Furia JP, Marquardt JD. Hematoma block for ankle fractures: a safe and efficacious technique for manipulations. J Orthop Trauma. 1995 Apr. 9(2):113-6. [QxMD MEDLINE Link].
Barnett PL, Lee MH, Oh L, et al. Functional outcome after air-stirrup ankle brace or fiberglass backslab for pediatric low-risk ankle fractures: a randomized observer-blinded controlled trial. Pediatr Emerg Care. 2012 Aug. 28(8):745-9. [QxMD MEDLINE Link].
Mora S, Zalavras CG, Wang L, et al. The role of pulsatile cold compression in edema resolution following ankle fractures: a randomized clinical trial. Foot Ankle Int. 2002 Nov. 23(11):999-1002. [QxMD MEDLINE Link].
Okcu G, Yercan HS. Is it possible to decrease skin temperature with ice packs under casts and bandages? A cross-sectional, randomized trial on normal and swollen ankles. Arch Orthop Trauma Surg. 2006 Dec. 126(10):668-73. [QxMD MEDLINE Link].
Jensen CM, Serritslev R, Abrahamsen C. Patients' perspective on treatment and early rehabilitation after an ankle fracture: a longitudinal qualitative study. Int J Orthop Trauma Nurs. 2021 Oct 29. 100916. [QxMD MEDLINE Link].
[Guideline] Ottawa Hospital Research Institute. Ottawa Ankle Rules for ankle injury radiography. Available at http://www.ohri.ca/emerg/cdr/docs/cdr_ankle_poster.pdf. 2013; Accessed: October 26, 2016.
Yeung DE, Jia X, Miller CA, et al. Interventions for treating ankle fractures in children. Cochrane Database Syst Rev. 2016 Apr 1. 4:CD010836. [QxMD MEDLINE Link].
Shariff SS, Nathwani DK. Lauge-Hansen classification--a literature review. Injury. 2006 Sep. 37(9):888-90. [QxMD MEDLINE Link].
Michelson JD, Magid D, McHale K. Clinical utility of a stability-based ankle fracture classification system. J Orthop Trauma. 2007 May. 21(5):307-15. [QxMD MEDLINE Link].
Ashworth MJ, Patel N. Compartment syndrome following ankle fracture-dislocation: a case report. J Orthop Trauma. 1998 Jan. 12(1):67-8. [QxMD MEDLINE Link].
Birrer R, Cartwright T, Denton J. Immediate diagnosis of ankle trauma. The Physician and Sports Medicine. McGraw Hill; 1994. Vol 22: 95-103.
Bucholz RW, Heckman JD. Fractures in adults. Rockwood and Green's Fractures in Adults. 5th ed. Lippincott Williams & Wilkins; 2001.
Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures--an increasing problem?. Acta Orthop Scand. 1998 Feb. 69(1):43-7. [QxMD MEDLINE Link].
Cummings RJ, Hahn GA. The incisural fracture. Foot Ankle Int. 2004 Mar. 25(3):132-5. [QxMD MEDLINE Link].
Daffner RH. Ankle trauma. Radiol Clin North Am. 1990 Mar. 28(2):395-421. [QxMD MEDLINE Link].
Derksen RJ, Bakker FC, Geervliet PC, et al. Diagnostic accuracy and reproducibility in the interpretation of Ottawa ankle and foot rules by specialized emergency nurses. Am J Emerg Med. 2005 Oct. 23(6):725-9. [QxMD MEDLINE Link].
Duke Orthopaedics. Ankle Fractures. Wheeless' Textbook of Orthopaedics online. 2005. [Full Text].
Fox A, Wykes P, Eccles K, et al. Five years of ankle fractures grouped by stability. Injury. 2005 Jul. 36(7):836-41. [QxMD MEDLINE Link].
Greenfield DM, Eastell R. Risk factors for ankle fracture. Osteoporos Int. 2001. 12(2):97-103. [QxMD MEDLINE Link].
Holroyd BR, Wilson D, Rowe BH, et al. Uptake of validated clinical practice guidelines: experience with implementing the Ottawa Ankle Rules. Am J Emerg Med. 2004 May. 22(3):149-55. [QxMD MEDLINE Link].
Kannus P, Palvanen M, Niemi S, et al. Increasing number and incidence of low-trauma ankle fractures in elderly people: Finnish statistics during 1970-2000 and projections for the future. Bone. 2002 Sep. 31(3):430-3. [QxMD MEDLINE Link].
Kirkpatrick DP, Hunter RE, Janes PC, et al. The snowboarder's foot and ankle. Am J Sports Med. 1998 Mar-Apr. 26(2):271-7. [QxMD MEDLINE Link].
Koury SI, Stone CK, Harrell G, et al. Recognition and management of Tillaux fractures in adolescents. Pediatr Emerg Care. 1999 Feb. 15(1):37-9. [QxMD MEDLINE Link].
Koval KJ, Lurie J, Zhou W, et al. Ankle fractures in the elderly: what you get depends on where you live and who you see. J Orthop Trauma. 2005 Oct. 19(9):635-9. [QxMD MEDLINE Link].
Koval KJ, Zhou W, Sparks MJ, et al. Complications after ankle fracture in elderly patients. Foot Ankle Int. 2007 Dec. 28(12):1249-55. [QxMD MEDLINE Link].
Martin AG. Weber B ankle fracture: an unnecessary fracture clinic burden. Injury. 2004 Aug. 35(8):805-8. [QxMD MEDLINE Link].
Muthukumar T, Butt SH, Cassar-Pullicino VN. Stress fractures and related disorders in foot and ankle: plain films, scintigraphy, CT, and MR Imaging. Semin Musculoskelet Radiol. 2005 Sep. 9(3):210-26. [QxMD MEDLINE Link].
Nugent PJ. Ottawa Ankle Rules accurately asses injuries and reduce reliance on radiographs. J Fam Pract. 2004 Oct. 53(10):785-8. [QxMD MEDLINE Link].
Park JW, Kim SK, Hong JS, et al. Anterior tibiofibular ligament avulsion fracture in weber type B lateral malleolar fracture. J Trauma. 2002 Apr. 52(4):655-9. [QxMD MEDLINE Link].
Perry JJ, Stiell IG. Impact of clinical decision rules on clinical care of traumatic injuries to the foot and ankle, knee, cervical spine, and head. Injury. 2006 Dec. 37(12):1157-65. [QxMD MEDLINE Link].
Ruiz E, Cicero J. Emergency Management of Skeletal Injuries. 1st ed. Mosby-Year Book, Inc; 1995. 517-41.
Schmittenbecher PP. What must we respect in articular fractures in childhood?. Injury. 2005 Feb. 36 Suppl 1:A35-43. [QxMD MEDLINE Link].
Stiell IG, McKnight RD, Greenberg GH, et al. Implementation of the Ottawa Ankle Rules. JAMA. 1994 Mar 16. 271(11):827-32. [QxMD MEDLINE Link].
Tang CW, Roidis N, Vaishnav S, et al. Position of the distal fibular fragment in pronation and supination ankle fractures: a CT evaluation. Foot Ankle Int. 2003 Jul. 24(7):561-6. [QxMD MEDLINE Link].
Thordarson DB. Detecting and treating common foot and ankle fractures: Part 1: The ankle and hindfoot. Phys Sportsmed. 1996 Sep. 24 (9):
Werner CM, Lorich DG, Gardner MJ, et al. Ankle fractures: it is not just a "simple" ankle fracture. Am J Orthop. 2007 Sep. 36(9):466-9. [QxMD MEDLINE Link].
Wexler RK. The injured ankle. Am Fam Physician. 1998 Feb 1. 57(3):474-80. [QxMD MEDLINE Link].

Media Gallery

Maisonneuve injury. Mortise view shows transverse fracture of the medial malleolus and widening of the tibiofibular syndesmosis without a fracture of the fibula. This injury is suggestive of a proximal fibula fracture (Maisonneuve fracture).
Pilon fracture in a 35-year-old man who fell 20 ft. Anteroposterior radiograph shows at least 2 fracture lines extending to the articular surface (plafond) of the tibia.
A 13-year-old girl with triplane fracture. Anteroposterior radiograph shows a sagittal component through the distal tibia epiphysis.
An 11-year-old girl with juvenile Tillaux fracture. Mortise view shows fracture involving the lateral portion of tibial epiphysis.

of 4

Author

Kara Iskyan, MD Staff Physician, Departments of Internal Medicine and Emergency Medicine, Allegheny General Hospital

Kara Iskyan, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Coauthor(s)

Andrew A Aronson, MD, FACEP Vice President, Physician Practices, Bravo Health Advanced Care Center; Consulting Staff, Department of Emergency Medicine, Taylor Hospital

Andrew A Aronson, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, Society of Hospital Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David B Levy, DO, FAAEM Senior Consultant in Emergency Medicine, Waikato District Health Board, New Zealand; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Fellowship of the Australasian College for Emergency Medicine, American Medical Informatics Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Francis Counselman, MD, FACEP Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School

Francis Counselman, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Norfolk Academy of Medicine, Association of Academic Chairs of Emergency Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Jerome FX Naradzay, MD, to the development and writing of this article.