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SportsOttawa Ankle Rules
Twenty flashcards on when an injured ankle or midfoot needs X-rays: each finding of the rule and what the evidence says.
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20 cards
- What are the Ottawa Ankle Rules for?
- A bedside decision tool that rules out ankle fractures so patients avoid X-rays they do not need.
- Who developed the Ottawa Ankle Rules?
- Stiell and colleagues.
- Ankle X-rays: where must the pain be first?
- In the malleolar zone, plus at least one of three findings.
- Ankle finding 1: which bone tenderness?
- Along the distal 6 cm of the posterior edge of the medial or lateral malleolus.
- Ankle finding 2: which bone tenderness?
- Right at the tip of the medial or lateral malleolus.
- Finding 3, shared by ankle and foot?
- Cannot bear weight and walk 4 steps right after the injury or in the emergency room.
- Foot X-rays: where must the pain be?
- In the midfoot zone, plus at least one finding.
- Midfoot rule: which two bones are checked for tenderness?
- The navicular and the base of the fifth metatarsal.
- NATA rating of the Ottawa Ankle Rules?
- Evidence category A: a valid tool to decide on X-rays of the ankle or midfoot.
- Foot and ankle trauma in the ER: how many get X-rays vs. have fractures?
- 80% to 95% get X-rays, yet only about 15% have a fracture.
- What did Leddy's modification add?
- Tenderness at the middle third of the malleoli: better specificity, same sensitivity.
- Bachmann's review of the rules: size and sensitivity?
- 27 studies, 15,581 patients, nearly 100% sensitivity for ankle or midfoot fracture.
- In that review, how many fractures did the rules miss?
- 1.4%: fewer than 2 in 100 rule-negative patients had a fracture.
- Young patients aged 6 to 19: how much could the rules cut X-rays?
- By 24.8%, with a pooled sensitivity of 98.5%.
- 2022 meta-analysis in adults: how big?
- 15 studies, 8,560 patients, 13 countries.
- Pooled sensitivity and specificity in that meta-analysis?
- Sensitivity 0.91, specificity 0.25.
- High sensitivity, low specificity: what does it mean at the bedside?
- A negative rule reliably rules out fracture; a positive one brings many false positives.
- So can a positive rule be the only reason for an X-ray?
- No: the review says it should not be the sole indicator.
- What gains does the review link to using the rules?
- Fewer unneeded X-rays, less radiation, lower costs and shorter waits.
- Inversion injury: which fracture can occur at the fifth metatarsal?
- An avulsion of its base, pulled by the peroneus brevis.
Official sources
PubMed Central, National Library of Medicine
Diagnostic accuracy of the Ottawa ankle rule to exclude fractures in acute ankle injuries in adults: a systematic review and meta-analysis (BMC Musculoskelet Disord 2022)
National Athletic Trainers' Association (PubMed Central, National Library of Medicine)
National Athletic Trainers' Association Position Statement: Conservative Management and Prevention of Ankle Sprains in Athletes (J Athl Train 2013)
Making Synapses is not affiliated with, sponsored by or endorsed by the NATA, the BOC, CAATE, the Ottawa Hospital Research Institute or any university. NATA, BOC and CAATE are trademarks of their respective owners and are named only to describe the content.