QuestionSBA
QuestionChoice
This is not a first-line investigation for possible ankle fractures and would be more suited for assessing ligament damage.
10017148
c
Arrange an ankle MRI
QuestionChoice
The Ottawa rules recommend an ankle X-ray if following an ankle injury, a patient has pain in the malleolar zone and one of the following; 1) Inability to weight bear immediately after the injury and on examination, 2) Bony tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus, or 3) Bony tenderness along the distal 6cm of the posterior edge of the tibia or tip of the medial malleolus. As this patient meets these criteria, an ankle X-ray should be carried out in order to rule out ankle fracture.
10017146
a
Arrange an immediate ankle X-ray
QuestionChoice
As there is no evidence of an open fracture on examination and fracture is yet to be confirmed on X-ray, this would not be a reasonable first step in management.
10017149
d
Immediate surgical reduction and fixation
QuestionChoice
This would not be appropriate as the patient meets the criteria for an ankle X-ray.
10017147
b
Discharge home with advice for elevation, compression, and analgesia
QuestionChoice
Whilst in some injuries, a watch and wait approach can be useful, the patient clearly meets the ankle X-ray criteria listed above and as such, imaging should not be delayed.
10017150
e
Arrange an ankle X-ray in 14 days if symptoms have not improved
Concept
Chapter
# Indication

The Ottawa ankle rules are a decision aid for use in the assessment of acute ankle injuries and the need for radiological imaging. It was developed to reduce the number of unnecessary x-rays being performed, as many ankle injuries do not display a fracture and can be managed conservatively.

# Requirement for x-ray if there is malleolar pain

Ankle x-ray is required only if there is pain in the malleolar zone and any of:

- 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 bear weight both immediately and in emergency department for four steps.

# Requirement for x-ray if there is midfoot pain

Foot x-ray is only required if there is midfoot zone pain and any of the below:

- Bone tenderness at base of the fifth metatarsal.
- Bone tenderness at navicular bone.
- Inability to bear weight both immediately and in emergency department for four steps.

# Reasons why the Ottawa Ankle Rules may not be accurate

It is important also to use clinical judgement and appreciate this decision aid might not be accurate if:

- The patient is intoxicated or has reduced consciousness
- The patient has other distracting painful injuries
- The patient has evidence of reduced sensation in the lower limb

# References

[- The Ottawa Ankle Rules](http://www.theottawarules.ca/ankle_rules)
[- BMJ Best Practice: Ankle Fractures](https://bestpractice.bmj.com/topics/en-gb/385/)
1020
1076
Ottawa Ankle Rules
Topic
37
Orthopaedics
15973
In ankle injuries, the Ottawa rules indicate an X-ray is necessary if there is malleolar zone pain and inability to weight bear.
A 19-year-old female inverts her right ankle whilst playing football. Immediately after the injury she is only able to take two steps using her right foot. On examination, her foot is swollen and bruised and she is extremely tender over her right lateral malleolus. Her foot is warm and well perfused and her dorsalis pedis pulse is palpable. She is unable to weight bear at the time of examination.

What is the most appropriate way to manage this injury?
a