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The Ottawa rules have been described and evaluated by Steil et al (1,2). More
recent evidence also supports the Ottawa ankle rules as an accurate instrument
for excluding fractures of the ankle and mid-foot. The instrument has a sensitivity
of almost 100% and a modest specificity, and its use should reduce the number
of unnecessary radiographs by 30-40% (3). 
Diagram
reproduced with permission from www.gp-training.net Ottawa
Rules with Respect to Ankle X-rays An ankle x-ray is required
only if there is any pain in malleolar zone and any of these findings: -
boney tenderness at the lateral malleolar zone A (from the tip of the lateral
malleolus to include the lower 6 cm of posterior border of the fibular)
-
boney tenderness at the medial malleolar zone B (from the tip of the medial malleolus
to the lower 6 cm of the posterior border of the tibia)
- inability to
walk four weight bearing steps immediately after the injury and in the emergency
department
Ottawa Rules with Respect to Foot X-rays A
foot x-ray is required if there is any pain in the midfoot zone and any of these
findings: - bone tenderness at Navicular bone (C)
- bone tenderness
at base of the 5th metatarsal (D)
- inability to weight bear both immediately
and in the emergency department
Ottawa Rules with
Respect to Knee X-rays An xray is indicated in patients
with knee injuries with any of the following: - age 55 years or older
- tenderness at the head of the fibula
- isolated tenderness of
the patella
- inability to flex knee to 90 degrees
- inability to
walk four weight bearing steps immediately after the injury and in the emergency
department
Notes:
- the Ottawa ankle rules apply to children from the age of 3 years to adults
up until the age of 55 years
- tenderness over the navicular, calcaneum, base of 5th metatarsal or proximal
fibula require specific xrays to exclude fractures
- the Ottawa ankle rules appear to be a reliable tool to exclude fractures
in children greater than 5 years of age presenting with ankle and midfoot
injuries (4)
Reference:
- Stiell IG et al.Multicentre trial to introduce the Ottawa ankle rules for
use of radiography in acute ankle injuries BMJ 1995;311:594-597
- Stiell IG et al. Implementation of the Ottawa ankle rules. JAMA 1994;271:827-32
- Bachmann LM et al. Accuracy of Ottawa ankle rules to exclude fractures of
the ankle and mid-foot: systematic review BMJ, Feb 2003; 326: 417.
- Dowling
S 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
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