A foot x-ray series is required only if there is pain in the midfoot zone and any one of the following:

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Maude Chapman
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RADIOGRAPHY OF THE ANKLE AND FOOT (OTTAWA ANKLE RULES) Clinical Practice Guideline January 2007 This guideline has been adapted frm the Ottawa Ankle Rules develped by Dr.

1 RADIOGRAPHY OF THE ANKLE AND FOOT (OTTAWA ANKLE RULES) Clinical Practice Guideline January 2007 This guideline has been adapted frm the Ottawa Ankle Rules develped by Dr. Ian Stiell et al. Dr. Stiell received financial supprt frm the Institute f Clinical and Evaluative Studies in Ontari. OBJECTIVE The Ottawa Ankle Rules will assist Alberta clinicians assess if radigraphy f the ft and ankle is required fr adult patients presenting with blunt ankle trauma at health care facilities. TARGET POPULATION Adults, 18 years f age and lder EXCLUSIONS Under 18 years f age, intxicated, multiple painful injuries, pregnant, head injury, diminished sensatin due t neurlgical deficit RECOMMENDATIONS An ankle x-ray series is required nly if there is pain in the mallelar zne and any ne f the fllwing: Bne tenderness alng the distal 6 cm f the psterir edge f the fibula r tip f the lateral mallelus Bne tenderness alng the distal 6 cm f the psterir edge f the tibia r tip f the medial mallelus Inability t bear weight fr fur steps immediately and in the emergency department A ft x-ray series is required nly if there is pain in the midft zne and any ne f the fllwing: Bne tenderness at the base f the 5 th metatarsal Bne tenderness at the navicular bne Inability t bear weight fr fur steps bth immediately and in the emergency department OTTAWA ANKLE RULES POSTER PDF (link available as f March 2014) These recmmendatins are systematically develped statements t assist practitiner and patient decisins abut apprpriate health care fr specific clinical circumstances. They shuld be used as an adjunct t sund clinical decisin making.

2 Radigraphy f the Ankle and Ft (Ottawa Ankle Rules) January 2007 BACKGROUND The Ottawa Ankle Rules were adapted by TOP s predecessr, the Alberta Clinical Practice Guideline Prgram, in 1996 as a guideline t assist physicians t make decisins abut use f radigraphy fr patients with ankle injuries. The Ottawa Ankle Rules were develped, clinically tested and demnstrated that the use f these rules decreased ankle radigraphy use, waiting times, and csts withut patient dissatisfactin r missed fractures. The investigatr, Dr. Ian Stiell, a clinical epidemilgist with a fcus n health services research in emergency medicine, led this wrk. Dr. Stiell cnducted five studies t examine the rle f radigraphic imaging f the ankle and midft and the resulting decisin rules fr use f radigraphy in ankle injury. Dr. Stiell s studies are summarized belw. RESEARCH FINDINGS AGREEMENT IN THE EXAMINATION OF ACUTE ANKLE INJURY PATIENTS The first study invlved a methd fr measuring interbserver agreement t determine the reliability f physical findings when emergency physicians assessed patients with ankle injuries. Tw adult emergency departments in Ottawa participated. Patients were eligible if they had suffered acute blunt trauma t the ankle, regardless f the cause f injury. Patients were excluded if they were under 18 years f age, pregnant, had islated superficial skin injury, had been injured mre than ten days previusly and/r had returned fr reassessment f the same injury. Ten areas f pint tenderness and fur areas f sft tissue tenderness were included. As well, ecchymsis, range f mtin, degree f swelling in fur lcatins, anterir drawer sign and ability t bear weight fr at least fur steps in the emergency department. The best agreement was judging ability t bear weight and gd agreement judging bne tenderness. Findings related t ecchymsis, range f mtin, sft tissue tenderness and anterir drawer sign were unreliable. The interbserver agreement was mst reliable fr bearing weight fr fur steps in the emergency department, swelling f the lateral mallelus, lcalized bne tenderness f the base f the fifth metatarsal, the anterir and psterir edges f the lateral mallelus, and the inferir tip f the medial mallelus. DEVELOPING CLINICAL DECISION RULES FOR THE USE OF RADIOGRAPHY IN ACUTE ANKLE INJURIES A secnd study was cnducted t develp decisins rules that wuld predict fractures in patients with ankle and midft injuries. This prspective study was cnducted in tw adult emergency departments in Ottawa. Clinical Practice Guideline Page 2 f 5 Backgrund

3 Radigraphy f the Ankle and Ft (Ottawa Ankle Rules) January 2007 An initial (pilt) study included 155 patients, fllwed by the main study including 750 patients. They assessed 32 standardized clinical variables and these were assessed fr reliability by the kappa cefficient, fr assciatin with significant fracture f the ankle r midft. The gal was 100% sensitivity fr detecting fractures f the ankle and midft. But when applying the rules t the 750 patients, they fund 70 (9.3%) significant mallelar fractures and 32 (4.3%) significant midft fractures cncluding that an ankle X-ray was necessary nly if the patient had pain near the malleli and ne r mre f the fllwing criteria: ver age 55, unable t bear weight fr fur steps in the emergency department, bne tenderness at the psterir edge r tip f the mallelus. A ft X-ray was necessary if the patient had pain in the midft and bne tenderness at the navicular, cubid, r base f the fifth metatarsal. Clinicians reprted that the rules were practical and maintained 100% sensitivity. Hwever, 77% f the X-rays were still negative. When excluding bne tenderness f the inferir tip f the lateral mallelus as part f the examinatin, specificity increased t 55.7% frm 40%, and a ptential cst savings f 49.8% but the sensitivity decreased t 95.7% cncluding that this decrease in sensitivity wuld nt be acceptable t physicians in Nrth America. DECISION RULES FOR THE USE OF RADIOGRAPHY IN ACUTE ANKLE INJURIES The third study validated and refined the clinical decisin rules fr acute ankle injuries. A prspective cnvenience survey was administered in tw stages: validatin and refinement f the riginal rules, fllwed by validatin f the refined rules. The findings revealed that an ankle X-ray was necessary nly if the patient had pain near the malleli and ne f the fllwing: inability t bear weight fr fur steps in the emergency department, bne tenderness at the psterir edge r tip f either mallelus. Ft X-ray was necessary nly if the patient had pain in the midft and inability t bear weight fr fur steps r bne tenderness at the navicular r base f the fifth metatarsal. IMPLEMENTING THE OTTAWA ANKLE RULES The furth study addressed the Ottawa Ankle Rules implementatin and the impact n clinical practice. Applying the rules resulted in a relative reductin in ankle radigraphs f 28% and in ft radigraphs f 14%. The rules were fund t be 100% sensitive. Wait times decreased, patients were satisfied with their treatment, and significant fractures did nt g undetected. The findings frm this study led t the final decisin rules stated in the current Ottawa Ankle Rules, fr the use f radigraphy in ankle injury. MULTI TRIAL TO INTRODUCE THE OTTAWA ANKLE RULE FOR THE USE OF RADIOGRAPHY IN ACUTE ANKLE INJURIES The fifth study assessed the feasibility and impact f intrducing the Ottawa Ankle Rules in a wide variety f teaching and cmmunity hspital settings. Findings suggested that applying the Ottawa Clinical Practice Guideline Page 3 f 5 Backgrund

4 Radigraphy f the Ankle and Ft (Ottawa Ankle Rules) January 2007 Ankle Rules was feasible in a wide variety f hspital and cmmunity settings. When physicians applied the rules, ankle radigraphy, waiting times and csts decreased, and the rate f undetected fractures did nt increase. VALIDATION STUDIES Subsequent validatin studies were als reviewed and results varied. One study was fund t be methdlgically flawed. One replicated the 100% sensitivity f Stiell s wrk, and anther cncluded that the rules were mre sensitive than clinical suspicin alne but culd nt replicate the 100% sensitivity. Hwever the undetected fractures in the latter study were diagnsed by physician assistants r emergency medicine residents. SUMMARY Althugh physicians have clinical skills t identify patients at lw risk f fracture, there is always cncern fr a missed fracture. This guideline prvides evidence-based guidance when making a diagnsis and several benefits fr patients and the health care system including unnecessary radiatin expsure, reduced wait times and decreased health care csts. Hwever, the rules are guidelines nly and nt meant t be inflexible r dgmatic. Physician judgement and cmmn sense is still the best apprach. PHYSICIAN ADVICE TO PATIENTS An integral part f managing patients when radigraphy is nt used is clear cmmunicatin. It is imprtant t explain t the patient the nature f a sprained ankle, the reasn fr the decisin t cnduct r nt cnduct an X-ray, and what the patient shuld expect in the week fllwing the examinatin. Patients require written instructin recmmending treatment and need fr fllw-up in five t seven days if pain and/r ability t walk d nt imprve. Nte: The Ottawa Ankle Rules apprach 100% sensitivity in emergency departments with trained physicians. T date, we are nt aware f any implementatin research that has been cnducted utside emergency departments. Validatin studies will likely cntinue and may affect these recmmendatins in the future. PRIMARY REFERENCES 1. Stiell IG, McKnight RD, Greenberg GH, et al. Interbserver agreement in the examinatin f acute ankle injury patients. Am J Emerg Med. 1992;10: Stiell IG, Greenberg GH, McKnight RD, et al. A study t develp clinical decisin rules fr the use f radigraphy in acute ankle injuries. Ann Emerg Med. 1992;21: Stiell IG, Greenberg GH, McKnight RD, et al. Decisin rules fr the use f radigraphy in acute ankle injuries: refinement and prspective validatin. JAMA. 1993;269: Stiell IG, McKnight RD, Greenberg GH, et al. Implementatin f the Ottawa ankle rules. JAMA. 1994;271: Stiell IG, Wells G, Laupacis A, et al. Multicentre trial t intrduce the Ottawa ankle rules fr use f radigraphy in acute ankle injuries. BMJ. 1995;311: Clinical Practice Guideline Page 4 f 5 Primary References

5 Radigraphy f the Ankle and Ft (Ottawa Ankle Rules) January 2007 ADDITIONAL REFERENCES 1. Pigman EC, et al. Evaluatin f the Ottawa clinical decisin rules fr the use f radigraphy in acute ankle and midft injuries in the emergency department: an independent site assessment. Ann Emerg Med. 1994;24:1: Kerr L, et al. Failed validatin f a clinical decisin rule the use f radigraphy in acute ankle injury. N Z Med J Jul; Stiell IG, McKnight RD, Greenberg GH, Well G. Ottawa ankle rules fr radigraphy f ankle injuries. N Z Med J. 1995;108: Lucchesi GM, Jacksn RE, Cerasani C, Swr RA. Sensitivity f the Ottawa rules. Ann Emerg Med. 1995;26-1:1-5. SUGGESTED CITATION Tward Optimized Practice (TOP) Cmmittee n Ankle Injuries. January Radigraphy f the ankle and ft (Ottawa ankle rules): clinical practice guideline. Edmntn, AB: Available frm: Fr mre infrmatin see GUIDELINE COMMITTEE The cmmittee cnsisted f representatives f general practitiners, emergency physicians, a radilgist, rthpedist, internist, nurse, health system representative, and a member f the public. March 1996 Reviewed January 2007 Reviewed March 2014 These recmmendatins are systematically develped statements t assist practitiner and patient decisins abut apprpriate health care fr specific clinical circumstances. They shuld be used as an adjunct t sund clinical decisin making. Clinical Practice Guideline Page 5 f 5 Additinal References

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