Can the Ottawa Ankle Rules Rule Out Arthritis?

December 31, 2006

The Ottawa ankle rules are said to help in ruling out ankle fractures and cuttingdown on needless ordering of roentgenograms. How effective are they in differentiatingbetween strain or sprain and inflammatory or noninflammatory arthritis inthe ankle?

The Ottawa ankle rules are said to help in ruling out ankle fractures and cuttingdown on needless ordering of roentgenograms. How effective are they in differentiatingbetween strain or sprain and inflammatory or noninflammatory arthritis inthe ankle?-- MDThe Ottawa ankle rules are a well-established protocolto rule out ankle fracture in patients presentingwith ankle or midfoot complaints after theyexperience trauma. They do not differentiate betweenstrain and sprain or between inflammatoryand noninflammatory arthritis.The Ottawa ankle rules (Box) are an excellent screeningtest to rule out ankle fracture because they have a veryhigh sensitivity. Numerous studies have validated the rules,and a recent meta-analysis concluded that they are highlyaccurate in ruling out fractures.1Ankle sprains are common injuries that often occurduring routine or recreational activity. Radiographs takento rule out fracture in the acute care setting rarely reveala fracture. Stiell and colleagues2 showed that following theOttawa ankle rules reduced ankle radiography by 28% andfoot radiography by 14%. The time and cost of initial evaluationwere also significantly decreased, and patient satisfactionwas unchanged.Application of the Ottawa ankle rules involves clinicallyexamining the posterior aspect of the distal medialand lateral malleoli. The navicular bone and fifth metatarsalare palpated to evaluate the midfoot for tenderness. Patientsare also asked to take 4 steps to determine whetherthey can bear weight. If they clear the criteria, ankle andfoot radiographs are deemed unnecessary.Whether an ankle is strained or sprained, the acutemanagement is the same. Most ankle sprains result froman inversion injury and involve the anterior talofibularand calcaneofibular ligaments on the lateral side of theankle. A removable air-cell-containing cast may be usedto immobilize the joint, or a simple compression wrapmay be applied. Initially, the RICE (Rest, Ice, Compression,Elevation) treatment plan should be followed. Thepatient may bear weight as tolerated with use of a caneor crutches.Patients with arthritis will have a longer-term historyof pain or, possibly, a remote history of trauma. Evaluationto differentiate between inflammatory and noninflammatoryarthritis should include a detailed history of orthopedic,endocrine, or rheumatologic disorders and medication useas well as routine radiographs of the ankle.-- Charles F. Preston, MD and Kenneth A. Egol, MD
  &nbspNew York University-Hospital for Joint Diseases
  &nbspNew York

References:

REFERENCES:
1.

Bachmann LM, Kolb E, Koller MT, et al. Accuracy of Ottawa ankle rules toexclude fractures of the ankle and mid-foot: systematic review.

BMJ.

2003;326:417.

2.

Stiell IG, McKnight RD, Greenberg GH, et al. Implementation of the Ottawaankle rules.

JAMA.

1994;271:827-832.