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Broken Bones, Broken Hearts And The Ottawa Ankle Rules by Art Horne

Posted by Boston Sports Medicine and Performance Group on Sep 27, 2010 6:11:00 PM

by Art Horne

A review of:
Jenkin M Sitler MR, Kelly JD. Clinical Usefulness of the Ottawa Ankle Rules for Detecting Fractures of the Ankle and Midfoot. J Ath Train. 2010;45(5):480-482.

Basketball season is back and with it comes a new season of early morning conditioning runs, late night pick-up games, and of course, a few ankle sprains along the way.  Like clockwork, gasps by teammates and spectators can be heard followed by the uncertain question after such injury, “is it broken?” 

First introduced in 1992 by Stiell et al, the Ottawa Ankle Rules were a guideline for caregivers after ankle trauma to determine whether or not an ankle/foot x-ray was warranted in the evaluation and care of the athlete.  Having been designed to have a high sensitivity for detecting significant fractures, its other goals include decreasing unwarranted radiation and avoiding long waits in the emergency rooms for x-ray evaluation.

Based on the Ottawa Ankle Rules, Stiell et al recommended x-ray evaluation after an ankle sprain for the following:

1. Patients 55 years and older (not the typical NCAA college basketball athlete)
2. Those that were unable to bear weight for 4 steps both at the time of injury and during evaluation.
3. bone tenderness at the inferior tip or posterior edge of the lateral malleolus or
4. bone tenderness at the inferior tip or posterior edge of the medial malleolus.

For those athletes with a suspected mid-foot fracture, x-ray evaluation were recommended for those that:

1. had pain at the base of the 5th metatarsal, cuboid or navicular.

Exclusion criteria include:

1. injury past 10 days
2. pregnancy
3. patients under the age of 18
4. presence of isolated injuries to the skin.

What does this all mean?

If a college athlete sustains an ankle sprain and is able to walk off the court and does not have bony pain either the medial or lateral malleolus and is void of bony pain at the base of the 5th (or other midfoot bone) then it is highly likely that he/she does not have a fracture.  Conversely, if an athlete sprains their ankle and is unable to bear weight at both the time of injury and at the time of evaluation (once the emotional piece has settled), an x-ray evaluation is warranted due to the very high likelihood of a fracture.

The Ottawa Ankle Rules Modified – Buffalo Rule

“The Buffalo Rule was derived to increase the diagnostic accuracy of the Ottawa Ankle Rules, with the point tenderness criterion directed to the crest or midportion of the malleoli (distal 6 cm of the fibula and tibia), reducing the likelihood of palpating over injured ligament structures.”

Big Cost Savings

“The Ottawa Ankle Rules are reported to result in a 19% to 38 % reduction in radiography costs associated with excluding ankle fractures after sprain injury.”

“The Buffalo Rule is reported to result in a 54% reduction in radiography costs."

“National cost savings estimates with implementation of the Ottawa Ankle Rules range from $18 to $90 million annually (depending on the payor mix involved).”

Conclusion

“Based on the current research, it is recommended that the Ottawa Ankle Rules and, by extension, the Buffalo Rule be included in both athletic training clinical practice and educational programs.  In the present era of cost containment, increased awareness of unnecessary tests and procedures will only become meaningful.  Accordingly, clinicians will need to use the information presented in the systematic review, combined with their own practical experience and the patient’s values, to determine how best to apply the data in an evidence-based manner.”

References

Jenkin M Sitler MR, Kelly JD. Clinical Usefulness of the Ottawa Ankle Rules for Detecting Fractures of the Ankle and Midfoot. J Ath Train. 2010;45(5):480-482.

Leddy JJ, Smolinksi RJ, Lawrence J, Snyder JL, Priore RL. Prospective evaluation of the Ottawa Ankle Rules in a university sports medicine center: with a modification to increase specificity for identifying malleolar fractures. Am J Sports Med. 1998;26(2):158-165.

Leddy JJ, Kesari A, Smolinski RJ. Implementation of the Ottawa Ankle Rules in a university sports medicine center. Med Sci Sports Exerc. 2002;34(1):57-62.

Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. 1992;21(4):384-390.

Topics: Art Horne, Health & Wellness