# Ottawa Ankle Rules Protocol

## Summary

The Ottawa Ankle Rules are a set of guidelines to help determine the need for X-ray imaging in patients with acute ankle injuries. These rules aim to identify fractures and reduce unnecessary radiography. The decision-making process involves assessing specific criteria related to the location of pain, tenderness, and weight-bearing ability.

## Setting of Care

The Ottawa Ankle Rules are intended to be used in emergency departments, urgent care clinics, and other acute care settings where patients present with ankle injuries. These rules are designed to help healthcare providers quickly and accurately determine the need for X-ray imaging.

## Exclusion Criteria

The Ottawa Ankle Rules should not be applied in the following situations:
- Patients younger than 18 years of age
- Patients with multiple painful (distracting) injuries
- Patients with altered levels of consciousness or cognitive impairment
- Patients with a history of previous ankle fractures or significant ankle surgery
- Patients presenting more than 10 days after the injury

## Acute Ankle Injury Evaluation

1. **Location of Pain:**
    - **Malleolar Zone:**
        1. **Bone tenderness at posterior edge or tip of lateral malleolus?**
            - **Yes:** Ankle X-ray indicated
            - **No:** Assess tenderness at posterior edge or tip of medial malleolus
        2. **Bone tenderness at posterior edge or tip of medial malleolus?**
            - **Yes:** Ankle X-ray indicated
            - **No:** Assess ability to bear weight
        3. **Inability to bear weight immediately after injury AND in ED?**
            - **Yes:** Ankle X-ray indicated
            - **No:** No X-ray indicated
    
    - **Midfoot Zone:**
        1. **Bone tenderness at base of 5th metatarsal?**
            - **Yes:** Foot X-ray indicated
            - **No:** Assess tenderness at navicular
        2. **Bone tenderness at navicular?**
            - **Yes:** Foot X-ray indicated
            - **No:** Assess ability to bear weight
        3. **Inability to bear weight immediately after injury AND in ED?**
            - **Yes:** Foot X-ray indicated
            - **No:** No X-ray indicated

If there is a positive finding in the malleolar zone, an ankle X-ray series is recommended. If there is a positive finding in the midfoot zone, a foot X-ray series is recommended.