This nonrandomized controlled trial tested what happens when the Ottawa ankle rules are put into routine ED practice. It compared radiography rates, ED times, costs, and satisfaction at a university hospital that implemented the rules versus a community control hospital over matched 5-month periods. 2,342 adults with acute ankle injuries were enrolled.
Historically, physicians imaged nearly every acute ankle injury — roughly 85% of those films were negative, generating enormous cost and delay with no diagnostic benefit. The barrier was not clinical ability: physicians could identify low-risk patients, but without an endorsed guideline, medicolegal fear kept the x-ray rate near 100%.
This paper is the reason we use the Ottawa ankle rules as a standard of care. When a patient presents with acute ankle injury, apply the rules before ordering films: bone tenderness at the posterior malleoli or inability to bear weight (4 steps) triggers ankle imaging; tenderness at the base of the fifth metatarsal or navicular triggers foot imaging. If neither criterion is met, you can safely discharge without radiographs. This study confirms zero missed fractures with that approach.
Two important boundaries: the rules do not apply to patients under 18, and reliability drops with intoxication, head injury, multiple painful injuries, or sensory deficit. Outside those scenarios, withholding imaging is supported by the data.
This nonrandomized controlled trial tested what happens when the Ottawa ankle rules are put into routine ED practice. It compared radiography rates, ED times, costs, and satisfaction at a university hospital that implemented the rules versus a community control hospital over matched 5-month periods. 2,342 adults with acute ankle injuries were enrolled.
Historically, physicians imaged nearly every acute ankle injury — roughly 85% of those films were negative, generating enormous cost and delay with no diagnostic benefit. The barrier was not clinical ability: physicians could identify low-risk patients, but without an endorsed guideline, medicolegal fear kept the x-ray rate near 100%.
This paper is the reason we use the Ottawa ankle rules as a standard of care. When a patient presents with acute ankle injury, apply the rules before ordering films: bone tenderness at the posterior malleoli or inability to bear weight (4 steps) triggers ankle imaging; tenderness at the base of the fifth metatarsal or navicular triggers foot imaging. If neither criterion is met, you can safely discharge without radiographs. This study confirms zero missed fractures with that approach.
Two important boundaries: the rules do not apply to patients under 18, and reliability drops with intoxication, head injury, multiple painful injuries, or sensory deficit. Outside those scenarios, withholding imaging is supported by the data.