Positive Ottawa Ankle Rule

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Obtain x-ray (Class I)

Positive

Negative

X-rays are relatively quick to obtain and are accessible in most ED settings. When obtaining x-ray imaging, it is important to incorporate multiple views. Most routine radiographic studies include anteroposterior, lateral, and oblique views. Ligamentous injuries may show joint widening on plain or weight-bearing films, but the findings may be subtle. Additionally, several fractures (eg, toddler fracture, Salter-Harris type I fracture) can often be radiographically occult early on. For all of these reasons, patients with a concerning examination and negative films may need further imaging, presumptive immobilization, and/or repeat radiographs in 10 days to look for signs of healing fractures.

Certain fractures may be better seen on specific additional views. Weight-bearing films might assist in the diagnosis of a Lisfranc injury. An oblique view may demonstrate a toddler fracture not appreciated on other views, and a calcaneal series should be performed for a suspected calcaneus fracture. A mortise view can be particularly helpful for diagnosis of a lateral talar process fracture.