When does an ankle injury need an x-ray?

by James Hubbard, M.D., M.P.H.

I still remember when a sweet, smiling little girl came into my office a few years back.She had injured her wrist.I did my usual exam which includes palpating areas of tenderness.Well I hit a sore spot; she let out a yelp and sobbed “why did you hurt me?”I felt so bad, but was tempted to tell her that’s what doctors do (not really).Instead I explained I needed to know what specific area was injured so I would know where to look on an x-ray.I don’t think she bought it.

At any rate, I thought of this when I read an Academy of Emergency Medicine study concluded the Ottawa Ankle Rules could be applied to as young as 6 years old and up.What are these rules?

They are simple guidelines to help a doctor determine whether an injured ankle or foot should be x-rayed.Of course judgment and type of injury is always considered, but these rules are about 95 percent accurate.They were set up to try to cut down on needless x-rays.

An ankle should be x-rayed if:

  1. There is inability to bear weight.
  2. There is tenderness anywhere along the last 6 cm (about 2.5 inches) of the tibia (inside shin bone) or the fibula (outside smaller leg bone).

A foot should be x-rayed if:

  1. There is inability to bear weight.
  2. There is tenderness along the end of the fifth metatarsal (a little area that juts out on the outside of your foot an inch or so from the tip of the fibula) or tenderness around the top, inside of the foot.

To me that just means if you find a tender spot, x-ray it.Emergency clinicians may be able to discern it better since they see more injuries.

Certainly the Ottawa rules are not perfect and fractures can be missed.I saw one guy who had been walking on his broken leg for weeks before he came in.On the other side of the coin, a fracture may not show up on x-ray immediately, so be sure to follow up a week or so afterwards if the pain continues.

By the way, a crack or break is all the same to doctors.Both are considered fractures.

Full disclosure:My youngest daughter fell off her bike when she was little.She hurt her wrist but I couldn’t find an area of tenderness (she’s tough).The next day she was still hurting.An x-ray revealed a fracture.Of course medically it didn’t hurt to wait, but I know I felt more horrible than she.I can commiserate when I see a child whose mother has done the same.

Are there any more of us out there?

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7 Responses to “When does an ankle injury need an x-ray?”

  1. cathy Says:

    I hope that I never have to apply these rules, but I’m glad to know them!

    cathys last blog post..Sinupret gift pack winners!

  2. James Hubbard, M.D., M.P.H. Says:

    Thanks Cathy. Something just to keep in storage in your brain.

    James Hubbard, M.D., M.P.H.s last blog post..Sleep Apnea: Doctors answer your frequently asked questions

  3. Ahmed Eid Says:

    Really it is important to decide if patient should x-rayed or not and thanks to know that Ottawa rule not accurate.

  4. Dr. J Says:

    I’ve definitely seen x-rays, CT, and MRI scans used with, what I consider, way too much frequency. I’m glad to see some guidelines for their appropriate usage.

    Dr. Js last blog post..Bundles from Britain: Foot fatness, former fattest teen and clueless parents

  5. James Hubbard Says:

    Yes Dr. J.

    Just wanted to let people know why the doctor might not order one.


    James Hubbards last blog post..Sleep Apnea: Doctors answer your frequently asked questions

  6. FatFighterTV Says:

    Good information – I don’t think I ever really knew when it’s time to go to the doctor – just figure if it hurts bad enough, I’m there!

  7. WarmSocks Says:

    Count me as one who waits to take kids to the doctor. When my son hurt his foot, I waited a few days before taking him in. Dx: broken foot. Less than a year later he got kicked by a cow, and I waited a week before taking him to the doctor. Dx: broken hand.

    WarmSockss last blog post..Welcome!

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