Ankle Injury (Suspected)

Population Covered By The Guidance

This pathway provides guidance on imaging adult patients with suspected traumatic ankle injuries. It incorporates the Ottawa Ankle Rules.

Lead Researcher: Shashini Dissanayake

Experts & Contributors: Andrew Boyden, Eamon Koh, Michael Manson, Richard Mendelson

Date reviewed: June 2016

Date Published: June 2017

Image 1a (Plain Radiograph): Lateral view demonstrating a posterior tibial fracture.

Tri-malleolar Fracture

Image 1b (Plain Radiograph): AP view demonstrating fractures through both medial and lateral malleoli.

Tri-malleolar Fracture

Image 2 (Plain Radiograph): Oblique fracture of the lateral malleolus of the right ankle. There is lateral displacement within the ankle mortise with widening of the medial joint space.

Lateral Malleolus Fracture of Right Ankle

Image 3 (Plain Radiograph): Fracture of the base of the 5th metatarsal.

Fractured Fifth metatarsal

Image 4 (Magnetic Resonance Imaging): Sagittal proton density image showing a chronic undisplaced osteochondral talar dome fracture.

Talar Dome Fracture

  • Most patients presenting following acute ankle injury can be managed conservatively and do not require imaging
  • The Ottawa Ankle Rules and Ottawa Foot Rules should be used to select patients who require ankle and/or foot radiography and can safely exclude those who do not require imaging
  • MRI of the ankle may be useful in selective patients and may assist in further management
  • CT of the ankle is not indicated as the initial investigation but may assist with further management
  • Stress radiography may be useful in suspected latent syndesmotic diastasis

Date of literature search: June 2016

The search methodology is available on request. Email

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

  1. Mosher TJ, Kransdorf MJ, Adler R, Appel M, Beaman FD, Bernard SA, et al. ACR Appropriateness Criteria acute trauma to the ankle. J Am Coll Radiol. 2015;12(3):221-7. (Guidelines). View the reference
  2. Polzer H, Kanz KG, Prall WC, Haasters F, Ockert B, Mutschler W, et al. Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm. Orthop Rev (Pavia). 2012;4(1):e5. (Guidelines). View the reference
  3. Cheng Y, Cai Y, Wang Y. Value of ultrasonography for detecting chronic injury of the lateral ligaments of the ankle joint compared with ultrasonography findings. Br J Radiol. 2014;87(1033):20130406. (Level III evidence). View the reference
  4. 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):384-90. (Level II evidence). View the reference
  5. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. Jama. 1993;269(9):1127-32. (Level I evidence). View the reference
  6. Kelly AM, Richards D, Kerr L, Grant J, O'Donovan P, Basire K, et al. Failed validation of a clinical decision rule for the use of radiography in acute ankle injury. N Z Med J. 1994;107(982):294-5. (Level II evidence). View the reference
  7. Lucchesi GM, Jackson RE, Peacock WF, Cerasani C, Swor RA. Sensitivity of the Ottawa rules. Ann Emerg Med. 1995;26(1):1-5. (Level II evidence). View the reference
  8. Pigman EC, Klug RK, Sanford S, Jolly BT. Evaluation of the Ottawa clinical decision rules for the use of radiography in acute ankle and midfoot injuries in the emergency department: an independent site assessment. Ann Emerg Med. 1994;24(1):41-5. (Level II evidence). View the reference
  9. Stiell I, Wells G, Laupacis A, Brison R, Verbeek R, Vandemheen K, et al. Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle injuries. Multicentre Ankle Rule Study Group. Bmj. 1995;311(7005):594-7. (Level II evidence). View the reference
  10. Papacostas E, Malliaropoulos N, Papadopoulos A, Liouliakis C. Validation of Ottawa ankle rules protocol in Greek athletes: study in the emergency departments of a district general hospital and a sports injuries clinic. Br J Sports Med. 2001;35(6):445-7. (Level II evidence). View the reference
  11. Leddy JJ, Smolinski 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):158-65. (Level II evidence). View the reference
  12. Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003;326(7386):417. (Level II evidence). View the reference
  13. Stiell IG, McKnight RD, Greenberg GH, McDowell I, Nair RC, Wells GA, et al. Implementation of the Ottawa ankle rules. JAMA. 1994;271(11):827-32. (Level I evidence). View the reference
  14. Jonckheer P, Willems T, De Ridder R, Paulus D, Holdt Henningsen K, San Miguel L, et al. Evaluating fracture risk in acute ankle sprains: Any news since the Ottawa Ankle Rules? A systematic review. Eur J Gen Pract. 2016;22(1):31-41. (Level II evidence). View the reference
  15. Clark TW, Janzen DL, Ho K, Grunfeld A, Connell DG. Detection of radiographically occult ankle fractures following acute trauma: positive predictive value of an ankle effusion. AJR Am J Roentgenol. 1995;164(5):1185-9. (Level III evidence). View the reference
  16. Clark TW, Janzen DL, Logan PM, Ho K, Connell DG. Improving the detection of radiographically occult ankle fractures: positive predictive value of an ankle joint effusion. Clin Radiol. 1996;51(9):632-6. (Level III evidence). View the reference
  17. Gaebler C, Kukla C, Breitenseher MJ, Nellas ZJ, Mittlboeck M, Trattnig S, et al. Diagnosis of lateral ankle ligament injuries. Comparison between talar tilt, MRI and operative findings in 112 athletes. Acta Orthop Scand. 1997;68(3):286-90. (Level III evidence). View the reference
  18. Zanetti M, De Simoni C, Wetz HH, Zollinger H, Hodler J. Magnetic resonance imaging of injuries to the ankle joint: can it predict clinical outcome? Skeletal Radiol. 1997;26(2):82-8. (Level III/IV evidence). View the reference
  19. Oae K, Takao M, Naito K, Uchio Y, Kono T, Ishida J, et al. Injury of the tibiofibular syndesmosis: value of MR imaging for diagnosis. Radiology. 2003;227(1):155-61. (Level III evidence) View the reference
  20. Cheung Y, Rosenberg ZS. MR imaging of ligamentous abnormalities of the ankle and foot. Magn Reson Imaging Clin N Am. 2001;9(3):507-31, x. (Review article). View the reference
  21. van den Bekerom MP. Diagnosing syndesmotic instability in ankle fractures. World J Orthop. 2011;2(7):51-6. (Review article). View the reference
  22. Chan GM, Yoshida D. Fracture of the lateral process of the talus associated with snowboarding. Ann Emerg Med. 2003;41(6):854-8. (Level IV evidence). View the reference
  23. Ryan LP, Hills MC, Chang J, Wilson CD. The lambda sign: a new radiographic indicator of latent syndesmosis instability. Foot Ankle Int. 2014;35(9):903-8. (Level III evidence). View the reference
  24. Lin CF, Gross ML, Weinhold P. Ankle syndesmosis injuries: anatomy, biomechanics, mechanism of injury, and clinical guidelines for diagnosis and intervention. J Orthop Sports Phys Ther. 2006;36(6):372-84. (Review article). View the reference
  25. Hunt KJ. Syndesmosis injuries. Curr Rev Musculoskelet Med. 2013;6(4):304-12. (Review article). View the reference

Pathway User Guide

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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.

SYMBOL RRL EFFECTIVE DOSE RANGE
No radiation None 0
Minimal radiation Minimal < 1 millisieverts
Low radiation Low 1-5 mSv
Medium radiation Medium 5-10 mSv
High radiation High >10 mSv

Disclaimer

Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.

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Trauma