Traumatic ankle pain - Adequacy of clinical information with reference to the Ottawa ankle rules

Adequacy of clinical information provided by Emergency Department (ED) clinicians with reference to the Ottawa ankle rules.

The Ottawa ankle rules state that ankle radiographs are only required if there is pain in the malleolar zone and any of the following:

- Bone tenderness of the posterior edge or tip of lateral malleolus

- Bone tenderness of the posterior edge or tip of medial malleolus

- An inability to weight bear both immediately and in the ED for 4 steps

The standard: 

- All ankle x-ray requests for traumatic ankle pain should provide adequate clinical information with reference to the Ottawa ankle rules

- All ankle x-ray requests for trauma should provide adequate clinical information including point tenderness according to Ottawa Rules

Target: 

100%

Indicators: 

Percentage of request cards providing adequate clinical information with reference to the Ottawa ankle rules.

Data items to be collected: 

Request cards to assess clinical information provided by ED clinicians.

Suggested number: 

100 consecutive requests

1. Presentation of results at ED education meeting highlighting areas for improvement

2. Identify referrers with poor record of completing requests and discuss benefits of improved clinical information

3. Re-audit after introduction of ED ankle injury proforma, which specifies the Ottawa ankle rules under examination findings, to assess if there was improvement in clinical information provided

4. An educational reminder as a report macro reiterating the Ottawa Rule is an (evidence-based) effective intervention

Patient list compilation by clerical staff (2 hours)

Radiologist analysis of request card clinical information (4 hours)

1. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR (April 1992). "A study to develop clinical decision rules for the use of radiography in acute ankle injuries". Ann Emerg Med 21 (4): 384–90.

2. Dowling S, Spooner CH, Liang Y, et al. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and midfoot in children: A meta-analysis. Acad Emerg Med 2009;16(4):277-287

3. Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G (February 2003). "Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review". BMJ 326 (7386): 417.

4. Stiell IG, McKnight RD, Greenberg GH, et al. (March 1994). "Implementation of the Ottawa ankle rules". JAMA 271 (11): 827–32.

5. Royal College of Radiologists. Making the best use of clinical radiology. MBUR7/iRefer V. 8. 2017 BFCR(17)2

Khalid Ali Updated by CRAC 2016, A L Chang 2019