Ankle fracture and Ottawa ankle rules — Rapid

Synopsis

Apply the Ottawa ankle rules correctly, recognise unstable or skin-threatening injury, reduce urgent deformity without imaging delay, define malleolar and syndesmotic patterns, and prescribe safe fixation, mobilisation and follow-up.

Inspect before palpation: gross deformity, threatened medial skin, open wound or neurovascular compromise takes priority over applying a decision rule or obtaining ideal radiographs.
In people older than 5 years with traumatic ankle or midfoot pain, NICE recommends the Ottawa ankle and foot rules to decide whether radiographs are needed.
Request ankle radiographs for posterior-edge or tip tenderness over the distal 6 cm of either malleolus, or inability to take four steps both immediately after injury and during assessment.

Key red flags

A tented, blanched or insensate skin bridge over a displaced malleolus, absent pulses, cool foot or gross fracture-dislocation requires immediate reduction and reassessment before routine imaging.

Investigation priorities

Ottawa ankle and foot rulesFirst step

Select patients with acute ankle or midfoot trauma who need radiography.

First-line ankle radiographsFirst line

Define malleolar fracture and mortise alignment.

Management branches

ImmediateReduce skin or circulation threat

The ankle is grossly deformed, open, neurovascularly compromised or tenting the skin.

Perform trauma assessment, expose and photograph wounds once under policy, document pulses and named nerve function and give analgesia.
Cover an open wound and give immediate network intravenous prophylaxis while preparing urgent reduction and orthopaedic escalation.

StableProtect while restoring movement

The mortise is congruent and the fracture or ligament injury is judged stable after adequate imaging.

Key medicines

ParacetamolGive 1 g orally up to four times daily as required, leaving at least 4 hours between doses and not exceeding 4 g in 24 hours; reduce the maximum for low body weight, frailty, malnutrition or hepatic risk.

Low-molecular-weight heparin for selected lower-limb immobilisationWhen individual VTE assessment favours prophylaxis, prescribe the locally selected low-molecular-weight heparin at its licensed prophylactic dose adjusted for renal function and weight, continuing for the planned immobilisation period and considering cessation if immobilisation exceeds 42 days.

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