Ottawa Rules for Ankle and Foot X Rays

Arrange immediate referral to an Emergency Department if suspected

Fracture
Dislocation.
Damage to nerves or circulation.
Tendon rupture.
Wound penetrating the joint.
Known bleeding disorder.
Signs of septic arthritis (for example fever, joint swollen and warm to the touch) or haemarthrosis (very painful and tender joint swelling immediately after injury).
A large intramuscular haematoma.
A complete tear, or tear of more than half the muscle belly.

To manage their injury using the PRICE measures:

Protection — protect from further injury (for example by using a support or high-top, lace-up shoes).
Rest — avoid activity for the first 48–72 hours following injury.
Ice — apply ice wrapped in a damp towel for 15–20 minutes every 2–3 hours during the day for the first 48–72 hours following the injury. This should not be left on whilst the person is asleep.
Compression — with a simple elastic bandage or elasticated tubular bandage, which should be snug but not tight, to help control swelling and support the injury. This should be removed before going to sleep.
Elevation — keep the injured area elevated and supported on a pillow until the swelling is controlled. If the leg is injured, prolonged periods with the leg not elevated should be avoided.
To avoid HARM in the first 72 hours after the injury:
Heat — for example hot baths, saunas, and heat packs.
Alcohol — increases bleeding and swelling and decreases healing.
Running — or any other form of exercise which may cause further damage.
Massage — may increase bleeding and swelling.

Consider the need for immobilization.

For sprains:
- If severe, a short period of immobilization can result in quicker recovery.
- For less severe sprains, it is advisable not to immobilize the joint. Begin flexibility (range of motion) exercises as soon as they can be tolerated without excessive pain.
For strains:
- Immobilize the injured muscle for the first few days after the injury. Consider the use of crutches in severe injuries.
- Start active mobilization after a few days if the person has pain-free use of the muscle in basic movements and the injured muscle can stretch as much as the healthy contralateral muscle.

Following an ankle injury, if there is pain in the malleolar zone, and one of the following:

Inability to bear weight (walk four steps) immediately after the injury and when examined.
Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus.
Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus.

Following a foot injury, if there is pain in the midfoot zone, and one of the following:

Inability to bear weight (walk four steps) immediately after the injury and when examined.
Bone tenderness at the base of the fifth metatarsal.
Bone tenderness of the navicular bone.

Following a knee injury, if there is one or more of the following:

Inability to bear weight (walk four steps) at the time of injury and when examined.
The person is aged 55 years or more.
Tenderness at the head of the fibula.
Isolated tenderness of the patella.
Inability to flex the knee to 90 degrees.

An X-ray is also recommended:

Following a wrist injury, if there is pain or tenderness over the scaphoid bone (palpate at the base of the anatomical snuff box).

Use clinical judgement when considering an X-ray:

For people who:

Are younger than 18 years of age.
Are intoxicated.
Have multiple painful injuries, head injury, or diminished sensation in the lower extremities (for example due to neurological deficit).
Have an altered mental status.
Are pregnant.
If gross swelling makes palpation of the area impossible.
If there is a language barrier.