Don’t request imaging for acute ankle trauma unless indicated by the Ottawa Ankle Rules (localised bone tenderness or inability to weight-bear as defined in the Rules).
Most clinically significant acute ankle injuries can be diagnosed with history, examination, and selective use of plain radiography.
Extensive validation studies have shown that the Ottawa Ankle Rules can be safely applied to adult and paediatric populations.
Selective use of plain radiography in patients with acute ankle injury is useful in identifying patients who have sustained clinically important fracture, dislocation, and osteochondral injuries. However, acute ligamentous injuries involving the anterior talofibular ligament can be diagnosed clinically and treated symptomatically.
When there are persistent symptoms (such as pain and swelling) after an acute injury, which raise suspicion of either instability or other internal derangement, such as osteochondral injury, MRI can be used if the non-urgent (or delayed or elective or similar) weight bearing x-rays show no abnormality.
Recommendation released April 2015
- 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.
- 1 Don’t request imaging for acute ankle trauma unless indicated by the Ottawa Ankle Rules (localised bone tenderness or inability to weight-bear as defined in the Rules).
- 2 Don’t request duplex compression ultrasound for suspected lower limb deep venous thrombosis in ambulatory outpatients unless the Wells Score (deep venous thrombosis risk assessment score) is greater than 2, OR if less than 2, D dimer assay is positive.
Don’t request any diagnostic testing for suspected pulmonary embolism (PE) unless indicated by Wells Score (or Charlotte Rule) followed by PE Rule-out Criteria (in patients not pregnant). Low risk patients in whom diagnostic testing is indicated should have PE excluded by a negative D dimer, not imaging.
- 4 Don't perform imaging for patients with non-specific acute low back pain and no indicators of a serious cause for low back pain.
- 5 Don't request imaging of the cervical spine in trauma patients, unless indicated by a validated clinical decision rule.
- 6 Don’t request computed tomography (CT) head scans in patients with a head injury, unless indicated by a validated clinical decision rule.
- 7 Don’t initiate whole-breast radiation therapy as a part of breast conservation therapy in women age ≥50y with early-stage invasive breast cancer without considering shorter treatment schedules.
- 8 Don’t initiate management of low risk prostate cancer without discussing active surveillance.
- 9 Don’t routinely use extended fractionation schemes (>10 fractions) for palliation of bone metastases.
- 10 Don't routinely add adjuvant whole-brain radiation therapy to stereotactic radiosurgery for limited brain metastases.
- 11 Don’t routinely use extensive locoregional therapy in most cancer situations where there is metastatic disease and minimal symptoms attributable to the primary tumour.