The Ottawa foot rules are a tool that predicts significant midfoot fractures. They are used to determine whether radiographs are necessary. [13] A radiograph is required if a patient has pain in the midfoot in conjunction with any of the following [13] :
Although developed and validated in adults, the Ottawa foot rules also appear to be reliable for excluding fractures in children aged 5 years or older. [17] When foot radiographs are obtained, a systematic approach to reading them is important and reduces the risk of missing important injuries. [18] pocket radio
In a study by Pires et al, the Ottawa ankle rules were found to be highly reliable for determining when to take radiographs in patients with foot or ankle sprains. [19] Weightbearing inability was the most important isolated predictor of a fracture (69.4% sensitivity, 61.6% specificity, 63.1% accuracy, 21.9% positive predictive value [PPV], and 93% negative predictive value [NPV]). Orthopedic surgeon subjective analysis had a 55.6% sensitivity, 90.1% specificity, 85.4% accuracy, 46.5% PPV, and 92.9% NPV. The Ottawa ankle rules had a 97.2% sensitivity, 7.8% specificity, 19.9% accuracy, 13.9% PPV, and 95% NPV. The Ottawa ankle rules are more sensitive than they are specific. [20]
The Shetty test has been described as a potential alternative to the Ottawa rules in this setting, being somewhat easier to apply, but it has not been shown to be preferable. [21, 22]
The American College of Radiology (ACR) has developed appropriateness criteria for imaging in patients who have sustained acute trauma to the foot. [11] These criteria address several varying scenarios, including some where the Ottawa rules can be followed and others where they cannot be followed or do not apply.
The following images show various foot fractures as they appear on radiographs.
Computed tomography (CT; see the image below), magnetic resonance imaging (MRI), ultrasonography (US), and bone scanning may help diagnose certain foot fractures that are occult on plain radiography. [23, 24, 25]
Although some anecdotal reports and small diagnostic trials have suggested that US may prove to have a role in routine assessment of acute foot fractures, [26, 27] second-line imaging studies generally need not be performed while the patient is in the ED and are usually ordered only after consultation with a foot surgeon.
In a study by Tollefson et al, bedside US in conjunction with the Ottawa foot and ankle rules (OFAR) in acutely injured patients was found to reduce the number of ordered radiographs and the length of ED stay in patients aged 18 years or older. [28] The sensitivity of US in detecting foot and ankle fractures was 100%, and the specificity of OFAR increased from 50% to 100% with the addition of US. The NPV and the PPV were both 100%.
A systematic review by Deutekom et al (13 studies; N = 1455) assessed the accuracy of US for identifying ankle injuries in the ED. [12] High values for sensitivity and specificity were reported, but the quality of the evidence was low, and higher-quality data would be required to confirm the findings.
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Robert Silbergleit, MD Professor, Department of Emergency Medicine, University of Michigan Medical School Robert Silbergleit, MD is a member of the following medical societies: American Association for the Advancement of Science, Alpha Omega Alpha, American Stroke Association, American Academy of Emergency Medicine, American Heart Association, National Association of EMS Physicians, Sigma Xi, The Scientific Research Honor Society, Society for Academic Emergency Medicine, Society for Neuroscience Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.
Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians Disclosure: Nothing to disclose.
Francis Counselman, MD, FACEP Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School Francis Counselman, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Norfolk Academy of Medicine, Association of Academic Chairs of Emergency Medicine, Society for Academic Emergency Medicine Disclosure: Nothing to disclose.
Tom Scaletta, MD President, Smart-ER (https://smart-er.net); Chair, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine
spiral fracture Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine