Ottawa ankle rules

Editor—In his editorial supporting the use of the Ottawa rules, Heyworth suggests that injured ankles be separated into two groups: those with simple ligamentous injury to soft tissue or a small avulsion fracture and those with more serious fractures requiring immobilisation.¹ This unfortunately reflects the casual treatment given to patients with ligamentous ankle sprains in British accident and emergency departments. Up to a third of patients with an ankle sprain may develop disabling problems such as recurrent instability or chronic pain.

Figure 1.

Doctors and nurses should be aware that the Ottawa rules are simply guidelines to decide which group of patients should have radiography. Patients with severe ankle sprains—for example, those who cannot bear weight—need more than a compression bandage and advice on ice and elevation: they also need protection in an ankle stirrup or cast, and they should be referred for physiotherapy for stretching, strengthening, balance, and return to sports exercises.²

A more thorough approach to patients with severe ankle sprains should prevent long term problems. This requires a culture change in the country's accident and emergency departments to recognise that ligament sprains can be more disabling injuries than fractures.

The decreased popularity of the Ottawa rules in the United States and mainland Europe could also possibly be explained by the use of stress radiography, etc, in patients with ankle sprains.