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The Ottawa ankle rules in children
  1. Man-Cheuk Yuen, Senior Medical Officer,
  2. Fiona Saunders, Specialist Registrar
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
  1. Correspondence to: Kevin Mackway-Jones, Consultant (kevin.mackway-jones{at}

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Report by Man-Cheuk Yuen, Senior Medical Officer Checked by Fiona Saunders, Specialist Registrar

Clinical scenario

A 5 year old boy attends the emergency department after sustaining a twisting injury to his left ankle. On examination there is swelling and tenderness over the lateral malleolus. You know that the Ottawa ankle rules are applicable in adult patients and you wonder whether they are applicable in children too.

Three part question

In [paediatric patients with blunt ankle injuries] are [the Ottawa ankle rules] sensitive in [detecting fractures]?

Search strategy

Medline 1966–08/01 using the OVID interface. [exp ankle/ or or exp ankle injuries/ or exp ankle joint/ or exp lateral ligament, ankle/] AND [clinical or exp Decision Support Systems, Clinical/ or exp Decision Support Techniques/ or] AND [pediatr$.mp. or paed$.mp. or exp Age Factors/ or age or Child/] LIMIT to human and english

Search outcome

Altogether 14 papers were found of which 10 were irrelevant or of insufficient quality for inclusion. The remaining four papers are shown in the table.


Apart from Chande's study, the other studies did not examine all patients with radiography. Therefore, fractures might be missed by the Ottawa ankle rules and unidentified because of the design of the study. It is anticipated that application of the Ottawa ankle rules in preschool children is difficult as the rules rely on their ability to report tenderness. However, the number of preschool children included in all these studies was small. Hence the role of the Ottawa ankle rules in small children is not yet answered.

Clinical bottom line

More work is required to determine if the Ottawa rules are applicable in children. Early results suggest that they will.

Table 6

Report by Man-Cheuk Yuen, Senior Medical Officer Checked by Fiona Saunders, Specialist Registrar