Scenario: A 43-year-old man fell off of a ladder from approximately 7 ft high and landed completely on one foot. He reported immediate pain in the foot with inability to bear weight. He presented with constant pain, swelling of the foot and ankle and worsening pain with all ankle/foot movements. Patient presents on the day of injury as a direct access patient. The patient is still unable to bear weight. Patient is positive in the Ottawa ankle rules and referred to the emergency room for an X-ray. Radiographs showed a calcaneus fracture.

Question: What are the Ottawa ankle rules and why are they important in diagnosing a calcaneal fracture?

Potential answers:

1. The Ottawa ankle rules are the rules used to typify ankle and foot fractures. They are integral to diagnosing a calcaneal fracture because they help to distinguish identifiers between the multiple types of distal lower extremity fractures.
2. The Ottawa ankle rules are a screening tool to determine the need for imaging of the affected area. They are important in diagnosing a calcaneal fracture because radiographs of the ankle and foot are integral in confirming diagnosis and assisting in determining type of fracture.
3. The Ottawa ankle rules are the rules radiologists need to follow when radiographing the ankle to identify a fracture. They are integral to diagnosing a calcaneal fracture because if they are not followed, any ankle fracture may not be properly identified.
4. The Ottawa ankle rules are used to determine the weight bearing level of a patient during the initial assessment. They are integral to diagnosing a calcaneal fracture because the rules help to typify ankle and foot fractures, and dictate a level of weight bearing appropriate for initial rehabilitation.

Answer with rationale: The Ottawa ankle rules are a screening tool to determine the need for imaging of the affected area. They are important in diagnosing a calcaneal fracture because radiographs of the ankle and foot are integral in confirming diagnosis and assisting in determining type of fracture.

The Ottawa Ankle Rules are 5 sectional tests which assess the ankle and foot for point tenderness and weight bearing disruptions. These tests are used to determine whether the fracture affects the foot or ankle, and whether radiographs are appropriate. These rules are utilized by physical therapists in an initial assessment.

Other important imaging includes CT scans for more detail, and bone scans if the fracture appears to be a stress fracture.

For more information see chapter 204 Calcaneal Fractures in the Color Atlas of Physical Therapy

Axial CT section showing a fracture of the calcaneus caused by an axial loading mechanism. (From Doherty GM. Current Diagnosis & Treatment: Surgery. 13th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)