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Acute Trauma to the Ankle

Variant: 1   Adult or child 5 years of age or older. Acute trauma to the ankle or acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks. No exclusionary criteria present. Initial imaging. Patient meets the requirements for evaluation by the Ottawa Ankle Rules which are positive: 1. Inability to bear weight immediately after the injury, OR 2. Point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, talus, or calcaneus, OR 3. Inability to ambulate for 4 steps in the emergency department.
Procedure Appropriateness Category Relative Radiation Level
Radiography ankle Usually Appropriate ☢
US ankle Usually Not Appropriate O
MRI ankle without and with IV contrast Usually Not Appropriate O
MRI ankle without IV contrast Usually Not Appropriate O
CT ankle with IV contrast Usually Not Appropriate ☢
CT ankle without and with IV contrast Usually Not Appropriate ☢
CT ankle without IV contrast Usually Not Appropriate ☢
Bone scan ankle Usually Not Appropriate ☢☢☢

Variant: 2   Adult or child 5 years of age or older. Acute trauma to the ankle. No exclusionary criteria present (eg, neurologically intact (including no peripheral neuropathy)). Patient meets the requirements for evaluation by the Ottawa Ankle Rules which are negative: No point tenderness over the malleoli, talus, or calcaneus on physical examination. Able to walk. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
US ankle Usually Not Appropriate O
Radiography ankle Usually Not Appropriate ☢
MRI ankle without and with IV contrast Usually Not Appropriate O
MRI ankle without IV contrast Usually Not Appropriate O
CT ankle with IV contrast Usually Not Appropriate ☢
CT ankle without and with IV contrast Usually Not Appropriate ☢
CT ankle without IV contrast Usually Not Appropriate ☢
Bone scan ankle Usually Not Appropriate ☢☢☢

Variant: 3   Adult or child 5 years of age or older. Acute trauma to the ankle. Exclusionary criteria are present (eg, neurologic disorder, neuropathy, or other). Patient does not meet requirements for evaluation by the Ottawa Ankle Rules. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Radiography ankle Usually Appropriate ☢
CT ankle without IV contrast May Be Appropriate ☢
US ankle Usually Not Appropriate O
Radiography ankle stress views Usually Not Appropriate ☢
MRI ankle without and with IV contrast Usually Not Appropriate O
MRI ankle without IV contrast Usually Not Appropriate O
CT ankle with IV contrast Usually Not Appropriate ☢
CT ankle without and with IV contrast Usually Not Appropriate ☢
Bone scan ankle Usually Not Appropriate ☢☢☢

Variant: 4   Adult or child 5 years of age or older. Acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks. No exclusionary criteria present. Initial radiographs negative. Next study.
Procedure Appropriateness Category Relative Radiation Level
MRI ankle without IV contrast Usually Appropriate O
CT ankle without IV contrast Usually Appropriate ☢
Radiography ankle May Be Appropriate ☢
Radiography ankle stress views May Be Appropriate ☢
US ankle Usually Not Appropriate O
MRI ankle without and with IV contrast Usually Not Appropriate O
CT ankle with IV contrast Usually Not Appropriate ☢
CT ankle without and with IV contrast Usually Not Appropriate ☢
Bone scan ankle Usually Not Appropriate ☢☢☢

Variant: 5   Adult or child 5 years of age or older. Acute trauma to the ankle. No exclusionary criteria present. Radiographs demonstrate fracture or potential osteochondral injury. Next study.
Procedure Appropriateness Category Relative Radiation Level
MRI ankle without IV contrast Usually Appropriate O
CT ankle without IV contrast Usually Appropriate ☢
Radiography ankle Broden’s view May Be Appropriate ☢
US ankle Usually Not Appropriate O
MRI ankle without and with IV contrast Usually Not Appropriate O
CT ankle with IV contrast Usually Not Appropriate ☢
CT ankle without and with IV contrast Usually Not Appropriate ☢
Bone scan ankle Usually Not Appropriate ☢☢☢

Variant: 6   Adult or child 5 years of age or older. Acute trauma to the ankle. Radiographs negative for osseous injury and physical examination or radiographs demonstrate alignment abnormality suggesting syndesmotic/ligamentous injury or dislocation. Next study.
Procedure Appropriateness Category Relative Radiation Level
Radiography ankle stress views Usually Appropriate ☢
Radiography leg Usually Appropriate ☢
MRI ankle without IV contrast Usually Appropriate O
CT ankle without IV contrast Usually Appropriate ☢
US ankle Usually Not Appropriate O
MRI ankle without and with IV contrast Usually Not Appropriate O
CT ankle with IV contrast Usually Not Appropriate ☢
CT ankle without and with IV contrast Usually Not Appropriate ☢
Bone scan ankle Usually Not Appropriate ☢☢☢

Panel Members
Stacy E. Smith, MDa; Eric Y. Chang, MDb; Alice S. Ha, MD, MSc; Roger J. Bartolotta, MDd; Matthew D. Bucknor, MDe; Tushar Chandra, MD, MBBSf; Karen C. Chen, MDg; Tetyana Gorbachova, MDh; Bharti Khurana, MDi; Alan K. Klitzke, MDj; Kenneth S. Lee, MD, MBAk; Pekka A. Mooar, MDl; Andrew B. Ross, MD, MPHm; Richard D. Shih, MDn; Adam D. Singer, MDo; Mihra S. Taljanovic, MD, PhDp; Jonelle M. Thomas, MD, MPHq; Katherine M. Tynus, MDr; Mark J. Kransdorf, MDs.
Summary of Literature Review
Introduction/Background
Special Imaging Considerations
Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

  • There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

OR

  • There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).
Discussion of Procedures by Variant
Variant 1: Adult or child 5 years of age or older. Acute trauma to the ankle or acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks. No exclusionary criteria present. Initial imaging. Patient meets the requirements for evaluation by the Ottawa Ankle Rules which are positive: 1. Inability to bear weight immediately after the injury, OR 2. Point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, talus, or calcaneus, OR 3. Inability to ambulate for 4 steps in the emergency department.
Variant 1: Adult or child 5 years of age or older. Acute trauma to the ankle or acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks. No exclusionary criteria present. Initial imaging. Patient meets the requirements for evaluation by the Ottawa Ankle Rules which are positive: 1. Inability to bear weight immediately after the injury, OR 2. Point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, talus, or calcaneus, OR 3. Inability to ambulate for 4 steps in the emergency department.
A. Bone scan ankle
Variant 1: Adult or child 5 years of age or older. Acute trauma to the ankle or acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks. No exclusionary criteria present. Initial imaging. Patient meets the requirements for evaluation by the Ottawa Ankle Rules which are positive: 1. Inability to bear weight immediately after the injury, OR 2. Point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, talus, or calcaneus, OR 3. Inability to ambulate for 4 steps in the emergency department.
B. CT Ankle 
Variant 1: Adult or child 5 years of age or older. Acute trauma to the ankle or acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks. No exclusionary criteria present. Initial imaging. Patient meets the requirements for evaluation by the Ottawa Ankle Rules which are positive: 1. Inability to bear weight immediately after the injury, OR 2. Point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, talus, or calcaneus, OR 3. Inability to ambulate for 4 steps in the emergency department.
C. MRI Ankle
Variant 1: Adult or child 5 years of age or older. Acute trauma to the ankle or acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks. No exclusionary criteria present. Initial imaging. Patient meets the requirements for evaluation by the Ottawa Ankle Rules which are positive: 1. Inability to bear weight immediately after the injury, OR 2. Point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, talus, or calcaneus, OR 3. Inability to ambulate for 4 steps in the emergency department.
D. Radiography Ankle
Variant 1: Adult or child 5 years of age or older. Acute trauma to the ankle or acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks. No exclusionary criteria present. Initial imaging. Patient meets the requirements for evaluation by the Ottawa Ankle Rules which are positive: 1. Inability to bear weight immediately after the injury, OR 2. Point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, talus, or calcaneus, OR 3. Inability to ambulate for 4 steps in the emergency department.
E. US Ankle
Variant 2: Adult or child 5 years of age or older. Acute trauma to the ankle. No exclusionary criteria present (eg, neurologically intact (including no peripheral neuropathy)). Patient meets the requirements for evaluation by the Ottawa Ankle Rules which are negative: No point tenderness over the malleoli, talus, or calcaneus on physical examination. Able to walk. Initial imaging.
Variant 2: Adult or child 5 years of age or older. Acute trauma to the ankle. No exclusionary criteria present (eg, neurologically intact (including no peripheral neuropathy)). Patient meets the requirements for evaluation by the Ottawa Ankle Rules which are negative: No point tenderness over the malleoli, talus, or calcaneus on physical examination. Able to walk. Initial imaging.
A. Bone scan ankle
Variant 2: Adult or child 5 years of age or older. Acute trauma to the ankle. No exclusionary criteria present (eg, neurologically intact (including no peripheral neuropathy)). Patient meets the requirements for evaluation by the Ottawa Ankle Rules which are negative: No point tenderness over the malleoli, talus, or calcaneus on physical examination. Able to walk. Initial imaging.
B. CT Ankle
Variant 2: Adult or child 5 years of age or older. Acute trauma to the ankle. No exclusionary criteria present (eg, neurologically intact (including no peripheral neuropathy)). Patient meets the requirements for evaluation by the Ottawa Ankle Rules which are negative: No point tenderness over the malleoli, talus, or calcaneus on physical examination. Able to walk. Initial imaging.
C. MRI Ankle
Variant 2: Adult or child 5 years of age or older. Acute trauma to the ankle. No exclusionary criteria present (eg, neurologically intact (including no peripheral neuropathy)). Patient meets the requirements for evaluation by the Ottawa Ankle Rules which are negative: No point tenderness over the malleoli, talus, or calcaneus on physical examination. Able to walk. Initial imaging.
D. Radiography Ankle
Variant 2: Adult or child 5 years of age or older. Acute trauma to the ankle. No exclusionary criteria present (eg, neurologically intact (including no peripheral neuropathy)). Patient meets the requirements for evaluation by the Ottawa Ankle Rules which are negative: No point tenderness over the malleoli, talus, or calcaneus on physical examination. Able to walk. Initial imaging.
E. US Ankle
Variant 3: Adult or child 5 years of age or older. Acute trauma to the ankle. Exclusionary criteria are present (eg, neurologic disorder, neuropathy, or other). Patient does not meet requirements for evaluation by the Ottawa Ankle Rules. Initial imaging.
Variant 3: Adult or child 5 years of age or older. Acute trauma to the ankle. Exclusionary criteria are present (eg, neurologic disorder, neuropathy, or other). Patient does not meet requirements for evaluation by the Ottawa Ankle Rules. Initial imaging.
A. Bone scan ankle
Variant 3: Adult or child 5 years of age or older. Acute trauma to the ankle. Exclusionary criteria are present (eg, neurologic disorder, neuropathy, or other). Patient does not meet requirements for evaluation by the Ottawa Ankle Rules. Initial imaging.
B. CT Ankle
Variant 3: Adult or child 5 years of age or older. Acute trauma to the ankle. Exclusionary criteria are present (eg, neurologic disorder, neuropathy, or other). Patient does not meet requirements for evaluation by the Ottawa Ankle Rules. Initial imaging.
C. MRI Ankle
Variant 3: Adult or child 5 years of age or older. Acute trauma to the ankle. Exclusionary criteria are present (eg, neurologic disorder, neuropathy, or other). Patient does not meet requirements for evaluation by the Ottawa Ankle Rules. Initial imaging.
D. Radiography Ankle
Variant 3: Adult or child 5 years of age or older. Acute trauma to the ankle. Exclusionary criteria are present (eg, neurologic disorder, neuropathy, or other). Patient does not meet requirements for evaluation by the Ottawa Ankle Rules. Initial imaging.
E. Radiography Ankle Stress Views
Variant 3: Adult or child 5 years of age or older. Acute trauma to the ankle. Exclusionary criteria are present (eg, neurologic disorder, neuropathy, or other). Patient does not meet requirements for evaluation by the Ottawa Ankle Rules. Initial imaging.
F. US Ankle
Variant 4: Adult or child 5 years of age or older. Acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks. No exclusionary criteria present. Initial radiographs negative. Next study.
Variant 4: Adult or child 5 years of age or older. Acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks. No exclusionary criteria present. Initial radiographs negative. Next study.
A. Bone scan ankle
Variant 4: Adult or child 5 years of age or older. Acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks. No exclusionary criteria present. Initial radiographs negative. Next study.
B. CT Ankle 
Variant 4: Adult or child 5 years of age or older. Acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks. No exclusionary criteria present. Initial radiographs negative. Next study.
C. MRI Ankle
Variant 4: Adult or child 5 years of age or older. Acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks. No exclusionary criteria present. Initial radiographs negative. Next study.
D. Radiography Ankle
Variant 4: Adult or child 5 years of age or older. Acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks. No exclusionary criteria present. Initial radiographs negative. Next study.
E. Radiography Ankle Stress Views
Variant 4: Adult or child 5 years of age or older. Acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks. No exclusionary criteria present. Initial radiographs negative. Next study.
F. US Ankle
Variant 5: Adult or child 5 years of age or older. Acute trauma to the ankle. No exclusionary criteria present. Radiographs demonstrate fracture or potential osteochondral injury. Next study.
Variant 5: Adult or child 5 years of age or older. Acute trauma to the ankle. No exclusionary criteria present. Radiographs demonstrate fracture or potential osteochondral injury. Next study.
A. Bone scan ankle
Variant 5: Adult or child 5 years of age or older. Acute trauma to the ankle. No exclusionary criteria present. Radiographs demonstrate fracture or potential osteochondral injury. Next study.
B. CT Ankle
Variant 5: Adult or child 5 years of age or older. Acute trauma to the ankle. No exclusionary criteria present. Radiographs demonstrate fracture or potential osteochondral injury. Next study.
C. MRI Ankle
Variant 5: Adult or child 5 years of age or older. Acute trauma to the ankle. No exclusionary criteria present. Radiographs demonstrate fracture or potential osteochondral injury. Next study.
D. Radiography Ankle Broden’s View
Variant 5: Adult or child 5 years of age or older. Acute trauma to the ankle. No exclusionary criteria present. Radiographs demonstrate fracture or potential osteochondral injury. Next study.
E. US Ankle
Variant 6: Adult or child 5 years of age or older. Acute trauma to the ankle. Radiographs negative for osseous injury and physical examination or radiographs demonstrate alignment abnormality suggesting syndesmotic/ligamentous injury or dislocation. Next study.
Variant 6: Adult or child 5 years of age or older. Acute trauma to the ankle. Radiographs negative for osseous injury and physical examination or radiographs demonstrate alignment abnormality suggesting syndesmotic/ligamentous injury or dislocation. Next study.
A. Bone scan ankle
Variant 6: Adult or child 5 years of age or older. Acute trauma to the ankle. Radiographs negative for osseous injury and physical examination or radiographs demonstrate alignment abnormality suggesting syndesmotic/ligamentous injury or dislocation. Next study.
B. CT Ankle
Variant 6: Adult or child 5 years of age or older. Acute trauma to the ankle. Radiographs negative for osseous injury and physical examination or radiographs demonstrate alignment abnormality suggesting syndesmotic/ligamentous injury or dislocation. Next study.
C. MRI Ankle
Variant 6: Adult or child 5 years of age or older. Acute trauma to the ankle. Radiographs negative for osseous injury and physical examination or radiographs demonstrate alignment abnormality suggesting syndesmotic/ligamentous injury or dislocation. Next study.
D. Radiography Ankle Stress Views
Variant 6: Adult or child 5 years of age or older. Acute trauma to the ankle. Radiographs negative for osseous injury and physical examination or radiographs demonstrate alignment abnormality suggesting syndesmotic/ligamentous injury or dislocation. Next study.
E. Radiography Leg
Variant 6: Adult or child 5 years of age or older. Acute trauma to the ankle. Radiographs negative for osseous injury and physical examination or radiographs demonstrate alignment abnormality suggesting syndesmotic/ligamentous injury or dislocation. Next study.
F. US Ankle
Summary of Highlights
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations

Relative Radiation Level*

Adult Effective Dose Estimate Range

Pediatric Effective Dose Estimate Range

O

0 mSv

 0 mSv

☢

<0.1 mSv

<0.03 mSv

☢☢

0.1-1 mSv

0.03-0.3 mSv

☢☢☢

1-10 mSv

0.3-3 mSv

☢☢☢☢

10-30 mSv

3-10 mSv

☢☢☢☢☢

30-100 mSv

10-30 mSv

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”
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Disclaimer
The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.  Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document.  The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged.  The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination