Traumatic Ankle Injuries in the Emergency Department: Evaluating the Adequacy of Clinical Documentation With Reference to the Ottawa Ankle Rules

Introduction Ankle trauma is a frequent presentation to the emergency department (ED) and poses a significant demand on radiology services. Efficient triage is essential to identify patients requiring urgent imaging, optimising resources, reducing waiting times, and minimising unnecessary radiation exposure. Injuries range from soft tissue damage to fractures of the distal tibia, fibula, or malleoli. Not all ankle injuries require immediate imaging, and clinical decision-making tools can guide the use of radiographs. The Ottawa Ankle Rules (OAR) are a validated tool, endorsed by the Royal College of Radiologists (RCR), designed to identify ankle injuries requiring radiographs. Imaging is indicated if the patient is unable to bear weight both immediately after injury and during examination, or if there is bone tenderness along the distal six centimetres of the posterior edge of the tibia or fibula, or over the lateral or medial malleoli. Adherence to the OAR has been shown to reduce unnecessary imaging while maintaining high sensitivity for fractures. Methods A two-cycle retrospective review was conducted of patients presenting with traumatic ankle injuries who underwent radiography. Records were reviewed via the Picture Archiving and Communication System (PACS) until 100 patients per cycle were included. Data collected included whether the OAR were referenced in radiograph requests and whether a fracture was diagnosed. After the first cycle, educational interventions were implemented to increase guideline awareness. The second cycle evaluated the impact of these interventions. Statistical analysis assessed the significance of observed changes. Exclusions included patients aged ≤16 years or ≥55 years, those with non-traumatic or chronic ankle presentations, and those with polytrauma or high-energy mechanisms of injury. Results were compared against RCR standards, which state that 100% of all ankle plain-film requests for trauma should reference the OAR. Results were presented at departmental governance meetings, and recommendations were subsequently implemented. Results In the first cycle, 37 (37%) of radiograph requests referenced the OAR. Fractures were identified in 21 (21%) patients, with 13 (61.9%) of these requests documenting the OAR and 8 (38.1%) omitting them. Following educational interventions, the second cycle demonstrated significant improvement, with 51 (51%) of requests referencing the OAR (P = 0.046). The proportion of patients with fractures increased to 31 (31%), of whom 26 (83.9%) had OAR documented, compared with 5 (16.1%) without documentation (P < 0.001). These findings reinforce that adherence to the OAR improves fracture detection, reduces unnecessary imaging, and remains a sensitive tool for ankle trauma assessment. Conclusion This quality improvement project demonstrates that focused interventions, particularly clinician education and guideline awareness, can enhance adherence to the OAR. Increased documentation and use of the OAR were associated with a higher diagnostic yield for fractures, improved triage, and a potential reduction in unnecessary imaging. Although full compliance was not achieved, incremental improvements contribute to patient safety and alignment with national recommendations. Future strategies may include regular departmental teaching sessions and system-based interventions such as electronic prompts to sustain compliance.

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