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Appropriateness Criteria

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 SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography ankle Usually appropriate Strong ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 0 0 0 0 0 0 0 0 17
References Study Quality
31 (10845508) 3
15 (12595378) 4
32 (19834751) 4
40 (17785745) 3
37 (17613502) 4
36 (15827363) 2
8 (19187397) Good
38 (28673281) 3
14 (28764972) 4
33 (27465987) 4
13 (26691309) 4
35 (26265187) 4
34 (26190779) 4
39 (25036414) 4
30 (23646202) 3
US ankle Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 15 1 0 1 0 0 0 0 0
References Study Quality
41 (24942618) 4
MRI ankle without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 16 0 1 0 0 0 0 0 0
References Study Quality
29 (27888851) 4
MRI ankle without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 15 0 0 2 0 0 0 0 0
References Study Quality
29 (27888851) 4
CT ankle with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 15 0 2 0 0 0 0 0 0
CT ankle without and with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 17 0 0 0 0 0 0 0 0
CT ankle without IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 12 1 0 4 0 0 0 0 0
Bone scan ankle Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 0 0 0 0 0 0 0 0
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 SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US ankle Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 0 0 0 0 0 0 0 0
Radiography ankle Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 16 1 0 0 1 1 0 0 0
MRI ankle without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 0 0 0 0 0 0 0 0
MRI ankle without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 0 0 1 0 0 0 0 0
CT ankle with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 17 0 0 0 0 0 0 0 0
CT ankle without and with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 17 0 0 0 0 0 0 0 0
CT ankle without IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 16 0 0 1 0 0 0 0 0
Bone scan ankle Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 0 0 0 0 0 0 0 0
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 SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography ankle Usually appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 0 0 0 0 0 0 0 1 16
References Study Quality
25 (9774943) 4
CT ankle without IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 1 0 2 5 7 3 1 0 0
References Study Quality
42 (26922668) 4
41 (24942618) 4
US ankle Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 0 1 0 0 0 0 0 0
Radiography ankle stress views Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 16 1 0 2 0 0 0 0 0
MRI ankle without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 1 1 0 0 0 0 0 0
MRI ankle without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 1 2 1 0 0 0 0 0
CT ankle with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 14 0 0 0 2 0 1 0 0
References Study Quality
42 (26922668) 4
41 (24942618) 4
CT ankle without and with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 15 0 0 1 0 0 1 0 0
References Study Quality
42 (26922668) 4
41 (24942618) 4
Bone scan ankle Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 0 0 0 0 0 0 0 0
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 SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI ankle without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 2 0 7 8
References Study Quality
53 (23334625) 4
55 (25920051) 3
50 (26244618) 4
29 (27888851) 4
51 (27467862) 4
52 (25895834) 3
54 (24753239) 3
CT ankle without IV contrast Usually appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 7 7 0 0 0 0 4 3 3 3 4
References Study Quality
43 (7717229) 3
44 (8810692) 3
47 (21316885) 4
48 (15333345) 3
45 (12533393) 4
49 (11858605) 4
46 (21343690) 4
Radiography ankle May be appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 5 5 1 0 1 4 10 1 2 0 0
References Study Quality
37 (17613502) 4
Radiography ankle stress views May be appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 5 5 0 0 0 2 10 5 2 0 0
US ankle Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 6 1 2 2 5 0 1 0 0
References Study Quality
58 (19181977) 4
57 (23773880) 4
56 (25023100) 4
41 (24942618) 4
MRI ankle without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 15 1 1 0 0 0 0 0 0
References Study Quality
53 (23334625) 4
55 (25920051) 3
50 (26244618) 4
29 (27888851) 4
51 (27467862) 4
52 (25895834) 3
54 (24753239) 3
CT ankle with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 15 0 2 0 0 0 0 0 0
References Study Quality
43 (7717229) 3
44 (8810692) 3
47 (21316885) 4
48 (15333345) 3
45 (12533393) 4
49 (11858605) 4
46 (21343690) 4
CT ankle without and with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 17 0 0 0 0 0 0 0 0
References Study Quality
43 (7717229) 3
44 (8810692) 3
47 (21316885) 4
48 (15333345) 3
45 (12533393) 4
49 (11858605) 4
46 (21343690) 4
Bone scan ankle Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 0 0 0 0 0 0 0 0
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 SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI ankle without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 1 2 3 11
References Study Quality
64 (17656737) 4
58 (19181977) 4
63 (23465947) 4
55 (25920051) 3
66 (25539277) 3
57 (23773880) 4
56 (25023100) 4
65 (28374052) 4
61 (26517167) 4
22 (25743919) 4
CT ankle without IV contrast Usually appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 9 9 0 0 0 0 1 2 2 1 11
References Study Quality
60 (19531659) 4
48 (15333345) 3
59 (22859663) 3
61 (26517167) 4
62 (26043240) 4
Radiography ankle Broden’s view May be appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 5 5 0 1 0 1 9 7 1 0 0
US ankle Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 14 0 1 1 0 1 0 0 0
References Study Quality
41 (24942618) 4
MRI ankle without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 17 0 0 0 0 0 0 0 0
References Study Quality
64 (17656737) 4
58 (19181977) 4
63 (23465947) 4
55 (25920051) 3
66 (25539277) 3
57 (23773880) 4
56 (25023100) 4
65 (28374052) 4
61 (26517167) 4
22 (25743919) 4
CT ankle with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 17 0 0 0 0 0 0 0 0
References Study Quality
60 (19531659) 4
48 (15333345) 3
59 (22859663) 3
61 (26517167) 4
62 (26043240) 4
CT ankle without and with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 17 0 0 0 0 0 0 0 0
References Study Quality
60 (19531659) 4
48 (15333345) 3
59 (22859663) 3
61 (26517167) 4
62 (26043240) 4
Bone scan ankle Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 0 1 0 0 0 0 0 0
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 SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography ankle stress views Usually appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 8 8 0 0 0 1 2 0 4 7 5
References Study Quality
73 (24296599) 4
72 (23955557) 3
Radiography leg Usually appropriate Limited ☢ <0.1 mSv 8 8 0 0 0 0 3 0 6 6 4
References Study Quality
74 (23079149) 4
MRI ankle without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 1 0 1 15
References Study Quality
71 (28419034) 4
51 (27467862) 4
52 (25895834) 3
CT ankle without IV contrast Usually appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 7 7 0 0 0 1 4 2 5 4 1
References Study Quality
69 (27623865) 3
71 (28419034) 4
70 (24177591) 4
US ankle Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 12 2 1 1 1 0 0 0 0
References Study Quality
75 (25682406) 3
MRI ankle without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 16 0 1 0 0 0 0 0 0
References Study Quality
71 (28419034) 4
51 (27467862) 4
52 (25895834) 3
CT ankle with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 17 0 0 0 0 0 0 0 0
References Study Quality
69 (27623865) 3
71 (28419034) 4
70 (24177591) 4
CT ankle without and with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 17 0 0 0 0 0 0 0 0
References Study Quality
69 (27623865) 3
71 (28419034) 4
70 (24177591) 4
Bone scan ankle Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 0 0 0 0 0 0 0 0
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.