American College of Radiology
ACR Appropriateness Criteria®

Acute Trauma to the Ankle

Variant 1: Adult or child >5 years old. Patient meets Ottawa Ankle Rules: 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
X-ray ankle Usually appropriate ☢ <0.1 mSv 9 n/a 0 0 0 0 0 0 0 0 0
Variant 2: Adult or child >5 years old. Acute injury to the ankle; does not meet the Ottawa Ankle Rules. No point tenderness over the malleoli, talus, or calcaneus on physical examination. Able to walk. Neurologically intact (including no peripheral neuropathy). First study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
X-ray ankle Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT ankle without IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT ankle without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT ankle with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MRI ankle without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI ankle without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
US ankle Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Adult or child >5 years old. Acute injury to the ankle. Does not meet Ottawa Ankle Rules. Patient is not neurologically intact and/or has a peripheral neuropathy that involves the ankle and foot. First study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
X-ray ankle Usually appropriate ☢ <0.1 mSv 9 n/a 0 0 0 0 0 0 0 0 0
CT ankle without IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT ankle without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT ankle with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MRI ankle without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI ankle without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
US ankle Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Adult or child >5 years old. Acute injury to the ankle with persistent pain. Radiographs not obtained at time of injury. Initial study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
X-ray ankle Usually appropriate ☢ <0.1 mSv 9 n/a 0 0 0 0 0 0 0 0 0
CT ankle without IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT ankle without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT ankle with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MRI ankle without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI ankle without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
US ankle Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 5: Adult or child >5 years old. Acute injury to the ankle with >1 week persistent pain. Initial radiographs negative.
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 May be appropriate O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
X-ray ankle May be appropriate ☢ <0.1 mSv 5 n/a 0 0 0 0 0 0 0 0 0
CT ankle without IV contrast May be appropriate ☢ <0.1 mSv 5 n/a 0 0 0 0 0 0 0 0 0
US ankle May be appropriate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
CT ankle without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT ankle with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MRI ankle without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 6: Adult or child >5 years old. Acute injury to the ankle. Radiographs demonstrate talus fracture. Next study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT ankle without IV contrast Usually appropriate ☢ <0.1 mSv 9 n/a 0 0 0 0 0 0 0 0 0
MRI ankle without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
X-ray ankle Broden’s view May be appropriate ☢ <0.1 mSv 5 n/a 0 0 0 0 0 0 0 0 0
CT ankle without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT ankle with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MRI ankle without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 7: Adult or child >5 years old. Acute injury to the ankle. Radiographs suggest an 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 O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
CT ankle without IV contrast May be appropriate ☢ <0.1 mSv 5 n/a 0 0 0 0 0 0 0 0 0
CT ankle without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT ankle with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MRI ankle without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 8: Adult or child >5 years old. Acute injury to the ankle. Radiographs and/or physical examination suggest syndesmotic injury. Next study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
X-ray tibia/fibula Usually appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
MRI ankle without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
CT ankle without IV contrast May be appropriate ☢ <0.1 mSv 5 n/a 0 0 0 0 0 0 0 0 0
CT ankle without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT ankle with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MRI ankle without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.