X Ray Referral Rules

Question 1

What do you use if patient has foot or ankle injury

Answer 1

Ottawa ankle and foot rules

Question 2

What do you use if patient has a knee injury

Answer 2

Ottawa knee rules

Question 3

According to Ottawa Knee Rules, a knee x-ray is only required for patients with knee injury and who have any of the following criteria

Answer 3

1. 55 or older
2. Isolated patellar tenderness without other bone tenderness
3. Tenderness of fibular head
4. Inability to flex knee to 90 deg
5. Inability to bear weight immediately after injury and in the emergency department
   all of these criteria are OR

Question 4

What should be done in order to apply Ottawa knee rules accurately

Answer 4

1. Test is designed to rule out fractures after acute knee injury
2. Advised to order radiography with one or more positive answer
3. Negative rest results are considered highly diagnostic of the absence of fracture

Question 5

According to the Ottawa ankle and foot rules, what should be done if you have an ankle patient

Answer 5

An ankle x-ray series is only required if there is any pain in the maleolar zone AND any of these findings…
1. Bone tenderness from the posterior edge/tip of the lateral malleolus extending 6cm proximally
2. Bone tenderness from the posterior edge/tip of the medial malleolus extending 6cm proximally
3. Inability to take 4 complete steps both immediately after injury and in the ER

Question 6

According to the Ottawa ankle and foot rules, what should be done if you have an foot patient

Answer 6

A foot x-ray series is only required if there is any pain in the midfoot zone AND any of these findings…
1. Bone tenderness at the vase of the 5th MT
2. Bone tenderness of the navicular
3. Inability to take 4 complete steps immediately and in ER

Question 7

What should be done in order to apply ankle rules accurately

Answer 7

1. Palpate the entire distal 6cm of the fibula and tibia
2. Do not neglect the importance of medial maleolar tenderness
3. Do not use for patients under 18 yo

Question 8

What do you use if you suspect an un-dx cervical spine injury

Answer 8

Canadian C-spine rules

Question 9

Flowchart of Canadian C spine rules

Answer 9

1. Any high risk factor that mandates radiography? Age >65 OR dangerous mechanism OR parenthesis in extremities
   — IF YES — are they able to rotate actively 45 deg to each side?
   — IF NO — radiography

— IF NO high risk factors — 2. Any low risk factors that allow safe assessment of ROM? Simple rear-end MVA OR sitting position in ER OR ambulatory at any time OR delayed onset of neck pain OR absence of midline cervical spine tenderness
— IF YES — are they able to rotate actively 45 deg to each side?
— IF NO — radiography

— If patient CAN actively rotate neck to each side then no radiography