Medical Malpractice Insights: Ottawa Ankle/Foot Rule

Here’s another case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. The goal of MMI-LFL is to improve patient safety, educate physicians, and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here.

Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights

Ottawa Ankle/Foot Rules: They RULE!

 Sometimes the standard of care is clear


Facts: A 42-year-old female feels a “pop” in her right lateral foot while hiking. She waits 3 days before seeing her PCP and presents with swelling, bruising, and pain when walking. She is a type I diabetic with neuropathy and an ulcer on the injured  right foot. Exam shows good pedal pulses and tender swelling of the dorsolateral right foot and both malleoli. Her PCP documents a “low index of suspicion for fracture” and discharges her without immobilization to ambulate as able. She returns 1 week later with persistent symptoms. An x-ray shows a fracture of the 2nd and 3rd metatarsals. She is referred to an orthopedic surgeon and undergoes an open reduction and fixation. She experiences a rocky post-op course, for which she blames her PCP. A lawsuit is filed.

Plaintiff: You should have gotten an x-ray when you first saw me. I had every indication of a fracture. I could walk on it because I have a neuropathy. You didn’t follow the Ottawa Ankle/Foot rules. Those rules have become the standard of care and say that you should have done an x-ray. You didn’t even immobilize my foot or ankle and just let me keep walking on it. That caused worsening displacement so that I needed surgery. And with my diabetes, I’m at high risk for complications of an injury like this. Your care was substandard.

Defense: You walked on your broken foot for 3 days before you even saw your doctor. A routine ankle x-ray does not always need to be immobilized. An x-ray at 3 days or 10 days would not be any different. You would have needed the same surgery whenever the fracture was discovered. It made no difference, and having diabetes doesn’t change what needs to be done. Your surgical care was fine and you’re doing as well as can be expected. Your care was appropriate, and hindsight is always 20/20.

Result: The case went to mediation and was settled pre-trial for an undisclosed amount estimated to be a “nuisance value” of less than $50,000. During mediation an ED/FP expert was able to support only the fact that the failure to follow the Ottawa Ankle/Foot Rules was below the standard of care. To determine if that failure/negligence actually caused the damages (made a difference in the outcome, i.e., “causation”) would require the opinion of an orthopedic expert and only add to the expenses of defending the matter further.



  • There are few instances where the standard of care is as clear as it is with ankle and foot injuries. The Ottawa Ankle/Foot Rules are the de facto standard and are violated at one’s peril.
  • Failing to x-ray an ankle or foot that falls within those “rules” is easily argued to be negligent.
  • However, there must also be a connection between the negligence and the damages in order for a plaintiff to prevail in a lawsuit. That connection (“causation”) is unclear in this case.
  • The defense would likely have prevailed had the case gone to trial, which would have led to substantial additional expense, so the defense chose to settle.
  • Nuisance settlements constitute less than 10% of med mal cases settled pre-trial. This seems to be one of them.



  1. Ottawa Ankle Rule. Stiell I. MDCalc.
  2. Foot Fracture. Silbergleit R. Medscape eMedicine, updated Sep 23, 2018

One thought on “Medical Malpractice Insights: Ottawa Ankle/Foot Rule”

  1. ERRATUM: Sorry for missing this but hope readers understood. The defense claimed “A routine 2ND AND/OR 3RD METATARSAL FX does not always need to be immobilized. ” See:
    Zenios M et al. Functional treatment of acute metatarsal fractures: a prospective randomised comparison of management in a cast versus elasticated support bandage. Injury. 2005 Jul. 36(7):832-5.
    // Chuck Pilcher MD, Editor, Med Mal Insights.

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