Ottawa Ankle Rule Age Criteria
The Ottawa Ankle Rules are validated for use in patients 5 years of age and older, and should not be applied to children younger than 5 years. 1, 2
Age-Specific Application
Validated Age Range
- Minimum age: 5 years and older for reliable application of the Ottawa Ankle Rules 1, 2
- The rules demonstrate 92-100% sensitivity for detecting ankle fractures in this age group 1
- Meta-analysis of pediatric studies (children >5 years) shows pooled sensitivity of 98.5% for fracture detection 3
Pediatric Considerations (Ages 5-17 Years)
- The rules maintain excellent diagnostic accuracy when applied by physicians in children over 5 years 4, 3
- For children between 5-12 years, some guidelines suggest radiographs may be beneficial despite lack of clinical symptoms, though this represents a more conservative approach 2
- When applied by non-physician providers in pediatric patients (ages 5-17), sensitivity remains very good at 88-100% depending on anatomic location 4
Adult Application
- No upper age limit exists for the Ottawa Ankle Rules 5
- In adults, the rules demonstrate sensitivity of 91% and specificity of 25% across multiple studies 5
- Age-specific modifications for elderly patients should be considered to improve sensitivity, particularly in those with underlying bone disease 2
Critical Exclusionary Criteria by Age
Do not apply the Ottawa Ankle Rules in patients with: 1, 2
- Age <5 years (primary age exclusion)
- Altered sensorium or neurologic abnormality affecting the foot
- Underlying bone disease
- Pregnancy
- Injuries >10 days old
- Polytrauma
- Penetrating trauma
Clinical Pitfall
The most common error is attempting to use the Ottawa Ankle Rules in children under 5 years of age, where they have not been validated and may miss clinically significant fractures, including Salter-Harris injuries that are more common in younger children 1, 3.