Bernese Ankle Rules | Ankle Fracture Assessment

If you follow our channel you are probably familiar with the Ottawa Ankle Rules which is one of the most famous clinical prediction rules in orthopedic physical assessment. The aim of the rule is to reduce the need for radiographs following ankle inversion trauma to rule out a fracture of the ankle or midfoot. 

The Ottawa ankle rules are not the only developed CPR for this purpose though. 

Among others, the Bernese Ankle Rules have been proposed as an alternative. They use an indirect stress technique to avoid directly palpating the injured region. Barelds et al. (2017) report a pooled positive likelihood ratio of 3.54 and a negative likelihood ratio of 0.39 which is why they have a moderate clinical value in excluding a fracture.

The Bernese ankle rules are positive and indicate the need for radiography if one of the following steps caused pain:

1. Indirect fibular stress where the malleolar fork is compressed approximately 10 cm proximal to the fibular tip.

2. Direct medial malleolar stress: the thumb is pressed flat on the medial malleolus.

3. Compression stress of the midfoot and the hindfoot: one hand fixes the calcaneus in a neutral position and the other hand applies a sagittal load on the forefoot so that the midfoot and hindfoot are compressed.

Other common tests to screen for ankle fractures are:

Ottawa Ankle Rules

Low Risk Ankle Rule for Ankle Fractures in Children

Malleolar Zone Algorithm for Fractures in Children

Midfoot Zone Algorithm for Fractures in Children

Barelds, I., Krijnen, W. P., van de Leur, J. P., van der Schans, C. P., & Goddard, R. J. (2017). Diagnostic accuracy of clinical decision rules to exclude fractures in acute ankle injuries: systematic review and meta-analysis. The Journal of emergency medicine, 53(3), 353-368.