Choosing Wisely: Imaging Requests Under Pressure

Ottawa Ankle Rules for ankle X-ray: indicated if there is pain in the malleolar zone AND any of: (1) bone tenderness at the posterior edge or tip of the lateral malleolus, (2) bone tenderness at the posterior edge or tip of the medial malleolus, or (3) inability to bear weight both immediately and in the ED/clinic (4 steps).

Mr. T: malleolar-zone pain yes; lateral malleolus tenderness yes. Therefore an X-ray is indicated by the rules - he meets a criterion. So this is not a case for refusing imaging; it is a case for ordering it appropriately.

Important nuance: he can bear weight, which lowers but does not eliminate fracture probability, and the rules are designed to be highly sensitive, not specific. Many positive-rule patients have no fracture. The correct action is to order the ankle X-ray (and consider whether a foot series is also needed using the foot rules: pain in the midfoot zone plus navicular or base-of-5th tenderness, or inability to bear weight).

So the answer is: order the indicated imaging, explain why it is indicated rather than merely requested, and do not let time pressure or cost push you into either refusing indicated imaging or ordering unnecessary extra views.

Structure the visit around safety, transparency, and efficiency.

1. Acknowledge the concern: 'It sounds like your brother's experience made you worried about missing something. That's completely reasonable.'
2. Explain the reasoning in plain terms: 'There are rules doctors use to decide who needs an X-ray. You have tenderness right over the outer ankle bone, so you do meet the criteria and I do want an X-ray. I'm not brushing you off - I'm ordering it.'
3. Address the 5-day wait: explain that most ankle fractures that need treatment are managed with immobilisation and that a delay of a few days rarely changes outcome, but give clear return precautions: inability to bear weight, worsening pain or swelling, numbness, or deformity means come back sooner or go to the ED. Provide crutches/brace advice and analgesia (acetaminophen/NSAID if appropriate).
4. Address cost: ask about insurance; check whether the fee can be waived or reduced; offer the option of the ED if he cannot wait and cannot afford it, with the trade-off explained (longer wait, higher cost, but same-day imaging).
5. Summarise and give written instructions; document the shared decision.

This is a Leader/Health Advocate moment: appropriate use of a scarce resource (the 5-day X-ray slot) while not sacrificing indicated care.

Propose system-level, evidence-aligned changes rather than blunt rationing.

Proposals:

• Embed clinical decision rules (Ottawa Ankle/Knee, Canadian CT Head, etc.) into the order-entry system as prompts, not hard stops.
• Provide a one-page laminated card at each room with the rules and return precautions.
• Audit a sample of requests against the rules and feed results back to clinicians monthly, non-punitively.
• Offer a nurse-led or physiotherapy-led minor-injury stream for low-acuity sprains, freeing physician time.
• Improve patient information (waiting-room poster, discharge handout) explaining why an X-ray is or is not needed.
• Track whether reduced imaging is accompanied by any increase in missed fractures or ED re-presentations.

What I would refuse:

• A blanket cap or quota that overrides clinical judgement in an individual patient.
• Any target that penalises clinicians for ordering indicated imaging.
• Removing the ability to order urgently when clinically needed.
• Reporting individual clinicians' ordering rates in a punitive way.

The metric should be 'proportion of imaging consistent with decision rules', not 'number of X-rays', and safety must be monitored alongside volume.