A prospective consecutive study of 252 adult patients presenting to Accident and Emergency (A&E) departments was performed to assess any advantage of the Ottawa vs. local guidelines for radiography of the acutely injured ankle or midfoot. All patients taking part in the study underwent an ankle or midfoot radiograph. A comparison was made to determine whether a safe reduction in radiography could be produced by following the Ottawa criteria. Simultaneously, the accuracy of both guidelines were assessed. Twenty-two fractures were diagnosed radiologically. Both guidelines had a sensitivity of 1.0 in detecting fractures and a negative predictive value of 1.0. Ottawa guidelines produced a specificity of 0.48 and a positive predictive value of 0.15. Local guidelines produced a specificity of 0.19 and a positive predictive value of 0.1. Following Ottawa guidelines produced a highly significant reduction (X = 74.0 P < 0.001) in radiography of 37%, and no fractures were missed. This could potentially save the department approximately 7500 Pounds per annum.