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Foot radiograph (an approach)

Changed by Yuranga Weerakkody, 15 Apr 2016

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Foot radiographs are commonly performed in Emergency departments, usually after sport-related trauma and often with a clinical request that states lateral border pain. Remember to check the whole film though. Often, a foot x-ray is also requested for the investigation of osteomyelitis, arthritides, or a bone lesion.

This article relates mainly to the traumatic injuries to the foot.

A basic review should start with AP and lateral views (including the entire foot and ankle). With the exception of the trauma, these views should be acquired with weight bearing if the patient can tolerate.

Systematic review

Lisfranc complex

The Lisfranc joint is hugely important for stability. Injury to it may be subtle and if missed, disastrous.

medial borders of ~~2nd~~2^nd metatarsal and intermediate cuneiform should line up on the DP (dorsiplantar) view
medial borders of ~~3rd~~3^rd metatarsal and lateral cuneiform should line up on the oblique view
if there is any step in either line, think Lisfranc injury

Medial aspect (DP)

~~1st~~1^st and ~~2nd~~2^nd metatarsals
medial and intermediate cuneiform

Lateral aspect (oblique)

~~3rd~~3^rd, ~~4th~~4^th and ~~5th~~ 5^thmetatarsals
lateral cuneiform
navicular and cuboid

Bone review

check around the cortex of every bone
- start proximally and work distally, medial to lateral
- check any tarsal coalition
look for any bone that isn't attached
- is it an ossicle, an avulsion or bone fragment?
- don't call normal variant anatomy a fracture!
don't call an unfused base of 5th apophysis a fracture!

Common pathology

Lisfranc injury

Lisfranc ligament between ~~1st~~1^st and ~~2nd~~2^nd metatarsal bases
the ligament stabilises the foot
widening of the ~~1st/2nd~~1^st/2^nd metatarsal space
a line along the medial margins of the ~~2nd~~2^nd metatarsal and intermediate cuneiform will be irregular
disruption suggests a huge injury
usually a crush injury or axial load to a plantarflexed foot
more: Lisfranc injury

Chopart injury

fracture / dislocation of the mid-tarsal joint (Chopart joint) of the foot, i.e. talonavicular and calcaneocuboid joints
foot is usually dislocated medially and superiorly as it is plantar flexed and inverted, usually as a result of high energy impact
more: Chopart fracture

Avulsion fractures associated with ankle sprain:

Avulsion of the 5th5^th metatarsal styloid

90% of base of ~~5th~~5^th metatarsal fractures
avulsion of peroneus brevis tendon
forced inversion of plantarflexed foot (tennis fracture)
transverse fracture through tuberosity extending to tarsometatarsal joint
excellent prognosis
more: 5th metatarsal styloid avulsion

Dorsal capsular avulsion

curvilinear calcification dorsal to talar head or navicular bone

Extensor digitorum brevis avulsion fracture

thin calcification adjacent to anterolateral calcaneus on oblique view

Snowboarder's fracture

lateral talar process fracture

Jones fracture

base of 5th metatarsal fracture
transverse fracture 1.5-2 cm from tip of proximal tuberosity
forced inversion of plantarflexed foot
transverse fracture through diaphysis
high risk of nonunion
more: Jones fractur e

Calcaneal fracture

calcaneal tuberosity avulsion fracture
extra-articular lover fracture (or Casanova fracture)
intra-articular lover fracture
calcaneal stress fracture

Don't miss

Stress fracture

commonly affect ~~2nd~~2^nd and ~~3rd~~ 3^rdmetatarsal shafts
abnormal stresses lead to microfractures, e.g. marching
look for transverse fracture, periosteal reaction or callus
more: metatarsal stress fracture

~~-<li>medial borders of 2nd metatarsal and intermediate cuneiform should line up on the DP (dorsiplantar) view</li>~~
~~-<li>medial borders of 3rd metatarsal and lateral cuneiform should line up on the oblique view</li>~~
+<li>medial borders of 2<sup>nd</sup> metatarsal and intermediate cuneiform should line up on the DP (dorsiplantar) view</li>
+<li>medial borders of 3<sup>rd</sup> metatarsal and lateral cuneiform should line up on the oblique view</li>
~~-<li>1st and 2nd metatarsals</li>~~
+<li>1<sup>st</sup> and 2<sup>nd</sup> metatarsals</li>
~~-<li>3rd, 4th and 5th metatarsals</li>~~
+<li>3<sup>rd</sup>, 4<sup>th</sup> and 5<sup>th </sup>metatarsals</li>
~~-<li>Lisfranc ligament between 1st and 2nd metatarsal bases</li>~~
+<li>Lisfranc ligament between 1<sup>st</sup> and 2<sup>nd</sup> metatarsal bases</li>
~~-<li>widening of the 1st/2nd metatarsal space</li>~~
~~-<li>a line along the medial margins of the 2nd metatarsal and intermediate cuneiform will be irregular</li>~~
+<li>widening of the 1<sup>st</sup>/2<sup>nd</sup> metatarsal space</li>
+<li>a line along the medial margins of the 2<sup>nd</sup> metatarsal and intermediate cuneiform will be irregular</li>
~~-</ul><h5>Avulsion fractures associated with ankle sprain:</h5><h6>Avulsion of the 5th metatarsal styloid</h6><ul>~~
~~-<li>90% of base of 5th metatarsal fractures</li>~~
+</ul><h5>Avulsion fractures associated with ankle sprain:</h5><h6>Avulsion of the 5<sup>th</sup> metatarsal styloid</h6><ul>
+<li>90% of base of 5<sup>th</sup> metatarsal fractures</li>
~~-<li>commonly affect 2nd and 3rd metatarsal shafts</li>~~
+<li>commonly affect 2<sup>nd</sup> and 3<sup>rd </sup>metatarsal shafts</li>

Images Changes:

Image 4 X-ray (Frontal) ( update )

Caption was changed:

~~Normal~~Figure 1: normal DP

Image 5 X-ray (Oblique) ( update )

Caption was changed:

~~Normal~~Figure 2: normal oblique

Image 7 Annotated image (Phalanges) ( update )

Caption was changed:

Figure 3: DP phalanges

Image 8 Annotated image (Metatarsals) ( update )

Caption was changed:

Figure 4: DP metatarsals

Image 9 Annotated image (Lisfranc) ( update )

Caption was changed:

Figure 5: DP Lisfranc

Image 10 Annotated image (Tarsals) ( update )

Caption was changed:

Figure 6: DP tarsals

Image 11 Annotated image (Oblique) ( update )

Caption was changed:

~~Oblique~~Figure 7: oblique phalanges

Image 12 Annotated image (Oblique) ( update )

Caption was changed:

~~Oblique~~Figure 8: oblique metatarsals

Image 13 Annotated image (Oblique) ( update )

Caption was changed:

~~Oblique~~Figure 9: oblique tarsals

Image 14 Annotated image (Oblique) ( update )

Caption was changed:

~~Oblique~~Figure 10: oblique Lisfranc

Image 15 Annotated image (Lateral projection.) ( update )

Caption was changed:

~~Annotated~~Figure 11: annotated lateral foot projection.

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Foot radiograph (an approach)