Consider An Additional View
Weight-Bearing Foot AP or lateral
- When: Obtain a weight-bearing view if there is any concern for Lisfranc injury
- Why: Weight-bearing views may not show diastasis of joint .
- Pearl: Consider CT as you may diagnose concomitant fractures
- Check out the EMRad ankle post for more information on this view.
Citation Doi & Article Data
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 bone lesion.
This article relates mainly to traumatic injuries to the foot.
A basic review should start with AP and lateral views . With the exception of trauma, these views should be acquired with weight bearing if the patient can tolerate it.
Before We Begin: Make Sure To Employ The Rule Of 2s
- 2 views: One view is never enough.
- 2 abnormalities: If you see one abnormality, look for another.
- 2 joints: Image above and below .
- 2 sides: If unsure regarding a potential pathologic finding, compare to another side.
- 2 occasions: Always compare with old x-rays if available.
- 2 visits: Bring patient back for repeat films.
Recommended Reading: Nevada Orthopedic And Spine Center Reviews
Check For Lisfranc Injuries
Normally aligned bones should have the second metatarsal aligning with the intermediate cuneiform on the DP view and the third metatarsal aligning with the lateral cuneiform on the oblique view. The Lisfranc ligament connects the cuneiforms and the second metatarsal. Disruption of this ligament leaves an unstable foot and so its an important one not to miss.
To see more about Lisfranc injuries, check out Andy Neills great video on this here.
Check The Base Of Fifth
Most fractures here are avulsions of the metatarsal tuberosity. This is where peroneus brevis attaches and an inversion injury can cause the fracture.
A Jones fracture is a transverse fracture at the proximal shaft of the fifth metatarsal. It is managed differently .
Also, dont confuse a base of fifth fracture with an unfused apophysis or vice versa. An unfused apophysis runs longitudinally, whereas fractures are usually transverse. The apophysis appears at age 12 for boys and age 10 for girls, and it usually fuses over the next few years.
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Find Any Bits That Arent Attached
Consider whether any floaty bits might be an ossicle. Pay particular attention to small avulsions from the bones these are very easy to miss.
There are a couple of common ossicles that you might see:
Os tibiale externum this is an ossicle present at the medial aspect of the navicular bone
Os peroneum this an accessory bone in the peroneus longus tendon
Avulsions commonly occur on:
The lateral aspect of the cuboid
The dorsal surface of navicular and talus