Foot radiograph (an approach)

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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 2 metatarsal and intermediate cuneiform should line up on the DP (dorsiplantar) view
  • medial borders of 3 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)
  • 1 and 2 metatarsals
  • medial and intermediate cuneiform
Lateral aspect (oblique)
  • 3, 4 and 5metatarsals
  • 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 is not attached
    • is it an ossicle, an avulsion or bone fragment?
    • do not call normal variant anatomy a fracture!
  • do not call an unfused base of 5 apophysis a fracture!

Common pathology

Lisfranc injury
  • Lisfranc ligament between 1 and 2 metatarsal bases
  • the ligament stabilizes the foot
  • widening of the 1/2 metatarsal space
  • a line along the medial margins of the 2 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
Avulsion fractures associated with ankle sprain:
Avulsion of the 5 metatarsal styloid
  • 90% of base of 5 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: 5 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
Jones fracture
  • base of 5 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 fracture
Calcaneal fracture

Do not miss

Stress fracture
  • commonly affect 2 and 3metatarsal shafts
  • abnormal stresses lead to microfractures, e.g. marching
  • look for transverse fracture, periosteal reaction or callus
  • more: metatarsal stress fracture
Approaches to radiographs