Foot radiograph (an approach)

Dr Owen Kang and Dr Jeremy Jones et al.

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 osteomyelitisarthritides, 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.

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

  • medial borders of 2nd metatarsal and intermediate cuneiform should line up on the DP (dorsiplantar) view
  • medial borders of 3rd metatarsal and lateral cuneiform should line up on the oblique view
  • if there is any step in either line, think Lisfranc injury
  • 1st and 2nd metatarsals
  • medial and intermediate cuneiform
  • 3rd, 4th and 5th metatarsals
  • lateral cuneiform
  • navicular and cuboid
  • 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 5th apophysis a fracture!
  • Lisfranc ligament between 1st and 2nd metatarsal bases
  • the ligament stabilises the foot
  • widening of the 1st/2nd metatarsal space
  • a line along the medial margins of the 2nd 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
  • 90% of base of 5th 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
  • curvilinear calcification dorsal to talar head or navicular bone 
  • thin calcification adjacent to anterolateral calcaneus on oblique view
  • 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 fracture
  • commonly affect 2nd and 3rd metatarsal shafts
  • abnormal stresses lead to microfractures, e.g. marching
  • look for transverse fracture, periosteal reaction or callus
  • more: metatarsal stress fracture
Approaches to radiographs
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Article information

rID: 28689
Section: Approach
Synonyms or Alternate Spellings:
  • Foot xray
  • Foot x-ray
  • Foot XR

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Cases and figures

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    Figure 1: normal DP
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    Figure 2: normal oblique
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    Figure 3: DP phalanges
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    Figure 4: DP metatarsals
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    Figure 5: DP Lisfranc
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    Figure 6: DP tarsals
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    Figure 7: oblique phalanges
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    Figure 8: oblique metatarsals
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    Figure 9: oblique tarsals
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    Figure 10: oblique Lisfranc
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    Figure 11: annotated lateral foot projection
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    Figure 12: annotated dorsoplantar foot projection
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