Foot x-rays

Cite this article as:
Davis, T. Foot x-rays, Don't Forget the Bubbles, 2018. Available at:
http://doi.org/10.31440/DFTB.12924

1. Check you have the right views. There are two views in foot x-rays DP (dorsal-plantar) and oblique. Both should ideally be done when weight-bearing if your patient can manage it.

 

2. Review the bones. 

Work round the bones one by one (including the metatarsals). Start proximally and work your way down, going medial lateral. This will ensure you check them all.

 

3. Find any bits that aren’t 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 (it appears at adolescence)

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 (seen only a lateral ankle view)

4. 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.

http://sprintforever.blogspot.co.uk/

A Jones fracture is a transverse fracture at the proximal shaft of the fifth metatarsal. It is managed differently (non-weight bearing).

Also, don’t 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.

https://radiopaedia.org/cases/fifth-metatarsal-apophysis

 

5. Check for calcaneus fractures. Look for an avulsion of the anterior process of the calcaneum (oblique view). Look lateral to the calcaneum where extensor digitorum brevis inserts (on the DP view). You can also get injuries to the anterio-lateral aspect of the calcaneus.

 

6. 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 it’s an important one not to miss.

https://emergencymedicineireland.com/

https://emergencymedicineireland.com/

To see more about Lisfranc injuries, check out Andy Neill’s great video on this here.

 

7. Consider stress fractures

These commonly occur on the second or third metatarsals. Sometimes they just present with callous formation or sometimes cannot be seen on plain x-ray and require further imaging (e.g. MRI) to diagnose.

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About Tessa Davis

AvatarTessa Davis is a Consultant in Paediatric Emergency Medicine at the Royal London Hospital and a Senior Lecturer at Queen Mary University of London.

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Author: Tessa Davis Tessa Davis is a Consultant in Paediatric Emergency Medicine at the Royal London Hospital and a Senior Lecturer at Queen Mary University of London.

8 Responses to "Foot x-rays"

  1. Avatar
    Cathy Booth 2 years ago .Reply

    These images are brilliant for our work in the non medical led fracture clinic, we deal mainly with minor injuries and need this knowledge to know when to refer on to our surgeons. Thank you

  2. Avatar
    khan 2 years ago .Reply

    excellent work for review

    • Avatar
      Sayuri Scott 11 months ago .Reply

      Alyssa

  3. Avatar
    Dr Azim 2 years ago .Reply

    Amazing x rays with beautiful explanation.

  4. Avatar
    Dr Ghada Farouk 1 year ago .Reply

    Informative and simple

    • Avatar
      Rana irshad 1 year ago .Reply

      Excellent explanation

  5. Avatar
    Mario TOUS 1 year ago .Reply

    Thanks for showing thw diference between Jones and avulsion of MTT tuberosity

  6. Avatar
    LEE GUANG ZHER 6 months ago .Reply

    Nice x Ray with good explanation. Thank you very much 🙇‍♂️

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