Standard Three-View Foot Radiographs (AP, Oblique, Lateral)
Order a standard three-view radiographic series of the right foot consisting of anteroposterior (AP), oblique, and lateral views 1. This is the appropriate initial imaging for acute foot trauma with bruising and concern for fracture, as radiographs have 99% sensitivity for detecting foot fractures and remain the mainstay of initial evaluation.
Algorithmic Approach to Ordering
Standard Initial Imaging
- Three-view foot series is the baseline study for all acute foot trauma 1
- Anteroposterior (AP) view
- Oblique view
- Lateral view
Consider Additional Views Based on Clinical Findings
If calcaneal (heel) involvement suspected:
- Add an axial calcaneal view to increase specificity for diagnosing calcaneal fractures and sensitivity for distinguishing intra-articular involvement 1
If midfoot injury or Lisfranc injury suspected:
- Consider weightbearing AP views of both feet for comparison if patient can tolerate it 1
- An AP view with 20-degree craniocaudal angulation can be added 1
- Weightbearing views are superior to non-weightbearing for detecting subtle Lisfranc injuries by increasing abnormal alignment visibility 1
If fifth metatarsal base tenderness:
- Ensure the base of the fifth metatarsal is adequately visualized, as standard foot views may miss avulsion fractures in this location 2
- Consider adding an AP ankle view that includes the fifth metatarsal base if clinical suspicion remains high
Why Not Other Modalities Initially?
CT is not routinely indicated as first-line imaging for acute foot trauma when standard radiographs can be obtained 1. CT is reserved for:
- Complex fracture characterization after radiographic diagnosis
- Polytrauma patients
- Complex midfoot regions requiring surgical planning
MRI is not routinely used as initial imaging for acute foot trauma 1
Ultrasound has inferior performance with only 90.9% sensitivity and specificity compared to radiography's 99% sensitivity 1
Common Pitfalls to Avoid
- Don't skip imaging based on Ottawa rules alone in this scenario—a heavy concrete object causing bruising warrants radiographic evaluation regardless of Ottawa criteria
- Don't order only two views—the three-view series is standard and necessary for adequate evaluation 1
- Don't forget to assess the fifth metatarsal base adequately—this is a commonly missed fracture site on standard foot views 2
- Don't order CT first—it's not cost-effective or appropriate as initial imaging when plain radiographs can establish the diagnosis 1