What type of foot X-ray should be requested to rule out a fracture?

Foot X-ray Types for Fracture Evaluation

For suspected foot fractures, a three-view radiographic study consisting of anteroposterior (AP), lateral, and oblique views should be requested as the initial imaging modality. 1

Standard Radiographic Protocol

• A three-view radiographic study (AP, lateral, and oblique) is the mainstay of initial imaging for acute foot trauma with 99% sensitivity for detecting foot fractures when indicated by positive Ottawa rules 1
• Additional views may be necessary depending on the clinical scenario and suspected fracture location 1
• Radiographs are the first-line imaging modality for suspected foot fractures, as CT, MRI, and ultrasound are not routinely used as initial imaging studies 1

Special Considerations by Fracture Location

Toe Fractures

• When a toe fracture is suspected, radiographs are necessary to document or rule out a fracture, as the Ottawa rules do not directly address injuries to the toes 2
• Standard three-view radiography is appropriate for toe fracture evaluation 2, 3

Calcaneal Fractures

• For suspected calcaneal fractures, an axial calcaneal view should be added to the standard three-view study 1
• This additional view increases specificity in diagnosing calcaneal fractures and sensitivity in distinguishing intra-articular calcaneal fractures 1, 4

Lisfranc Injuries

• For suspected Lisfranc injuries, the following radiographic protocol is recommended:
  • Standard three-view radiographic study (AP, lateral, and oblique) 1
  • An AP view with 20° craniocaudal angulation should be added 1
  • Weightbearing radiographs are strongly recommended when possible, as non-weightbearing views may miss subtle injuries 1
  • Including both feet on AP radiographs helps detect subtle malalignment when compared with the uninjured side 1

Value of Multiple Views

• The addition of an oblique view to standard AP and lateral views increases diagnostic confidence and can change interpretation in approximately 4.8% of examinations 5
• The oblique view can help convert equivocal findings to definitive diagnoses and reveal abnormalities not visible on other views 5

When to Consider Advanced Imaging

• CT is not routinely used as the first imaging study for foot trauma evaluation but may be considered for:
  • Evaluating the true extent of osseous injury in complex fractures 1
  • Initial imaging in polytrauma patients 1
  • Complex regions such as the midfoot 1

Important Clinical Considerations

• The Ottawa rules should not be applied in certain clinical situations, including:
  • Penetrating trauma, pregnancy, skin wounds 1
  • Patients transferred with radiographs already taken 1

  • 10 days after trauma or return visits for continued pain 1

  • Polytrauma, altered sensorium, neurologic abnormality affecting the foot 1
  • Underlying bone disease or diabetic neuropathy 1

Common Pitfalls to Avoid

• Relying solely on two views when three views (AP, lateral, and oblique) are standard for foot fracture evaluation 1, 5
• Failing to obtain weightbearing views when Lisfranc injuries are suspected 1
• Applying Ottawa rules to toe injuries, as these rules do not address toe fractures 2
• Using ultrasound as first-line imaging, as it has lower sensitivity (90.9%) compared to radiographs 1