How to Write a Toe X-ray Order to Rule Out Osteomyelitis
Order a plain X-ray of the foot with three standard views: anteroposterior (AP), medial oblique, and lateral projections, specifying weight-bearing films if the patient can tolerate standing. 1
Standard Radiographic Protocol
The proper X-ray order should include:
- Three standard foot views: anteroposterior (AP), medial oblique, and lateral projections to provide sufficient radiographic evaluation of the osseous anatomy 1, 2
- Weight-bearing (standing) radiographs when possible, as these detect dynamic abnormalities and structural changes not apparent on non-weight-bearing images 1, 2
- Bilateral comparison films if feasible, particularly in diabetic patients where Charcot neuro-osteoarthropathy must be differentiated from osteomyelitis 1
Key Ordering Details
Your X-ray requisition should specify:
- Anatomic location: "Foot X-ray" (not just "toe") to ensure adequate visualization of adjacent structures 1
- Clinical indication: "Rule out osteomyelitis" to guide the radiologist's interpretation 1
- Weight-bearing status: Request standing films unless contraindicated by patient mobility or risk of fracture displacement 1, 2
Important Clinical Context
If plain X-rays are normal but clinical suspicion for osteomyelitis remains high, MRI should be ordered next as it has high sensitivity for detecting early bone infection before radiographic changes appear. 1, 2 Plain radiographs may not show osteomyelitis changes for 10-14 days after infection onset, so negative initial films do not exclude the diagnosis. 1
Common Pitfalls to Avoid
- Don't order only "toe films" - the standard three-view foot series provides better anatomic coverage and context 1
- Don't skip weight-bearing views unless the patient cannot stand, as non-weight-bearing films may miss important structural abnormalities 1, 2
- Don't rely solely on X-rays in diabetic patients - if radiographs are normal but clinical findings suggest infection (warmth, swelling, probe-to-bone positive), proceed directly to MRI 1, 2
- Don't confuse osteomyelitis with Charcot neuro-osteoarthropathy in diabetic patients - both can present with similar clinical and radiographic features, making bilateral comparison films and advanced imaging critical 1