What is the proper format for writing a foot x-ray (radiograph) order?

How to Write a Foot X-Ray Order

A proper foot x-ray order should specify "X-ray foot, 3 views" (anteroposterior, lateral, and oblique) with weight-bearing views when evaluating structural deformities or alignment, and include the clinical indication, laterality (right/left/bilateral), and whether the patient meets Ottawa foot rules if trauma-related.

Essential Components of the Order

Basic Order Elements

• Procedure name: "X-ray foot" or "Radiography foot" 1
• Number of views: Typically 3 standard views (anteroposterior, lateral, and oblique) 2, 3
• Laterality: Specify right, left, or bilateral 2
• Weight-bearing status: Indicate if weight-bearing views are needed (critical for structural assessment) 1, 3
• Clinical indication: Brief reason for the study (e.g., "acute trauma," "chronic pain," "deformity evaluation") 1

Standard View Specifications

For routine evaluation, the order should include 2, 3:

• Anteroposterior (AP) view: Standard dorsoplantar projection for evaluating forefoot and midfoot alignment
• Lateral view: Essential for assessing longitudinal arch, hindfoot position, and bone relationships
• Oblique view: Provides additional detail of midfoot articulations

For specific clinical scenarios 1, 3:

• Weight-bearing views: Required for accurate assessment of structural deformities, arch collapse, or alignment issues
• Axial (calcaneal) view: May be added when evaluating hindfoot pathology
• Stress views: Occasionally needed for ligamentous injury assessment

Clinical Context-Specific Ordering

Acute Trauma Scenarios

When Ottawa rules are positive (pain in midfoot PLUS point tenderness of navicular OR base of 5th metatarsal OR inability to bear weight), order 1:

• "X-ray foot, 3 views, right/left"
• Include clinical indication: "Acute trauma, Ottawa rules positive"

When exclusionary criteria exist (penetrating trauma, polytrauma, neurologic abnormality, >10 days post-trauma, pregnancy, skin wound, or underlying bone disease), Ottawa rules cannot be applied and imaging should be ordered based on clinical judgment 1:

• Standard 3-view foot x-rays remain the initial study
• Consider CT for polytrauma patients or complex midfoot injuries 1

Non-Trauma Structural Evaluation

For deformity assessment or chronic conditions 1, 3:

• "X-ray foot with weight-bearing, 3 views, bilateral"
• Weight-bearing is critical as radiographic angles and measurements change significantly with loading 3
• Bilateral views allow comparison between feet 3

Common Pitfalls to Avoid

Critical Ordering Errors

• Omitting weight-bearing specification when evaluating structural problems leads to inaccurate assessment of arch height, alignment, and bone relationships 1, 3
• Not specifying laterality creates confusion and potential wrong-site imaging 2
• Ordering "foot series" without view specification may result in inadequate or excessive imaging 2, 3
• Applying Ottawa rules when exclusionary criteria exist (especially neurologic abnormalities like diabetic neuropathy where pain perception is diminished) leads to missed fractures 1

Documentation Requirements

• Clinical indication is mandatory for appropriate utilization and insurance authorization 1
• Specify if this is initial imaging or follow-up to guide radiologist interpretation 1
• Note any prior imaging to avoid unnecessary repeat studies 1

Special Populations

Pediatric Considerations

• Ottawa rules are validated for children >5 years of age 1
• Standard 3-view foot radiographs are appropriate for pediatric trauma when indicated 1
• Cone-beam CT may be considered as a lower-dose alternative to standard CT when cross-sectional imaging is needed 1

Patients with Neuropathy

• Do not apply Ottawa rules in diabetic neuropathy or other neurologic compromise 1
• Order foot x-rays based on clinical suspicion alone, as these patients may ambulate despite fractures 1
• Specify "diabetic foot" or "neuropathic foot" in clinical indication 1

Example Orders

Acute trauma with positive Ottawa rules: "X-ray foot, 3 views, left. Clinical indication: Acute trauma with point tenderness over navicular, unable to bear weight. Ottawa rules positive."

Structural deformity evaluation: "X-ray foot with weight-bearing, 3 views, bilateral. Clinical indication: Progressive flatfoot deformity, chronic pain."

Polytrauma patient: "CT foot without contrast, right. Clinical indication: High-energy polytrauma, clinical concern for midfoot fracture." 1