Initial Management of Acute Foot Trauma with Inability to Bear Weight
Obtain standard three-view radiographs of the foot (anteroposterior, oblique, and lateral) immediately, as this patient meets Ottawa Ankle Rules criteria with inability to bear weight and should be imaged to rule out fracture. 1, 2
Immediate Assessment and Imaging Decision
Your patient has already met the threshold for mandatory imaging based on established clinical decision rules:
Ottawa Ankle Rules are positive when a patient cannot bear weight immediately after injury or cannot take 4 steps in the emergency department, making radiographs indicated with 99% sensitivity for detecting foot fractures 1, 2
The intact neurovascular examination (normal sensation, palpable pulses, and preserved active range of motion) is reassuring and rules out vascular emergency, but does not eliminate the need for imaging given the inability to bear weight 1
Standard Radiographic Protocol
Order a three-view foot series as your initial imaging study:
- Anteroposterior, oblique, and lateral projections constitute the gold standard first-line study for acute foot trauma 1, 2
- This combination achieves 99% sensitivity for fracture detection when Ottawa rules are positive 2
- Request weight-bearing views if the patient can tolerate standing, as non-weight-bearing films may miss subtle malalignment and joint instability 2
Critical pitfall to avoid: Do not order ankle radiographs when evaluating midfoot pain—the tarso-navicular joint will not be properly visualized, and foot radiographs are required 2
Immediate Supportive Management While Awaiting Imaging
- Immobilize the foot with a splint or walking boot to prevent further injury and provide pain relief 3
- Prescribe appropriate analgesia with acetaminophen or NSAIDs as first-line agents 4
- Non-weight-bearing status should be maintained until fracture is ruled out 1
If Initial Radiographs Are Negative
Do not assume absence of fracture if pain persists:
- Stress fractures have only 12-56% sensitivity on initial plain films and symptoms often precede radiographic findings 4, 2
- Reexamine the patient 3-5 days post-injury, as excessive swelling and pain can limit the initial examination within 48 hours 4
- If pain persists beyond 1 week with negative radiographs, order MRI without contrast as the next appropriate study to detect occult fractures, bone marrow edema, and stress reactions invisible on radiographs 1, 2
- Alternatively, three-phase bone scan has 100% sensitivity and negative predictive value for ruling out stress fractures 2
Key Examination Details to Document
While awaiting imaging, document specific findings to guide differential diagnosis:
- Point tenderness location: Palpate the lateral malleolus, posterior superior calcaneus, lateral calcaneal wall, and over the calcaneofibular ligament course 4
- Calcaneal compression test: Squeeze the calcaneus from medial to lateral—pain suggests stress fracture 4
- Swelling pattern: Rapid onset suggests acute ligamentous injury or fracture; lateral gutter swelling indicates lateral ligament involvement 4