Adult Foot Trauma Radiographic Evaluation

Updated: Sep 19 2018

Leah Ahn MD

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NORMAL ANATOMY

Ossification

Ossification center		1° vs. 2°	Age at ossification	Age at fusion
Talus	head	1°	7 months gestational age	13-15 yo
Talus	body	2°	7 months gestational age	13-15 yo
Calcaneus	body	1°	6 months gestational age	13-15 yo
Calcaneus	tuberosity	2°	9 yo	13-15 yo
Navicular		1°	7 months gestational age	13-15 yo
Cuboid		1°	birtth	13-15 yo
Lateral cuneiform		1°	1 yo	13-15 yo
Middle cuneiform		1°	4 yo	13-15 yo
Medial cuneiform		1°	3 yo	13-15 yo
Metatarsals	shaft	1°	9 weeks gestational age	birth
Metatarsals	epiphysis	2°	5-8 yo	14-18 yo
Phalanges	body	1°	10 weeks gestational age	14-18 yo
Phalanges	epiphysis	2°	2-3 yo	14-18 yo

Osteology & Attachments

Superior view
Inferior view
Medial view
Lateral view

Columns

Medial
- 1st metatarsal
- medial cuneiform
- navicular
- talus
Middle
- 2nd + 3rd metatarsals
- middle + lateral cuneiforms
- navicular
- talus
Lateral
- 4th + 5th metatarsals
- cuboid
- calcaneus

Joints

Lisfranc
- divides forefoot + midfoot
Chopart
- divides midfoot + hindfoot

RADIOGRAPHIC VIEWS

AP view

Positioning
- patient
  - supine
  - knee flexed + foot flat on plate
- beam
  - aim at base of 3rd metatarsal + 10° cephalad
Indications
- hallux valgus = used to determine angle
Critique
- symmetrical concavity of 1st metatarsal shaft + intermetatarsal spaces
- alignment of 2nd metatarsal with medial cuneiform
- superimposition of 2nd-5th metatarsal bases
  - increased with ER (also aids visualization of navicular tuberosity)
- open tarsometatarsal + navicular-cuneiform + medial-middle cuneiform joints

Lateral view

Positioning
- patient
  - lateral decubitus on ipsilateral side
  - foot dorsiflexed 90°
- beam
  - aim at base of 3rd metatarsal
Critique
- superimposition of metatarsals
- visualization of talocalcaneal joint

Oblique view

Positioning
- patient
  - supine
  - knee flexed + foot IR 45°
- beam
  - aim at base of 3rd metatarsal
Indications
- cuboid joint space
Critique
- superimposition of base of 1st + 2nd metatarsals
- no superimposition of base of 3rd-5th metatarsals
  - overrotation leads to superimposition of 5th metatarsal base + 4th metatarsal tuberosity
  - underrotation leads to superimposition of 4th + 5th metatarsal base
- visualization of 5th metatarsal tuberosity + tarsal sinus
- open joints around cuboid

Tangential view

Positioning

METHOD	PATIENT		BEAM
Lewis	prone	toes dorsiflexed + ball of foot perpendicular to plate	1st MTP joint	n/a
Holly	seated vs. supine	ankle neutral + toes dorsiflexed 75°	1st MT	n/a
Causton	lateral decubitus on contralateral side	knee flexed + foot in lateral position	1st MTP joint	40° cephalad

Indications
- metatarsal heads
- sesamoid bones = Lewis view preferred over Holly view (Holly view tends to produce more magnification)
Critique
- Lewis/Holly
  - no superimposition of sesamoids + metatarsals
- Causton
  - slight superimposition of sesamoid bones

Weightbearing view

Positioning

VIEW	PATIENT	BEAM
AP	erect on plate	base of 3rd MT	10° cephalad
Lateral	erect with plate between feet	base of 3rd MT	n/a

Indications
- AP
  - assess integrity of transverse arch
  - lisfranc injury
- lateral
  - assess integrity of longitudinal arch

NORMAL FINDINGS

Normal variants
- accessory navicular
  - enlargement of plantar medial aspect
  - classification
    - type 1 = sesamoid bone in tibialis posterior insertion
    - type 2 = separate accessory bone attached to native navicular via synchondrosis
    - type 3 = complete bony enlargement
- apophysis of proximal 5th metatarsal
  - oriented longitudinally parallel to the shaft
  - important to differentiate from fracture, which is oriented transversely
- bipartite medial cuneiform
  - anatomical variant where there are 2 ossification centers
  - may cause medial cuneiform to be larger than normal medial cuneiform
  - "E" sign seen on lateral view

CLINICAL PEARLS

Ottawa foot rules

XRs are indicated if any of the following criteria are met
- TTP over navicular
- TTP over base of 5th MT
- inability to bear weight, i.e. ambulate >4 steps

Midfoot stress fractures

Type	Mechanism of Injury	Findings
Longitudinal (41%)	force through metatarsal heads on plantarflexed foot leads to compression of midfoot between metatarsals and talus	• vertical fracture = cuneiforms/navicular
Medial (30%)	inversion leads to adduction of midfoot on hindfoot	• flake fracture = dorsal talus/navvicular, lateral calcaneus, cuboid • dislocation = midfoot, isolated talonavicular, medial swivel (talonavicular joint dislocation + subtalar joint subluxation + intact calcaneocuboid joint)
Lateral (17%)	lateral force to forefoot leads to cuboid being crushed between 4th/5th metatarsal bases and calcaneus	• nutcracker fracture = comminuted cuboid and navicular avulsion • lateral subluxation of talonavicular joint • lateral column collapse = due to comminuted calcaneocuboid joint
Plantar (7%)	force to plantar foot	• avulsion fracture = navicular, talus, anterior process of calcaneus

Lisfranc injury

Recommended views
- AP
- lateral
- oblique
- stress
  - may be helpful to show instability when non-weight bearing radiographs are normal and there is high suspicion
- weight-bearing with comparison view
  - may be necessary to confirm diagnosis
Findings
- five critical radiographic signs that indicate presence of midfoot instability
  - discontinuity of a line drawn from the medial base of the 2nd metatarsal to the medial side of the middle cuneiform
    - seen on AP view
    - diagnostic of Lisfranc injury
  - widening of the interval between the 1st and 2nd ray
    - seen on AP view
    - may see bony fragment (fleck sign) in 1st intermetatarsal space
      - represents avulsion of Lisfranc ligament from base of 2nd metatarsal
      - diagnostic of Lisfranc injury
  - dorsal displacement of the proximal base of the 1st or 2nd metatarsal
    - seen on lateral view
  - medial side of the base of the 4th metatarsal does not line up with medial side of cuboid
    - seen on oblique view
  - disruption of the medial column line (line tangential to the medial aspect of the navicular and the medial cuneiform)
    - seen on oblique view
Treatment criteria
- nonoperative treatment acceptable if
  - no displacement on weight-bearing and stress radiographs and no evidence of bony injury on CT (usually dorsal sprains)
  - certain nonoperative candidates
    - nonambulatory patients
    - presence of serious vascular disease
    - severe peripheral neuropathy
    - instability in only the transverse plane
- ORIF if any evidence of instability (> 2mm shift)
- primary arthrodesis of 1st, 2nd, and 3rd TMT joints if
  - purely ligamentous arch injuries
  - delayed treatment
  - chronic deformity
- midfoot arthrodesis if
  - destabilization of the midfoot's architecture with progressive arch collapse and forefoot abduction
  - chronic Lisfranc injuries that have led toadvanced midfoot arthrosis and have failed conservative therapy

5th metatarsal base fracture

Classification

Classification
Class	Description	Images
Zone 1 (pseudo Jones fx)	Proximal tubercle (rarely enters 5th tarsometatarsal joint) Due to long plantar ligament, lateral band of the plantar fascia, or contraction of the peroneus brevis Nonunions uncommon
Zone 2 (Jones fx)	Metaphyseal-diaphyseal junction Involves the 4th-5th metatarsal articulation Vascular watershed area Acute injury Increased risk of nonunion (15-30%)
Zone 3	Proximal diaphyseal fracture Distal to the 4th-5th metatarsal articulation Stress fracture in athletes Associated with cavovarus foot deformities or sensory neuropathies Increased risk of nonunion

Recommended views
- AP
- lateral
- oblique
Treatment criteria
- nonoperative treatment acceptable if
  - zone 1
  - zone 2 (Jones fx) in recreational athlete
  - zone 3
- intramedullary screw fixation if
- - zone 2 (Jones fx) in elite or competitive athletes
  - zone 3 fx with sclerosis/nonunion or in athletic individual

Metatarsal fracture

Recommended views
- AP
- lateral
- oblique
Treatment criteria
- nonoperative treatment acceptable if
- - 1st metatarsal
  - - non-displaced fractures
  - 2nd-4th (central) metatarsals
    - isolated fractures
    - non-displaced or minimally displaced fractures
- ORIF if
- - open fractures
  - first metatarsal
    - any displacement
  - central metatarsals
    - sagittal plane deformity more than 10 degrees
    - >4mm translation
    - multiple fractures

Tarsal navicular fracture

Classification

avulsion
- results from plantarflexion vs. eversion/inversion
- can involve talonavicular or naviculocuneiform ligaments
tuberosity
- results from eversion with simultaneous contraction of PTT

body = Sangeorzan

results from axial loading

Sangeorzan Classification of Navicular Body Fractures (based on plane of fracture and degree of comminution)
Type I	Transverse fracture of dorsal fragment that involves < 50% of bone. No associated deformity
Type II	Oblique fracture, usually from dorsal-lateral to plantar-medial. May have forefoot aDDuction deformity.
Type IIII	Central or lateral comminution. ABDuction deformity.

Recommended views
- AP
- lateral
- oblique
  - best view to see tuberosity fractures
Treatment criteria
- nonoperative treatment acceptable if
  - acute avulsion fractures
  - most tuberosity fractures
  - minimally displaced ype I and II navicular body fractures
- ORIF if
  - avulsion fractures involving > 25% of articular surface
  - tuberosity fractures with > 5mm diastasis or large intra-articular fragment
  - displaced or intra-articular type I and II navicular body fractures
- ORIF followed by ex-fix vs. primary fusion if type III navicular body fractures

Sesamoid injury

Classification
- medial/tibial sesamoid
  - more common
  - attaches to adductor hallucis
- lateral/fibular sesamoid
  - attaches to abductor hallucis
Recommended views
- AP
- lateral
- tangential
  - lewis
  - causton
Findings
- proximal migration of sesamoids
  - be suspicious of intrinsic minus hallux
Treatment criteria
- nonoperative treatment acceptable in most cases
- partial or total sesamoidectomy if nonoperative management fails after 3-12 months
- autologous bone grafting if nonunion or fracture
- dorsiflexion osteotomy if plantarflexed first ray with sesamoid injury

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Adult Foot Trauma Radiographic Evaluation - Foot & Ankle (2025)