Foot Fracture Evaluation Guidelines

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, 2
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, 3
Additional views may be necessary depending on the clinical scenario and suspected fracture location 1

For suspected calcaneal fractures, an axial calcaneal view should be added to the standard three-view study to increase specificity in diagnosing calcaneal fractures and sensitivity in distinguishing intra-articular calcaneal fractures 1, 2
For suspected Lisfranc injuries, a standard three-view radiographic study (AP, lateral, and oblique) and an AP view with 20° craniocaudal angulation should be performed, and weightbearing radiographs are strongly recommended when possible 1, 2
Including both feet on AP radiographs helps detect subtle malalignment when compared with the uninjured side in Lisfranc injuries 1, 2

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, initial imaging in polytrauma patients, or complex regions such as the midfoot 1, 2

The Ottawa rules should not be applied in certain clinical situations, including penetrating trauma, pregnancy, skin wounds, patients transferred with radiographs already taken, >10 days after trauma or return visits for continued pain, polytrauma, altered sensorium, neurologic abnormality affecting the foot, or underlying bone disease or diabetic neuropathy 1, 2, 3
The American College of Radiology recommends that the Ottawa rules not be applied to toe injuries, as these rules do not address toe fractures 4

Failing to obtain weightbearing views when Lisfranc injuries are suspected 1, 2
Using ultrasound as first-line imaging, as it has lower sensitivity compared to radiographs 1, 3