Imaging

Patients with normal findings on examination of the hindfoot and forefoot and on examination of the ankle and midfoot (see Fig 268-2, the Ottawa Ankle Rules, from the previous chapter) probably do not need radiographs. Clinical judgment should always prevail in the decision-making process. Abnormal findings on examination mandate a complete, three-view, standard foot series. If there is pain about the heel, an axial view of the calcaneum should be added. The lateral view of the foot and the axial view of the calcaneum are important in excluding hindfoot injuries, while the anteroposterior (AP) and oblique projections are more useful in delineating midfoot and forefoot injuries.

Other plain radiographic views, bone scans, and computed tomographic (CT) scans are seldom utilized by emergency physicians in the evaluation of foot injuries. Emergency physicians, however, should occasionally order comparison weight-bearing AP radiographs of the foot to exclude a subtle diastasis (greater than 1 mm) at the Lisfranc joint. The criteria for a normal radiograph are detailed in Fig 269-2.1

FIG. 269-2. Normal radiographic anatomy of the Lisfranc joint.
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