CHAPTER 12

The Foot

Foot Checklists       4. Injuries likely to be missed

Minimally displaced Lisfranc fracture-dislocations
1. R
 adiographic examination Fracture of adjacent metatarsals
AP Lateral process fractures of talus (snowboarder’s fx)
Oblique Subtle nondisplaced fractures of base of metatarsals
Lateral
Axial view of calcaneus
5. Where else to look when you see
something obvious
2. C
 ommon sites of injury in adults
Obvious Look for
Metatarsals
Neck, base, shaft Fx metatarsal Fxs adjacent metatarsals
Fifth MT – tuberosity, Jones’ fracture Compression fx calcaneus Similar fx opposite calcaneus
Phalanges Compression fx thoracolumbar
Metatarsal/tarsal fracture-dislocation (Lisfranc) spine
Calcaneus – compression fracture
Talus
Neck
Lateral process (snowboarder’s fracture) 6. Where to look when you see nothing at all
Subtalar fracture-dislocation Lisfranc fracture-dislocation
Chopart’s fracture-dislocation Fine nondisplaced fracture of the neck of the talus
Navicular Fine nondisplaced fracture of anterior process of calcaneus
Body Subtle fine fracture of neck or base of metatarsals
Proximal pole If questionable radiographic findings – CT to clarify
Tarsal avulsion abnormality
Lateral view If radiographs negative – MRI to identify ligament tears,
Head of talus tendon injuries, and bone contusions
Anterior cortex navicular
Posterior tuberosity of talus
Dorsal surface of calcaneal tuberosity Foot – The Primer      
Anterior process of calcaneus
AP view 1. Radiographic examination
Lateral surface of calcaneus
AP
Oblique
3. C
 ommon sites of injury in children Lateral
and adolescents Axial view of calcaneus
  

Metatarsal A minimum of three views—AP (Figure 12-1A), internal

Bunk bed fracture (buckle fracture base of first MT)
Apophysis base of fifth MT (do not mistake for fracture)
Phalanges
Salter-Harris types 1 and 2 epiphyseal separation
Calcaneus
Under age 14 – extra articular fx of tuberosity
Over age 14 – adult pattern intraarticular compression fx
Talus
Nondisplaced fx of neck of talus; may be torus or
buckle-type fx
oblique (Figure 12-1B) and lateral (Figure 12-1C)—should
be obtained. In some cases fractures of the phalanges are seen
only on the internal oblique view and, therefore, may be over-
looked if the internal oblique is omitted. If there is a question
of injury to the calcaneus, an axial view of the calcaneus (Fig-
ures 12-1D and 12-1E) should be obtained in addition to the
standard views of the foot. When the suspected injury is con-
fined to the toes, AP (Figure 12-1F), oblique, and lateral views
of the toes should be obtained rather than the foot, as detail is
increased and disclosure of injuries is enhanced.
211

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212      The Foot

A B

Lateral
malleolus

5th D
metatarsal Medial
subtalar
Posterior joint
subtalar
joint Sustentaculum
tali

Tuberosity

Lateral Medial

Right os calcis
F
E
FIGURE 12-1  AP (A), internal oblique (B), and lateral (C). If there is a question of injury to the calcaneus, an axial view of the calcaneus (D, E)
should be obtained in addition to the standard views of the foot. When the suspected injury is confined to the toes, AP (F), oblique, and lateral
views of the toes should be obtained rather than of the foot, as detail is increased and disclosure of injuries is enhanced.

Navicular
2. C
 ommon sites of injury in adults Body
Metatarsals Proximal pole
Neck, base, shaft Anterior-superior cortical avulsion
Fifth MT – tuberosity, Jones’ fracture Dislocation
Phalanges Metatarsal/tarsal fracture-dislocation (Lisfranc)
Calcaneus Subtalar fracture-dislocation
Compression fracture Chopart’s fracture-dislocation
Noncompressive fractures
Avulsion Pattern of search in adults.  AP and lateral diagrams of the
Anterior process foot (Figure 12-2) pinpoint the common sites of fracture. The
Beak fracture tuberosity most common sites of fracture are identified by broad red
Lateral body (extensor digitorum brevis avulsion) lines. Less common sites are designated by fine red lines. Your
Talus pattern of search should include all sites.
Neck Metatarsal and phalangeal fractures account for the major-
Lateral process (snowboarder’s) ity of fractures of the foot. Metatarsal fractures are frequently
Posterior tuberosity multiple, with similar fractures involving the same site: neck

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 The Foot     213

Sesamoids:
Tibial
Fibular

Cuneiforms:
Medial
Middle
Lateral

Cuboid

Navicular

Talus Calcaneus

A B

FIGURE 12-2  AP (A) and lateral (B) diagrams of the foot pinpoint the common sites of fracture.

A B
FIGURE 12-3  Metatarsal fractures are frequently multiple with similar fractures involving the same site: neck (A), shaft, or base (B) of adjacent
metacarpals.

(Figure 12-3A), shaft, or base (Figure 12-3B) of adjacent meta-
carpals. Having identified one metatarsal fracture, look closely
at adjacent metatarsals for similar fractures. Similar fractures
of adjacent phalanges are less common.
Fractures of the fifth metatarsal are quite common. Avul-
sions of the tuberosity (Figure 12-4A) should be distinguished
from fractures of the base or the shaft of the metatarsal (also
known as Jones’ fracture) (Figure 12-4B).
Fractures of the phalanges are often due to heavy objects fall-
ing on the foot (Figure 12-5A) or stubbing the toe while walking
barefoot (Figure 12-5B). Mach bands formed by the underlying
sole of the foot or overlapping toes (Figure 12-5C) should not be
mistaken for fractures. It is imperative that oblique views of the
toes be obtained to avoid missing fractures, as some fractures of
the phalanges may only be visualized on the oblique projection
(Figures 12-6A and 12-6B). Dislocations of the metatarsopha-
langeal and interphalangeal joints are common (Figure 12-7A).
Make certain the joint is properly aligned on the postreduction
radiograph. Note the slight malalignment of the third PIP joint
on the postreduction examination (Figure 12-7B). This malalign-
ment proved to be due to entrapment of a flexor tendon.
Calcaneus.  Fractures of the calcaneus are divided into two
types, noncompressive and compression.

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214      The Foot

A B
FIGURE 12-4  Fractures of the fifth metatarsal. Avulsions of the tuberosity (A) should be distinguished from fractures of the base of the shaft
of the metatarsal (also known as Jones’ fracture) (B).

A B

A B
FIGURE 12-6  It is imperative that oblique views of the toes be
obtained to avoid missing fractures, as some fractures of the
phalanges may only be visualized on the oblique projection (A, B).

Compression fractures are due to high-impact trauma

C Boehler’s angle is a useful tool in the radiographic assess-
FIGURE 12-5  Fractures of the phalanges are often due to heavy
objects falling on the foot (A) or stubbing the toe while walking
barefoot (B). Mach bands formed by the underlying sole of the foot
or overlapping toes (C) should not be mistaken for fractures.
Noncompressive are avulsions of the periphery of the bone:
extensor digitorum brevis avulsion from the lateral aspect of
the body as seen on AP views of the ankle beneath the lat-
eral malleolus, posterior superior tuberosity (beak fracture)
(Figure 12-8A), and anterior process avulsion (arrow) (Figure
12-8B). An anterior process avulsion should be differentiated
from a secondary center of ossification, the os calcaneus second-
arius (arrow) (Figure 12-8C).
either falls from great heights and landing on the feet or in
motor vehicle crashes. In compression fractures the poste-
rior facet is fractured and compressed into the body of the
calcaneus (Figure 12-9A).
ment of these fractures (Figure 12-9B). The angle is drawn on
the lateral view of the foot and ankle. A line is first drawn from
the posterior superior tip of the tuberosity to the superior mar-
gin of the posterior facet. The second line is drawn from the
superior margin of the posterior facet to the superior surface
of the anterior process of the calcaneus. A normal Boehler’s
angle measures 20 degrees to 40 degrees (Figure 12-9B). In
the presence of a compression fracture, the angle is less than
20 degrees, often approaching 0 degrees or less (negative
degrees) (Figure 12-9C).
The principal anatomic features of the hindfoot are shown
by CT (Figure 12-10) and an anatomic drawing in the coro-
nal projection (Figure 12-11A). The anatomic features of a

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 The Foot     215

A B
FIGURE 12-7  Dislocations of the metatarsophalangeal and interphalangeal joints (A). Make certain the joint is properly aligned on the postre-
duction radiograph. Note the slight malalignment of the third PIP joint on the postreduction examination (B) due to entrapment of tendon.

A B C
FIGURE 12-8  Noncompressive fractures of the calcaneus are avulsions of the periphery of the bone: posterior superior tuberosity (beak frac-
ture) (A), and anterior process avulsion (arrow) (B). An anterior process avulsion should be differentiated from a secondary center of ossification,
the os calcaneus secondarius (arrow) (C).

Boehler’s angle

–13°

A
B C

FIGURE 12-9  Compression fractures of the calcaneus. The posterior facet is fractured and compressed into the body of the calcaneus (A).
Boehler’s angle is a useful tool in the radiographic assessment of these fractures (B). In the presence of a compression fracture, the angle is less
than 20 degrees, often approaching 0 degrees or less (negative degrees) (C).

compression fracture of the calcaneus in this projection are
displayed in Figure 12-11B.
The posterior facet sustains a vertical fracture with com-
minution and is depressed into the body of the calcaneus
(Figure 12-11B). The lateral cortex is comminuted, and the
sustentaculum tali is fractured. CT in the axial plane (Fig-
ure 12-12A) with 2-D reconstruction in the sagittal (Figure
12-12B) and coronal planes (Figure 12-12C) is required for
full evaluation
Talus. Fractures of the talus can be divided into those of
the neck and body and those of the peripheral non–weight-
bearing surfaces (i.e., posterior tuberosity, lateral process, and
superior cortex of the neck).
Small avulsions may occur from the neck or head of the
talus (Figure 12-13A). Fractures of the neck or body of the
talus are in the coronal plane, and 50% are associated with
subtalar dislocations (Figure 12-13B) or dislocations of the
body of the talus. The blood supply to the body of the talus

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216      The Foot

crosses the neck of the talus and is commonly disrupted by
fractures of the talar neck, leading to subsequent avascu-
lar necrosis of the body of the talus. When a fracture of the
talar neck is identified, the posterior facet of the subtalar joint
should be examined closely on the lateral radiograph for signs
of joint disruption: asymmetrical widening or narrowing of
the joint space and malalignment of the joint surfaces.
Fractures of the posterior tuberosity (Figure 12-14A) are to
be distinguished from a common accessory center of ossifica-
tion, the os trigonum (Figure 12-14B). Similarly, avulsion of the
superior cortex of the head and neck is to be distinguished from
the accessory center, os supratalare occurring in the same loca-
tion. Fractures of the lateral process of the talus (also known as
M
T
L margins of the calcaneocuboid joint or at the inferior pole seen
C (Figure 12-16).
snowboarder’s fractures) lie beneath the distal tip of the lateral
malleolus as seen on the AP view of the ankle (Figure 12-14C).
Fractures of this structure are easily overlooked if not specifi-
cally sought.
Navicular. Avulsions of the proximal pole are relatively
common and must be differentiated from a large secondary
center of ossification, the secondary navicular, or a smaller
one, the os tibiale externum. Vertical or transverse fractures
are the result of major trauma.
Fractures of the navicular bone are most commonly avul-
sions of the dorsal cortex (Figure 12-15A) or superior proxi-
mal corner of the bone as seen on the lateral view. The latter
must be differentiated from an accessory center of ossifica-
tion, the os supranaviculare, which occurs in the same posi-
tion (Figure 12-15B). Fractures of the proximal pole run in
coronal plane (Figure 12-15C) and must be distinguished
from the os tibiale externum (Figure 12-15D) that lies in
this same position (arrow). In this case the os tibiale exter-
num is multipartite.
Cuboid.  Fractures of the cuboid bone occur at the lateral
on the lateral view. The commonly occurring os peroneum
in the peroneus longus tendon at the lateral and inferior
margin of the cuboid should not be mistaken for a fracture

Lisfranc fracture-dislocation. Tarsometatarsal fracture-

FIGURE 12-10  The principal anatomic features of the hindfoot
are shown by CT. M, Medial malleolus; L, lateral malleolus; T, talus;
C, calcaneus; black arrows, subtalar joint; white arrow, peroneal
tendons.
dislocations are frequent injuries. The forefoot is locked into
distal row of tarsal bones. The middle cuneiform is shorter
than the medial and lateral cuneiforms that form a recess into
which extends the base of the second metatarsal, locking the
forefoot into the distal row of the tarsal bones. A fracture of
the base of the second metatarsal is necessary to dislocate the
forefoot at the tarsometatarsal joints.

Tibia

Talus Fibula

MF

MF PF
Sustentaculum
PF
FPB
FLH
FPL *
Calcaneus

A B
FIGURE 12-11  A, Anatomic drawing of the hindfoot in the coronal projection. B, The anatomic features of a compression fracture of the
calcaneus in this projection.

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 The Foot     217

A B C
FIGURE 12-12  The lateral cortex is comminuted, and the sustentaculum tali is fractured. CT in the axial plane (A) with 2-D reconstruction in
the sagittal and coronal planes (B) is required for full evaluation.

A B
FIGURE 12-13  Fractures of the talus. (A) Small avulsions may occur from the neck or head of the talus. Fractures of the neck or body of the
talus are in the coronal plane, and 50% are associated with subtalar dislocations (B) or dislocations of the body of the talus.

A B C
FIGURE 12-14  Fractures of the posterior tuberosity (A) are to be distinguished from a common accessory center of ossification, the os trigo-
num (B). Fractures of the lateral process of the talus (also known as snowboarder’s fractures) lie beneath the distal tip of the lateral malleolus as
seen on the AP view of the ankle (C).

A B C D
FIGURE 12-15  Navicular fractures. Fractures of the navicular bone are most commonly avulsions of the dorsal cortex (A) or superior proximal
corner of the bone as seen on the lateral view. The latter must be differentiated from an accessory center of ossification, the os supranavicu-
lare, that occurs in the same position (B). Fractures of the proximal pole run in coronal plane (C) and must be distinguished from the os tibiale
externum (D) that lies in this same position (arrow). In this case the os tibiale externum is multipartite.

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218      The Foot
FIGURE 12-16  Cuboid fractures. The commonly occurring os
peroneum in the peroneus longus tendon at the lateral and inferior
margin of the cuboid should not be mistaken for a fracture.
A B
Homolateral
FIGURE 12-18  Lisfranc fracture-dislocations are of two types: homolateral (all displaced in the same direction, usually lateral) and diver-
gent (the first metatarsal displaced medially and the second through fifth metatarsals displaced laterally). Fractures of the neck of the second
through fourth metatarsals are frequent.
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The normal alignment of the tarsometatarsal joints as seen
on the AP (Figure 12-17A) view of the foot shows that the
lateral cortex of the base of the first MT aligns with the lateral
cortex of the medial cuneiform and that the medial cortex of
the base of the second metatarsal aligns with the medial cortex
of the middle cuneiform. Note there is a slight normal sepa-
ration between the bases of the first and second metatarsals
and the subjacent medial and middle cuneiforms, more so
than that between the remaining tarsometatarsal joints. The
internal oblique (Figure 12-17B) shows that the medial cor-
tex of the base of the third metatarsal aligns with the medial
cortex of the lateral cuneiform and that the medial cortex at
the base of the fourth metatarsal aligns with the medial cortex
of the cuboid.
Lisfranc fracture-dislocations (Figure 12-18) are of two
types: homolateral (all displaced in the same direction, usually
lateral) and divergent (the first metatarsal displaced medially
and the second through fifth metatarsals displaced laterally).
Fractures of the neck of the second through fourth metatarsals
are frequent.
FIGURE 12-17  Lisfranc fracture-dislocation. 
(A) The normal alignment of the tarsometatarsal
joints as seen on the AP view of the foot shows
that the lateral cortex of the base of the first MT
aligns with the lateral cortex of the medial cunei-
form and that the medial cortex of the base of the
second metatarsal aligns with the medial cortex
of the middle cuneiform. The internal oblique (B)
shows that the medial cortex of the base of the
third metatarsal aligns with the medial cortex of
the lateral cuneiform and that the medial cortex
at the base of the fourth metatarsal aligns with
the medial cortex of the cuboid.
Divergent
 The Foot     219

A homolateral Lisfranc dislocation is shown. The PA view
(Figure 12-19A) shows lateral dislocation of all five metacarpals
and fracture of neck of second and third MTs. The lateral view
(Figure 12-19B) shows disruption of fourth and fifth MTT joints
with overlap of the base of the metatarsals and cuboid bone, and
the 3-D reconstruction (Figure 12-19C) clearly demonstrates a
dorsal dislocation of third, fourth, and fifth metatarsals.
Less-extensive injuries with minimal displacement are eas-
ily overlooked. Always look closely at the bases of the first and
second metatarsals and adjacent cuneiforms for evidence of
small avulsions and/or malalignment of metatarsals and adja-
cent tarsal bones and joint space widening between the first
and second metatarsals and cuneiforms. Weight-bearing AP
view may accentuate the widening (see Figure 12-26). CT may
be required to establish the diagnosis convincingly.
A minimal Lisfranc dislocation is shown in Figure 12-20.
Note the slight widening of the space between the base of the
second MT and the medial cuneiform (Figure 12-20A), the small
bone fragment in this space (Figure 12-20B), and the misalign-
ment of the base of the first and second MTs (Figure 12-20C).

Subtalar dislocation.  In its pure form, subtalar dislocation

of the foot consists of simultaneous dislocations of the
talocalcaneal and talonavicular joints. They are caused
by landing on the inverted foot in a fall or after jumping.
The medially displaced calcaneus and navicular bone are
accompanied by the forefoot. The ankle mortise remains
intact. The diagnosis of subtalar dislocation is best made on
the AP view of the ankle (Figure 12-21A). The talotibial joint
(ankle mortise) is undisturbed, while the calcaneus is inverted
and displaced medially leaving an unusually clear view of
the lateral process of the talus. On the AP view of the foot
(Figure 12-21B) the calcaneus remains aligned with the bones of
the foot, and the talonavicular and talocalcaneal joints are clearly
disrupted. On the lateral view of the ankle (Figure 12-21C) one
can confirm that the subtalar joint is disrupted, as evidenced by
A asymmetrical narrowing of the joint space and malalignment of
the opposing surfaces of the posterior facet. Note the fracture
of the neck of the talus. Subtalar dislocations are frequently
accompanied by fractures of the neck of the talus.

Chopart’s dislocation. Simultaneous dislocations of the

B C
FIGURE 12-19  A homolateral Lisfranc dislocation. The PA view (A)
shows lateral dislocation of all five metacarpals and fracture of neck
of second and third MTs. The lateral view (B) shows disruption of
fourth and fifth MTT joints with overlap of the base of the metatar-
sals and cuboid bone, and the 3-D reconstruction (C) clearly demon-
strates a dorsal dislocation of third, fourth, and fifth metatarsals.
Chopart’s joint between the midfoot and hindfoot involving
the talonavicular and calcaneocuboid joints are quite
uncommon.
3. Common sites of injury in children
and adolescents
Metatarsal
Bunk bed fracture (buckle fracture base of first MT)
Apophysis base of fifth MT (do not mistake for fracture)

A B C
FIGURE 12-20  A minimal Lisfranc dislocation. A, B, Note the slight widening of the space between the base of the second MT and the
medial cuneiform, the small bone fragment in this space, and the misalignment of the base of the first and second MTs with their adjacent
cuneiforms. (C) Axial CT demonstrates lateral subluxation of the first and second MTs.

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220      The Foot

Phalanges epiphyseal separations of the phalanx are common. The epiph-

Salter-Harris types 1 and 2 epiphyseal separation
Calcaneus
Under age 14 – extraarticular fx of tuberosity
Over age 14 – adult pattern intraarticular compression fx
Talus
Nondisplaced fx of neck of talus; may be torus or
buckle-type fx
Pattern of search in children.  Diagrams of the foot (Figures
12-22A and 12-22B) pinpoint the common sites of fracture in
children. The most common sites of fracture are identified by
broad red lines. Less common sites are designated by fine red
lines. Your pattern of search should include all sites.
Fractures of the phalanges and metatarsals are commonly
greenstick or torus-type fractures. Salter-Harris type 1 or 2
ysis of the proximal phalanx of the great toe may be bifid, which
should not be misconstrued as a fracture.
Fractures of the phalanges.  A “buckle-type” fracture of the
proximal phalanx of the fifth toe is shown in Figure 12-23A.
Note buckling of the lateral cortex of the metaphysis and
incomplete fracture of the metaphysis medially. Compare
normal fifth digit (Figure 12-23B) with Figure 12-23A. “The
stubbed toe” fracture is a Salter-Harris type 1 or 2 epiphyseal
separation of the terminal phalanx of the great toe (Figures
12-23C and 12-23D). Note the widening of the physis of the
terminal phalanx. The physis lies against the nail bed, and
plantarflexion of the stubbed toe results in an open injury
that may ultimately develop osteomyelitis. Remind referring
physicians of this potential complication.

A B C
FIGURE 12-21  Subtalar dislocation.  AP view of ankle (A) shows ankle mortise intact and calcaneus is inverted and displaced medially. Note
also clear view of lateral process of talus. On the AP view of the foot (B), the calcaneus remains aligned with the bones of the foot, and the
talonavicular and talocalcaneal joints are clearly disrupted. On the lateral view of the ankle (C), one can confirm that the subtalar joint is dis-
rupted as evidenced by asymmetrical narrowing of the joint space and malalignment of the opposing surfaces of the posterior facet.

FIGURE 12-22  Diagrams of the foot (A, B) pinpoint the common sites of fracture in children.

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 The Foot     221

Fractures of the metatarsals.  “Bunk bed” fracture, a buckle-
type fracture of the base of the first MT, is so characterized
by the buckle-like distortion of the medial cortex of the
proximal metaphysis (arrow) (Figure 12-24A). Compare
with appearance of a normal first MT (Figure 12-24B). The
apophysis at the base of the fifth metatarsal can easily be
4. Injuries likely to be missed
Minimally displaced Lisfranc fracture-dislocations
Fracture of adjacent metatarsals
Subtle nondisplaced fractures of base of metatarsals
Lateral process fractures of talus (snowboarder’s fx)
  

mistaken for a fracture (Figure 12-24C). This apophysis is
characteristically elongate and aligned with long axis of the
metacarpal as shown. The apophysis will more than likely be
bilateral. If there is any question about this diagnosis, compare
with radiographs of the opposite side.
Fractures of the tarsal bones are uncommon in children.
Prior to age 14 extraarticular fractures of the calcaneal tuber-
osity occur that spare the posterior facet. After age 14 the adult
patterns of calcaneal fractures appear.
Nondisplaced and incomplete fractures of the talar neck
may occur that are identified by disruption or distortion of
the dorsal cortex (see Figure 12-28A). Buckle impaction-type
fractures also occur, which distorts the normal concave cur-
vature of the talar neck cortex as seen on the lateral view. To
confirm the diagnosis, obtain radiographs of the opposite for
comparison. Obtain CT with 2-D sagittal reconstruction for
those who may still doubt your diagnosis.
Know what injuries you are likely to miss and make it a
point to look for them. In every body part there are a few inju-
ries that tend to be overlooked. Learn what these injuries are
and look for them. After you have viewed the radiographs and
found no abnormality, take a second look, looking specifically
for these commonly missed injuries. Your confidence in and
the accuracy of your interpretations are sure to improve.
In the foot, fractures of adjacent metatarsals may be over-
looked. Multiple simultaneous fractures of the metatarsals are
common. The AP view of the foot (Figure 12-25A) shows only a
fracture of the neck of the fourth MT. Oblique views are required
to avoid oversights. In this case an oblique view (Figure 12-25B)
reveals additional fractures of the necks of the third and fifth
MTs. Fractures of the base and neck of metatarsals may be subtle
nondisplaced linear fractures. If you see a fracture of a metacar-
pal, look closely at the adjacent metatarsals for additional frac-
tures in the same area as the original metacarpal fracture.

A B C D
FIGURE 12-23  Fractures of the phalanges.  A, A “buckle-type” fracture of the proximal phalanx of the fifth toe. Compare to normal fifth digit
(B). “The stubbed toe” fracture is a Salter-Harris type 1 or 2 epiphyseal separation of the terminal phalanx of the great toe (C, D).

A B C
FIGURE 12-24  Fractures of the metatarsals.  A, “Bunk bed” fracture, a buckle-type fracture of the base of the first MT, is so characterized
by the buckle-like distortion of the medial cortex of the proximal metaphysis (arrow). Compare to appearance of a normal first MT (B). The
apophysis at the base of the fifth metatarsal can easily be mistaken for a fracture (C).

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222      The Foot
Fractures of the lateral process of the talus can be obscure.
Look again specifically at this structure on the AP and oblique
views of the ankle for evidence of fracture.
Lastly, look again at the space between the bases of the first
and second metatarsals and adjacent cuneiforms for evidence
of Lisfranc fracture-dislocation manifest by widening of the
space between adjacent bones or malalignment of the meta-
tarsals and adjacent cuneiform bones. If there should be any
question about the diagnosis of a Lisfranc dislocation, the
findings may be accentuated by obtaining a weight-bearing
AP view of the foot with the patient standing.
Note the slight separation between the base of the sec-
ond MT and the medial cuneiform on this standard AP view
(Figure 12-26A). There is also minimal lateral displacement of
the second MT in relation to the medial cortex of the middle
cuneiform. A weight-bearing AP view of the foot was obtained
and makes the findings more obvious and more convincing;
the space between the second MT and medial cuneiform is
now definitely wider, and the offset of the second MT is
greater (Figure 12-26B). Note also the lateral offset of the first
MT relative to the lateral cortex of the medial cuneiform. The
correct diagnosis is a homolateral subluxation of the first, sec-
ond, and third metatarsals.
A B
FIGURE 12-25  In the foot, fractures of adjacent metatarsals may
be overlooked. Multiple simultaneous fractures of the metatarsals
are common. The AP view of the foot (A) shows only a fracture of the
neck of the fourth MT. Oblique views are required to avoid over-
sights. In this case an oblique view (B) reveals additional fractures of
the necks of the third and fifth MTs.
A B
FIGURE 12-26  Note the slight separation between the base of the
second MT and the medial cuneiform on this standard AP view (A).
A weight-bearing AP view of the foot was obtained and makes the
findings more obvious and more convincing; the space between the
second MT and medial cuneiform is now definitely wider, and the
offset of the second MT is greater (B).
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5. Where else to look when you see
something obvious
Obvious Look for
Fx metatarsal Fxs adjacent metatarsals
Compression fx calcaneus Similar Fx opposite calcaneus
Compression fx thoracolumbar
spine
Certain injuries tend to occur in relation with other inju-
ries. When you see one of these injuries, you should auto-
matically look for evidence of the other. You should not
stop when you identify one of these injuries and fail to look
for the other. This phenomenon is known as “satisfaction
of search.” You are so satisfied and so pleased to find one
injury that you fail to look for the well-known associated
injuries. In the foot, simultaneous fractures of adjacent
metatarsals are frequent. Having found a fracture of one
metatarsal, be sure to look at the adjacent metatarsals for
additional fractures.
In 10% to 12% of compression fractures of the calcaneus,
there is a similar fracture of the opposite calcaneus and/or a
fracture or fracture-dislocation of the thoracolumbar spine.
Simultaneous fractures of the right (Figure 12-27A) and left
(Figure 12-27B) calcanei and the second lumbar vertebra
(Figure 12-27C) are shown in this 37-year-old man who fell
from a significant height. There are symmetrical tongue-type
compression fractures of both calcanei (Figures 12-27A and
12-27B). Note anterior wedged compression fracture of the
second lumbar vertebral body (Figure 12-27C).
Avoid oversights. Be certain to rule out such injuries, at
least clinically, and obtain radiographs of the opposite foot or
CT of the thoracolumbar spine in those with any suggestion
of injury at these sites.
6. Where to look when you see nothing at all
Lisfranc fracture-dislocation
Fine nondisplaced fracture of the neck of the talus
Fine nondisplaced fracture of anterior process of calcaneus
Subtle, fine fracture of neck or base of metatarsals
If questionable radiographic findings – CT to clarify
abnormality
If radiographs negative – MRI to identify ligament tears,
tendon injuries, and bone contusions
A referring physician asks that you review the radiographs
on a youngster who had sustained an injury some 5 days
previously. You pull up the films and the request. The his-
tory given was simply, “Tripped, c/o pain in foot.” The ini-
tial radiographs were interpreted as negative, but the patient
continues to complain of pain. Your first response should be
to ask where the patient hurts. Knowing where the patient
hurts directs your attention to the area of injury and away
from any dubious radiographic findings outside of the area
in question. You are told the patient hurts over the dorsum
of the midfoot. You look in this area on the lateral view of the
foot and note a defect in the superior cortex of the neck of
the talus (Figure 12-28A), suggesting the possibility of a talar
neck fracture. This might be easily overlooked if you were not
directed to it by an appropriate history. Questionable findings
 The Foot     223

A B C
FIGURE 12-27  In 10% to 12% of compression fractures of the calcaneus, there is a similar fracture of the opposite calcaneus and/or a fracture
or fracture-dislocation of the thoracolumbar spine. Simultaneous fractures of the right (A) and left (B) calcanei and the second lumbar vertebra
(C) are shown in this 37-year-old man who fell from a significant height.

A B C
FIGURE 12-28  The lateral view of the foot shows a defect in the superior cortex of the neck of the talus (A), suggesting the possibility of a
talar neck fracture. This might be easily overlooked if you were not directed to it by an appropriate history. A fracture of the talar neck is con-
firmed on the CT sagittal 2-D (B) and CT coronal 2-D (C) reconstructions.

in the phalanges and metacarpal bones can often be clarified
by simply repeating the radiographic examination of the area
in question. However, if questionable uncertain radiographic
findings are noted in the tarsal bones, it is best to obtain CT
with 2-D image reconstruction to clarify the abnormality.
Therefore, a CT examination was suggested for clarification.
A fracture of the talar neck is confirmed on the CT sagittal
2-D (Figure 12-28B) and CT coronal 2-D (Figure 12-28C)
reconstructions.
If radiographs are truly negative, an MRI is required to
identify otherwise nonapparent ligament tears, tendon inju-
ries, and bone contusions.

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