X-Ray Analysis — Left Foot (46F, Post-Fall)

Views Provided

• Lateral view (Image 1)
• Dorsoplantar (DP) views (Images 2 & 3)

Radiological Findings

• Bony architecture of the ankle, hindfoot (calcaneus, talus), midfoot, and forefoot appears intact
• No obvious cortical disruption of the calcaneus or talus
• No significant step-off or angulation at the ankle mortise
• Soft tissue swelling may be present (clinically reported)

• All 5 metatarsals are visible; no obvious acute fracture line seen in the metatarsal shafts or necks
• The metatarsal cascade (relative lengths) appears preserved
• Tarsometatarsal (Lisfranc) joints appear congruent — no obvious diastasis between 1st and 2nd metatarsal bases
• Phalangeal bones appear intact
• Key area to scrutinize: The base of the 5th metatarsal — the tuberosity at the lateral border should be assessed for an avulsion fracture (Jones fracture zone), which is a common missed injury in inversion mechanism falls
• The navicular bone cortex appears intact
• No osteolytic or sclerotic lesions suggesting pathological fracture

Impression: No gross acute fracture is definitively visualized on these views. However, subtle fractures (avulsion at 5th MT base, stress fracture, navicular fracture) can be occult on initial plain films.

Clinical Assessment

• Tenderness at the base of the 5th metatarsal ✓ (check)
• Tenderness at the navicular ✓ (check)
• Inability to bear weight for 4 steps

Differential Diagnosis

Management Recommendations

1. Assess Ottawa Rules compliance — if criteria met, X-rays already obtained ✓
2. Palpate specifically: base of 5th MT, navicular, Lisfranc point (2nd MT base/medial cuneiform)
3. Weight-bearing status assessment

• RICE — Rest, Ice, Compression, Elevation for 24–48 hrs
• NSAIDs — Ibuprofen 400 mg TDS or Diclofenac 50 mg BD for analgesia
• Below-knee compression bandage / walking boot for comfort
• Follow-up X-ray at 10–14 days if pain persists (periosteal reaction becomes visible)
• Consider CT or MRI if high clinical suspicion of navicular stress fracture or Lisfranc injury despite normal X-ray

• Symptomatic treatment — firm-soled shoe or walking boot, weight-bearing as tolerated
• Analgesia; healing typically in 6–8 weeks

• Non-weight-bearing cast for 6–8 weeks OR early surgical fixation (especially in active patients)
• Higher non-union risk

Red Flags to Rule Out

• Lisfranc injury (requires weight-bearing X-rays for definitive assessment — do not miss)
• Any talar dome osteochondral injury (may need MRI)
• Compartment syndrome (unlikely given mild presentation, but monitor for worsening pain/tightness)

Sesamoid Bones of the 1st Metatarsal

• Two small, rounded bones embedded within the tendons of the flexor hallucis brevis muscle
• Designated as the medial (tibial) sesamoid and lateral (fibular) sesamoid
• Sit in grooves on the plantar surface of the 1st metatarsal head

• On the dorsoplantar view, they are seen end-on/plantar to the 1st MTP joint, producing the classic two round opacities
• They are part of the normal foot anatomy — present in virtually all individuals

• Act as a pulley for the flexor hallucis brevis tendons
• Absorb weight-bearing stress under the 1st MTP joint (bear ~50% of body weight during push-off)
• Protect the flexor hallucis longus tendon running between them

• In this patient's X-ray, both sesamoids appear intact and in normal position — no fracture, fragmentation, or proximal migration
• Sesamoid fractures (from direct trauma or stress) and sesamoiditis can occur but typically present with plantar 1st MTP tenderness
• Bipartite sesamoid (congenital division into two fragments) is a common normal variant (~10–30% of people), distinguished from fracture by smooth, corticated edges

1. Osteoporotic look?
   • On these foot films, I do not see clear severe generalized osteopenia/osteoporosis pattern.
   • But plain X-ray is not reliable to diagnose osteoporosis.
   • Best test is DEXA (hip/spine ± wrist), not foot X-ray (Bailey & Love, p. 533).
2. Base of 5th metatarsal osteophytes?
   • At the tuberosity/base of the 5th metatarsal, I do not see a definite acute fracture.
   • There appears to be a small cortical prominence/spur-like irregularity near the 5th metatarsal-cuboid region that could represent mild degenerative enthesopathic/osteophytic change rather than trauma.
   • No obvious displaced fragment or clear transverse lucent fracture line in the provided views.

• This looks more like minor chronic degenerative change than a new major bony injury at the 5th base.
• If point tenderness is exactly over the 5th base and pain persists, repeat X-ray in 10-14 days or CT can exclude a subtle occult fracture.