ACR Appropriateness Criteria Acute Trauma to the Foot

Abstract

This ACR Appropriateness Criteria article offers imaging triage guidance for several variants of patients presenting with acute foot trauma. Patients meeting inclusion criteria for the Ottawa Rules should undergo a 3-view radiographic series. Diabetic patients with peripheral neuropathy should undergo radiography, even though they do not meet the Ottawa Rules inclusion criteria. Patients with suspected midfoot and/or Lisfranc injury should undergo 3-view radiographs with weight bearing on at least the anterior-posterior view. Patients with suspected Lisfranc injury and normal radiographs should be considered for MRI and CT on a case-by-case basis. MRI or ultrasound could confirm cases of suspected acute tendon rupture. Radiography is the initial imaging modality for suspected plantar plate injury after metatarsal-phalangeal joint injury. Weight-bearing anterior-posterior, lateral, and sesamoid axial views may detect proximal migration of the hallux sesamoids. Ultrasound or MRI can directly evaluate the capsuloligamentous complex, specifically the plantar plate. Radiography can detect radiopaque penetrating foreign bodies, and ultrasound can be helpful in detecting those that are nonradiopaque. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures, by the panel. In instances in which evidence is lacking or is not definitive, expert opinion may be used to recommend imaging and treatment.

Review article: Best practice management of common ankle and foot injuries in the emergency department (part 2 of the musculoskeletal injuries rapid review series)

“…1). At full text level 22 primary articles, 35 review articles 6, and 14 guidelines [68][69][70][71][72][73][74][75][76][77][78][79][80][81] were included. Articles assigned NHMRC level of evidence 11 by two authors independently (see page 15 of this reference for further details https://www.nhmrc.gov.au/_files_nhmrc/file/ guidelines/developers/nhmrc_levels_grades_evidence_120423.…”

Weight-bearing MR Imaging of Knee, Ankle and Foot

“…During interpretation, the radiologist must pay attention above all to changes in the bone alignment/ angulation and the width of the articular spaces. 4,[30][31][32][33] Flatfoot (pes planus) is a congenital or acquired deformity of the foot characterized by the collapse of the medial longitudinal arch; in adults, it is most frequently caused by the presence of a posterior tibial tendon dysfunction resulting in planovalgus deformity of the hindfoot. Flatfoot is assessed radiographically as a concave dorsal deviation of the midfoot evaluated on the weight-bearing lateral film, whereas the opposite condition, with dorsal convexity, is termed a cavus foot.…”

“…Weight-bearing imaging has also proved useful in clinical decision making about nonoperative treatment in isolated lateral malleolar fractures of the supination external rotation type, in particular, to evaluate fracture stability. 30,32,33 Hallux valgus is a deformity characterized by the lateral (valgus) deviation of the big toe at the metatarsophalangeal joint with concomitant medial (varus) deviation of the first metatarsal. Preoperative planning requires a weight-bearing (standing) dorsoplantar radiograph of the foot with the beam centered on the midfoot.…”

Computed Tomography in the Evaluation of Pediatric Trauma

“…Any extremity injury severe enough to prevent ideal positioning for sufficient radiographs likely warrants evaluation by CT. 59 Additionally, approximately 25% of foot fractures are missed by radiographs but found on CT. 60 Because fractures in the midfoot can be complex, a CT could be indicated if there is a strong suspicion for complex foot injury such as a Lisfranc injury or comminuted calcaneal fracture. 61 In a limping child less than 5 years old, there is almost no role for CT in the emergent setting. 62,63 SUMMARY The popular saying in pediatric medicine-"Children are not just little adults"-has a significant application in the use of CT imaging for trauma.…”