Toes, Calcaneus and Foot Anatomy PDF

THE TOES, CALCANEUS AND FOOT  FOOT ANATOMY:  26 Bones in the foot  Forefoot – Metatarsals & Phalanges  Midfoot – Navicular, Cuboid & Medial, Intermediate and lateral Cuneiforms  Hindfoot – Calcaneus & Talus FOOT ANATOMY: THE JOINTS:...

THE TOES, CALCANEUS AND FOOT  FOOT ANATOMY:  26 Bones in the foot  Forefoot – Metatarsals & Phalanges  Midfoot – Navicular, Cuboid & Medial, Intermediate and lateral Cuneiforms  Hindfoot – Calcaneus & Talus FOOT ANATOMY: THE JOINTS: DIP: Distal interphalangeal joint PIP: Proximal interphalangeal joint MTP: Metatarsophalangeal joint TMT: Tarsometatarsal joint Subtalar Joint: between the inferior surface of the Talus and the superior surface of the Calcaneus. THE TARSAL BONES: FOOT MOVEMENTS: Positioning terminology: Medial rotation Lateral rotation Dorsiflexion Plantarflexion THE TOES INDICATIONS:  Trauma  Cuts  Pain  Bruising  Lumps  Loss of function  Foreign Body  Deformity  Swelling  Reduced Range of Movement (ROM)  Infections PREPARATION:  Correct Patient Identification  Pregnancy Check (if applicable)  Explanation of Procedure  Remove shoes, socks and jewellery (anklets, toe rings etc..)  Patient to sit or lay on the xray table  Lead apron / radiation protection  AP TOE: Xray: AP Toes kVp: 52kVp mAs: 2.5mAs FFD: 100-110cm (depending on system) CR: 24x30 plate DR: Imaging Receptor Cassette: Long axis of image receptor parallel with long axis of the foot Centre: Centre to the MTP joint of interest Collimation: To include a digit either side of the digit of interest Include all distal phalanx and distal metatarsal Pt sitting or supine on table with legs extended Patient Position: Flex knee so the foot of interest is flat on the image receptor Uncurl toes if possible (if Pt can’t uncurl toes an angle of 15deg may be used) 15-degrees Merrills Radiographic Positioning EVALUATION CRITERIA AP TOES:  Regional anatomy included – tip of digits to distal metatarsals, including soft tissue  Digits free of superimposition  No rotation – symmetry  Shafts equally concave on both sides  Metatarsophalangeal and interphalangeal joints open  Density and contrast optimal to visualise bone & soft tissue, no https://radiopaedia.org/articles/toes-ap-view-2 motion  AP MEDIAL OBLIQUE: Xray: AP Oblique Toes kVp: 52kVp mAs: 2.5mAs FFD: 100-110cm (depending on system) CR: 24x30 plate DR: Imaging Receptor Cassette: Long axis of image receptor parallel with long axis of the foot Centre: Center to the MTP joint of interest Collimation: To include a digit either side of the digit of interest Inclue all distal phalanx and distal metatarsal Pt sitting or supine on table with legs extended Patient Position: Flex knee so the foot of interest is flat on the image receptor Uncurl toes if possible Rotate foot 45deg medially (a radiographic positioning sponge may be added for support) Merrills Radiographic Positioning EVALUATION CRITERIA AP OBLIQUE TOES:  Regional anatomy included – tip of digits to distal metatarsals, including soft tissue  Digits free of superimposition  Metatarsophalangeal and interphalangeal joints open  Digit at 45o angle to show concavity on one side of the phalangeal shaft  Density and contrast optimal to visualise bone & soft tissue, no motion https://radiopaedia.org/articles/toes-oblique-view-1?lang=us  LATERAL 1st or 2nd TOE: Xray: Lateral 1st or 2nd Toes kVp: 52kVp mAs: 2.5mAs FFD: 100-110cm (depending on system) CR: 24x30 plate DR: Imaging Receptor Cassette: Long axis of image receptor parallel with long axis of the foot Centre: Center to the MTP joint of the 1st or 2nd toe Collimation: Include all distal phalanx and distal metatarsal Pt to lie on their unaffected lateral side Patient Position: Place the medial side of the 1st toe onto the image receptor To reduce superimposition tape other toes out of the way Bontrager’s Handbook of Radiographic Positioning and Techniques Merrill’s Atlas of Radiographic Positioning and Radiologic Procedures EVALUATION CRITERIA 1st or 2nd TOE:  Regional anatomy included – tip of digit to distal metatarsal, including soft tissue  Metatarsophalangeal and interphalangeal joints open  True lateral position – concave appearance of anterior surface of shaft of phalanges  Least possible overlap of other digits  Digit free of motion  Density and contrast optimal to visualise bone & soft tissue, no motion  LATERAL 3rd, 4th and 5th TOE: Xray: Lateral 3rd, 4th and 5th Toes kVp: 52kVp mAs: 2.5mAs FFD: 100-110cm (depending on system) CR: 24x30 plate DR: Imaging Receptor Cassette: Long axis of image receptor parallel with long axis of the foot Centre: Center to the MTP joint of the 3rd, 4th or 5th toe Collimation: Inclue all distal phalanx and distal metatarsal Pt to lie on their affected lateral side Patient Position: Place the lateral side of the foot on the image receptor To reduce superimposition tape other toes out of the way Merrill’s Atlas of Radiographic Positioning and Radiologic Procedures EVALUATION CRITERIA 3rd, 4th and 5th TOE:  Regional anatomy included – tip of digit to distal metatarsal, including soft tissue  Metatarsophalangeal and interphalangeal joints open  True lateral position – concave appearance of anterior surface of shaft of phalanges  Least possible overlap of other digits  Digit free of motion  Density and contrast optimal to visualise bone & soft tissue, no motion SESAMOIDS: THE FOOT  AP FOOT: Xray: AP Foot kVp: 52kVp mAs: 3.2mAs FFD: 100-110cm (depending on system) CR: 24x30 plate DR: Imaging Receptor Cassette: Long axis of image receptor parallel with long axis of the foot Centre: Center to the base of the 3rd metatarsal Collimation: Four sides to the outer margins of the foot (skin surface) Pt sitting or supine on table with legs extended Flex knee so the foot of interest is flat on the image receptor Patient Position: Uncurl toes if possible Central Ray 10-15deg towards the heel (posterior angle) Bontrager’s Handbook of Radiographic Positioning and Techniques EVALUTATION CRITERIA AP FOOT:  Regional anatomy included – visualize the phalanges and tarsals distal to the talus, including soft tissue  Digits free of superimposition  No rotation – symmetry  Shafts equally concave on both sides  Some overlap of 2nd-5th metatarsal bases  Metatarsophalangeal, interphalangeal and intertarsal joint spaces open  Density and contrast optimal to visualise bone & soft tissue, no motion https://radiopaedia.org/cases/normal-foot-x-rays  AP OBLIQUE FOOT: Xray: AP Oblique Foot kVp: 52kVp mAs: 3.2mAs FFD: 100-110cm (depending on system) CR: 24x30 plate DR: Imaging Receptor Cassette: Long axis of image receptor parallel with long axis of the foot Centre: Center to the base of the 3rd metatarsal Collimation: Four sides to the outer margins of the foot Pt sitting at table with legs extended Flex knee so the foot of interest is flat on the image receptor Rotate foot medially 45deg Patient Position: Uncurl toes if possible Immobilise with a radiographic positioning sponge Straight Central Ray Bontrager’s Handbook of Radiographic Positioning and Techniques EVALUATION CRITERIA AP OBLIQUE FOOT:  Regional anatomy included – tip of digits to distal tibia and fibula and calcaneus, including soft tissue  3rd-5th metatarsal bases free of superimposition  1st and 2nd metatarsal bases superimposed  Tuberosity of 5th metatarsal seen in profile  Cuboid clearly demonstrated  Metatarsophalangeal, interphalangeal and intertarsal joint spaces open  Density and contrast optimal to visualise bone & soft tissue, no motion https://radiopaedia.org/cases/normal-foot-x-rays  LATERAL FOOT: Xray: Lateral Foot kVp: 55kVp mAs: 3.2mAs FFD: 100-110cm (depending on system) CR: 24x30 plate DR: Imaging Receptor Cassette: Long axis of image receptor parallel with long axis of the foot Centre: Center to the base of the third metatarsal Collimation: Four sides to the outer margins of the foot Pt to lie on their affected lateral side Place the lateral side of the foot on the image receptor Patient Position: Dorsi flex foot to 90deg with ankle (where possible) Support knee with a sponge if needed Bontrager’s Handbook of Radiographic Positioning and Techniques EVALUATION CRITERIA LATERAL FOOT:  Regional anatomy included – tip of digits, distal tibia and fibula and calcaneus, including soft tissue  Metatarsals nearly superimposed  Tibiotalar joint open  Distal tibia and fibula superimposed  Density and contrast optimal to visualise bone & soft tissue, no motion Bontrager’s Handbook of Radiographic Positioning and Techniques WEIGHT BEARING FUNCTIONAL PROJECTIONS:  To assess alignment  AP demonstrates alignment of metatarsals and phalanges  Lateral demonstrates longitudinal arch (flat feet)  Bilateral is often done for comparison AP WEIGHT BEARING: Bontrager’s Handbook of Radiographic Positioning and Techniques LATERAL WEIGHT BEARING: Merrill’s Atlas of Radiographic Positioning and Radiologic Procedures  AXIAL CALCANEUS: Xray: Axial Calcaneus kVp: 60kVp mAs: 3.2mAs FFD: 100-110cm (depending on system) CR: 24x30 plate DR: Imaging Receptor Long axis of image receptor parallel with long axis of the tib/fib Cassette: It’s important to place the calcaneus on the lower aspect of the IR Center to the base of the 3rd metatarsal, to emerge just distal and inferior to Centre: ankle joint Collimation: Four sides to the outer margins of the calcaneus Pt supine on table Legs straight with ankle flexed at 90deg (bandage may help) Patient Position: Heel in contact with image receptor Central ray angled 40deg cephalic angle Bontrager’s Handbook of Radiographic Positioning and Techniques  EVALUATION CRITERIA AXIAL CALCANEUS:  Regional anatomy included – entire calcaneum and talocalcaneal joint  Talocalcaneal joint open  Density and contrast optimal to visualise bone & soft tissue, no motion  LATERAL (mediolateral) CALCANEUS: Xray: Lateral Calcaneus kVp: 55kVp mAs: 3.2mAs FFD: 100cm CR: 24x30 plate DR: Imaging Receptor Cassette: Long axis of image receptor parallel with long axis of the tib/fib Centre: Center 2.5cm distal to the medial malleolus Four sides to the outer margins of the calcaneus; include inferior and posterior margins Collimation: of the heel and medial malleolus to base of fifth metatarsal Roll Pt onto affected side Lateral aspect of the foot on the imaging receptor Patient Position: Flex ankle to 90deg Elevate knee slightly with a sponge (if needed) Bontrager’s Handbook of Radiographic Positioning and Techniques EVALUATION CRITERIA LATERAL CALCANEUS:  Regional anatomy included – calcaneus, distal tibia and fibula, navicular and cuboid, including soft tissue  Joint space between calcaneus and cuboid open  Talocalcaneal joint open  Lateral malleolus superimposed over the posterior half of the tibia and talus  Density and contrast optimal to visualise bone & soft tissue, no https://radiopaedia.org/articles/calcaneus-lateral-view-1 motion PATHOLOGY FRACTURES OF THE TOES: Jones fracture of the base of the 5th metatarsal. Be careful that apophysis is not mistaken for fracture in child https://radiopaedia.org/cases/base-of-5th-metatarsal- fracture-and-apophysis  CALCANEAL FRACTURE: https://www.footsurgeon.com.au/fracture-calcaneus-victorian-orthopaedic-foot- ankle-clinic.html https://radiopaedia.org/articles/calcaneal-fracture?lang=us LISFRANC FRACTURE:  Lisfranc is torn ligaments or broken bones in the mid foot area  Often from a crush injury to the mid foot. Eg. An object falling on the foot or a person landing on their feet after a fall from a height  Or from twising during a fall RHEUMATOID ARTHRITIS:  An autoimmune disease, which means that the immune system malfunctions and attacks the body instead of intruders.  Same radiographic appearance as hands  MTP Joints, particularly 5th  IP Joint 1st toe  Intertarsal joints https://radiopaedia.org/cases/rheumatoid-arthritis-foot OSTEOARTHRITIS:  Occurs when the smooth cartilage joint surface wears out. Osteoarthritis usually begins in an isolated joint  Degenerative joint disease  Same radiographic appearance as hands  MTP joint 1st toe affected  Hallux valgus deformity  GOUT:  Common but complex form of arthritis  Can affect anyone  Rare to see in acute phase  Extrinsic periarticular bony erosions with a distinctive lip of bone at the edge  In late stage joint space narrowing https://radiopaedia.org/cases/gout-feet  PLANTAR FASCIITIS:  Common cause of heel pain  Occurs when the band of tissue along the bottom of your foot (plantar fascia) gets irritated and inflamed  Risk factors include obesity, excessive running or standing  Often a heel spur is present and seen on xray https://radiopaedia.org/articles/plantar-calcaneal-spur PES PLANUS – FLAT FEET:  Also known as "fallen arches"  Longitudinal arch reduced on standing  Often seen by ankles rolled in towards each other  Causes  congenital  muscle weakness  Diagnosed: Bilateral AP & lateral weight bearing feet views HALLUX VALGUS DEFORMITY - BUNIONS  A bony bump that forms on the 1st toe  Lateral deviation of 1st toe occurs  Bilateral AP weight bearing views  More common in women REFERENCES:  Bontrager, K. L. (2005) Textbook of Radiographic Positioning and Related Anatomy. (6th edn.) St Louis: Mosby.  Eisenberg, R. L. (2003) Comprehensive Radiographic Pathology (3rd edn.) St Louis: Mosby.  McQuillen-Martensen, K. (1996) Radiographic Critique. Philadelphia : W.B. Saunders.  Weir, J. & Abrahams, S. P. (2003) Imaging Atlas of Human Anatomy (3rd ed). London: Mosby.  http://www.wikiradiography.net  https://radiopaedia.org  https://www.radiologymasterclass.co.uk/