Foot fractures on X-ray

Written by the X-Ray Atlas editorial team from the sources listed below · Medical review pending · Updated 24 October 2026 · Level: Intermediate

The foot contains 26 bones and many small joints, and most foot films are taken for minor injuries. Three injuries deserve particular attention because they are common, easy to miss and costly when missed: the Lisfranc (tarsometatarsal) injury, fractures at the base of the 5th metatarsal (where location determines prognosis), and calcaneal fractures, which often look subtle but signal a high-energy mechanism. This guide covers the views, the alignment rules and the measurements.

1. Views and how to look

A standard foot series is a dorsoplantar (DP, the AP of the foot) and an oblique. A lateral is added for the hindfoot and midfoot, and dedicated calcaneal views (lateral and axial) are used when heel injury is suspected. Weight-bearing views are valuable for subtle Lisfranc injuries. The Ottawa foot rules guide who needs imaging: tenderness at the base of the 5th metatarsal or the navicular, or inability to bear weight.

Read the foot in zones:

1. Hindfoot: calcaneus and talus (mainly on the lateral and axial views).
2. Midfoot: navicular, cuboid and the three cuneiforms, and the tarsometatarsal (Lisfranc) joints.
3. Forefoot: metatarsals, phalanges and sesamoids.
4. Alignment: check each tarsometatarsal joint on both DP and oblique views.
5. Soft tissues: swelling, gas and foreign bodies.

2. Lisfranc injury

The Lisfranc joint complex is the tarsometatarsal joint line. The base of the 2nd metatarsal is recessed between the cuneiforms like a keystone, and the Lisfranc ligament runs from the medial cuneiform to the base of the 2nd metatarsal. Injuries range from subtle ligament sprains to obvious fracture-dislocations, and they follow both high-energy trauma and simple twisting injuries (for example a misstep off a kerb, or a footballer whose foot is trodden on).

Signs of injury:

• Step or offset at the medial border of the 2nd metatarsal base, even of a millimetre or two.
• Widening of the gap between the 1st and 2nd metatarsal bases, or between the medial and intermediate cuneiforms.
• The "fleck sign": a small avulsion fragment in the space between the 1st and 2nd metatarsal bases, from the Lisfranc ligament.
• Fractures of the metatarsal bases or the cuboid ("nutcracker" fracture).

3. 5th metatarsal base fractures

The site of the fracture matters, because the blood supply to the proximal 5th metatarsal is poor at the junction of the metaphysis and diaphysis.

Zone	Fracture	Features	Healing
1. Tuberosity	Avulsion fracture ("pseudo-Jones")	The commonest type. From an inversion injury, with pull from peroneus brevis or the lateral band of the plantar fascia. Usually transverse across the tuberosity.	Usually good with symptomatic treatment
2. Metaphyseal-diaphyseal junction	Jones fracture	About 1.5–3 cm distal to the tip of the tuberosity, at the level of the 4th–5th intermetatarsal joint	Watershed blood supply: higher risk of delayed union or non-union; often managed more cautiously or surgically
3. Proximal diaphysis	Stress fracture	Distal to the Jones zone, often with prodromal pain, cortical thickening or periosteal reaction	High non-union risk

In children aged about 9–14, the apophysis of the 5th metatarsal base is a classic fracture mimic. It is a thin sliver of bone lying along the lateral side of the tuberosity, and its lucent line runs parallel to the shaft. Fractures usually run transversely across it. The os peroneum, a sesamoid in the peroneus longus tendon near the cuboid, is another mimic.

4. Calcaneal fractures

The calcaneus is the most commonly fractured tarsal bone. Most calcaneal fractures follow an axial load, typically a fall from height landing on the heels, and most are intra-articular, involving the posterior facet of the subtalar joint. The film can be deceptive: the calcaneus may look only slightly flattened.

CT is the standard for characterising intra-articular calcaneal fractures. Because of the axial loading mechanism, look for associated injuries:

• a fracture of the other calcaneus;
• a lumbar or thoracolumbar spine fracture (reported in about 10% of cases), see thoracolumbar spine fractures;
• pilon, tibial plateau and hip fractures.

Extra-articular calcaneal fractures include the anterior process fracture (from inversion; often mistaken for a sprain) and avulsion of the posterior tuberosity by the Achilles tendon, which can threaten the skin of the heel.

5. Other foot injuries

• Metatarsal shaft fractures: from crush injury or twisting. Multiple adjacent metatarsal fractures should prompt a careful look at the Lisfranc joint.
• Metatarsal stress fracture ("march fracture"): usually the 2nd or 3rd metatarsal neck or shaft, in walkers, runners and military recruits. The film is often normal initially. Periosteal reaction and callus may appear after about 2–3 weeks. MRI is more sensitive early.
• Talar fractures: talar neck fractures follow forced dorsiflexion and carry a risk of AVN of the talar body; the lateral process and posterior process fractures are subtle.
• Navicular fractures: including dorsal avulsions and stress fractures of the body, which are frequently occult on plain film.
• Toe fractures and dislocations are common; check the joints on the oblique view.
• Sesamoid fractures under the 1st metatarsal head must be distinguished from a bipartite sesamoid, which has smooth, rounded edges and is often bilateral.

6. Accessory ossicles and mimics

The foot has many normal accessory bones and sesamoids. They are distinguished from fractures by being smooth, rounded and fully corticated, often bilateral, and in typical locations. Acute fracture fragments have sharp, irregular, uncorticated edges and a matching defect in the parent bone.

Ossicle	Location	Mimics
Os trigonum	Behind the talus	Posterior process fracture
Os naviculare (accessory navicular)	Medial to the navicular tuberosity	Navicular avulsion
Os peroneum	Lateral to the cuboid	Cuboid or 5th metatarsal base fracture
Os vesalianum	Next to the 5th metatarsal base	5th metatarsal avulsion

Red flags: act now

What to focus on, by role

Role	Priorities
Medical student	The 2nd metatarsal–intermediate cuneiform alignment, avulsion vs Jones fracture, and Böhler's angle.
Nurse / ENP	Apply the Ottawa foot rules, recognise the 5th metatarsal base fractures and the apophysis mimic, and flag midfoot swelling.
Junior doctor	Check Lisfranc alignment on every foot film, measure Böhler's angle, and image the spine after a heel fracture from height.
Radiographer	Good DP and oblique views; consider weight-bearing views when local protocols allow for suspected Lisfranc injury; calcaneal axial views.
Advanced / FRCR	Subtle Lisfranc diastasis, talar and navicular fractures, Gissane angle and accessory ossicles.

Practise on real lower limb X-rays →

References

1. Radiopaedia. Lisfranc injury. radiopaedia.org
2. Radiopaedia. Böhler angle. radiopaedia.org
3. Bachmann LM, et al. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ 2003;326:417. bmj.com
4. British Orthopaedic Association. BOAST guidelines. boa.ac.uk
5. Radiology Masterclass. Musculoskeletal X-ray tutorials. radiologymasterclass.co.uk

For education only. Not a substitute for a formal report, senior review or your local policy. Never use this page to make decisions about a real patient.