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Acute Trauma to the Foot

Variant: 1   Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules can be evaluated without exclusionary criteria. Ottawa rules are negative. No suspected abnormalities in regions not evaluated by the Ottawa rules. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
US foot Usually Not Appropriate O
Radiography foot Usually Not Appropriate ☢
MRI foot without and with IV contrast Usually Not Appropriate O
MRI foot without IV contrast Usually Not Appropriate O
CT foot with IV contrast Usually Not Appropriate ☢
CT foot without and with IV contrast Usually Not Appropriate ☢
CT foot without IV contrast Usually Not Appropriate ☢

Variant: 2   Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules can be evaluated without exclusionary criteria. Ottawa rules are positive. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Radiography foot Usually Appropriate ☢
Radiography foot with weightbearing Usually Appropriate ☢
US foot Usually Not Appropriate O
MRI foot without and with IV contrast Usually Not Appropriate O
MRI foot without IV contrast Usually Not Appropriate O
CT foot with IV contrast Usually Not Appropriate ☢
CT foot without and with IV contrast Usually Not Appropriate ☢
CT foot without IV contrast Usually Not Appropriate ☢

Variant: 3   Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules cannot be evaluated due to exclusionary criteria. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Radiography foot Usually Appropriate ☢
CT foot without IV contrast May Be Appropriate ☢
US foot Usually Not Appropriate O
MRI foot without and with IV contrast Usually Not Appropriate O
MRI foot without IV contrast Usually Not Appropriate O
CT foot with IV contrast Usually Not Appropriate ☢
CT foot without and with IV contrast Usually Not Appropriate ☢

Variant: 4   Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules can be evaluated without exclusionary criteria. Ottawa rules are negative. Suspected pathology in an anatomic area not addressed by Ottawa rules (not involving the midfoot; eg, metatarsal-phalangeal joint, metatarsal, toe, tendon, etc). Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Radiography foot Usually Appropriate ☢
Radiography foot with weightbearing Usually Appropriate ☢
CT foot without IV contrast May Be Appropriate (Disagreement) ☢
US foot Usually Not Appropriate O
Fluoroscopy foot Usually Not Appropriate ☢
MRI foot without and with IV contrast Usually Not Appropriate O
MRI foot without IV contrast Usually Not Appropriate O
CT foot with IV contrast Usually Not Appropriate ☢
CT foot without and with IV contrast Usually Not Appropriate ☢

Variant: 5   Adult or child older than 5 years of age. Acute trauma to the foot. Suspect Lisfranc injury, tendon injury, or occult fracture or dislocation. Radiographs are normal or equivocal. Next imaging study.
Procedure Appropriateness Category Relative Radiation Level
MRI foot without IV contrast Usually Appropriate O
CT foot without IV contrast Usually Appropriate ☢
US foot May Be Appropriate O
MRI foot without and with IV contrast Usually Not Appropriate O
CT foot with IV contrast Usually Not Appropriate ☢
CT foot without and with IV contrast Usually Not Appropriate ☢

Variant: 6   Adult or child older than 5 years of age. Acute trauma to the foot. Suspect penetrating trauma with a foreign body. Radiographs of the foot are negative. Next imaging study.
Procedure Appropriateness Category Relative Radiation Level
US foot Usually Appropriate O
MRI foot without IV contrast May Be Appropriate O
CT foot without IV contrast May Be Appropriate ☢
MRI foot without and with IV contrast Usually Not Appropriate O
CT foot with IV contrast Usually Not Appropriate ☢
CT foot without and with IV contrast Usually Not Appropriate ☢

Tetyana Gorbachova, MDa; Eric Y. Chang, MDb; Alice S. Ha, MD, MSc; Behrang Amini, MD, PhDd; Scott R. Dorfman, MDe; Michael G. Fox, MD, MBAf; Bharti Khurana, MDg; Alan K. Klitzke, MDh; Kenneth S. Lee, MD, MBAi; Pekka A. Mooar, MDj; Nehal A. Shah, MDk; Kaushal H. Shah, MDl; Adam D. Singer, MDm; Stacy E. Smith, MDn; Mihra S. Taljanovic, MD, PhDo; Jonelle M. Thomas, MD, MPHp; Mark J. Kransdorf, MDq.
Summary of Literature Review
Introduction/Background
Discussion of Procedures by Variant
Variant 1: Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules can be evaluatedwithout exclusionary criteria. Ottawa rules are negative. No suspected abnormalities in regions notevaluated by the Ottawa rules. Initial imaging.
Variant 1: Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules can be evaluatedwithout exclusionary criteria. Ottawa rules are negative. No suspected abnormalities in regions notevaluated by the Ottawa rules. Initial imaging.
A. Radiography Foot
Variant 1: Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules can be evaluatedwithout exclusionary criteria. Ottawa rules are negative. No suspected abnormalities in regions notevaluated by the Ottawa rules. Initial imaging.
B. CT Foot
Variant 1: Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules can be evaluatedwithout exclusionary criteria. Ottawa rules are negative. No suspected abnormalities in regions notevaluated by the Ottawa rules. Initial imaging.
C. MRI Foot
Variant 1: Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules can be evaluatedwithout exclusionary criteria. Ottawa rules are negative. No suspected abnormalities in regions notevaluated by the Ottawa rules. Initial imaging.
D. US Foot
Variant 2:  Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules can be evaluatedwithout exclusionary criteria. Ottawa rules are positive. Initial imaging.
Variant 2:  Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules can be evaluatedwithout exclusionary criteria. Ottawa rules are positive. Initial imaging.
A. Radiography Foot
Variant 2:  Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules can be evaluatedwithout exclusionary criteria. Ottawa rules are positive. Initial imaging.
B. Radiography Foot with Weightbearing
Variant 2:  Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules can be evaluatedwithout exclusionary criteria. Ottawa rules are positive. Initial imaging.
C. CT Foot
Variant 2:  Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules can be evaluatedwithout exclusionary criteria. Ottawa rules are positive. Initial imaging.
D. MRI Foot
Variant 2:  Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules can be evaluatedwithout exclusionary criteria. Ottawa rules are positive. Initial imaging.
E. US Foot
Variant 3: Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules cannot beevaluated due to exclusionary criteria. Initial imaging.
Variant 3: Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules cannot beevaluated due to exclusionary criteria. Initial imaging.
A. Radiography Foot
Variant 3: Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules cannot beevaluated due to exclusionary criteria. Initial imaging.
B. CT Foot
Variant 3: Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules cannot beevaluated due to exclusionary criteria. Initial imaging.
C. MRI Foot
Variant 3: Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules cannot beevaluated due to exclusionary criteria. Initial imaging.
D. US Foot
Variant 4:  Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules can be evaluatedwithout exclusionary criteria. Ottawa rules are negative. Suspected pathology in an anatomic area notaddressed by Ottawa rules (not involving the midfoot; eg, metatarsal-phalangeal joint, metatarsal, toe,tendon, etc). Initial imaging.
Variant 4:  Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules can be evaluatedwithout exclusionary criteria. Ottawa rules are negative. Suspected pathology in an anatomic area notaddressed by Ottawa rules (not involving the midfoot; eg, metatarsal-phalangeal joint, metatarsal, toe,tendon, etc). Initial imaging.
A. Radiography Foot
Variant 4:  Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules can be evaluatedwithout exclusionary criteria. Ottawa rules are negative. Suspected pathology in an anatomic area notaddressed by Ottawa rules (not involving the midfoot; eg, metatarsal-phalangeal joint, metatarsal, toe,tendon, etc). Initial imaging.
B. Radiography Foot with Weightbearing
Variant 4:  Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules can be evaluatedwithout exclusionary criteria. Ottawa rules are negative. Suspected pathology in an anatomic area notaddressed by Ottawa rules (not involving the midfoot; eg, metatarsal-phalangeal joint, metatarsal, toe,tendon, etc). Initial imaging.
C. CT Foot
Variant 4:  Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules can be evaluatedwithout exclusionary criteria. Ottawa rules are negative. Suspected pathology in an anatomic area notaddressed by Ottawa rules (not involving the midfoot; eg, metatarsal-phalangeal joint, metatarsal, toe,tendon, etc). Initial imaging.
D. MRI Foot
Variant 4:  Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules can be evaluatedwithout exclusionary criteria. Ottawa rules are negative. Suspected pathology in an anatomic area notaddressed by Ottawa rules (not involving the midfoot; eg, metatarsal-phalangeal joint, metatarsal, toe,tendon, etc). Initial imaging.
E. US Foot
Variant 4:  Adult or child older than 5 years of age. Acute trauma to the foot. Ottawa rules can be evaluatedwithout exclusionary criteria. Ottawa rules are negative. Suspected pathology in an anatomic area notaddressed by Ottawa rules (not involving the midfoot; eg, metatarsal-phalangeal joint, metatarsal, toe,tendon, etc). Initial imaging.
F. Fluoroscopy Foot
Variant 5: Adult or child older than 5 years of age. Acute trauma to the foot. Suspect Lisfranc injury,tendon injury, or occult fracture or dislocation. Radiographs are normal or equivocal. Next imaging study.
Variant 5: Adult or child older than 5 years of age. Acute trauma to the foot. Suspect Lisfranc injury,tendon injury, or occult fracture or dislocation. Radiographs are normal or equivocal. Next imaging study.
A. CT Foot
Variant 5: Adult or child older than 5 years of age. Acute trauma to the foot. Suspect Lisfranc injury,tendon injury, or occult fracture or dislocation. Radiographs are normal or equivocal. Next imaging study.
B. MRI Foot
Variant 5: Adult or child older than 5 years of age. Acute trauma to the foot. Suspect Lisfranc injury,tendon injury, or occult fracture or dislocation. Radiographs are normal or equivocal. Next imaging study.
C. US Foot
Variant 6: Adult or child older than 5 years of age. Acute trauma to the foot. Suspect penetrating traumawith a foreign body. Radiographs of the foot are negative. Next imaging study.
Variant 6: Adult or child older than 5 years of age. Acute trauma to the foot. Suspect penetrating traumawith a foreign body. Radiographs of the foot are negative. Next imaging study.
A. CT Foot
Variant 6: Adult or child older than 5 years of age. Acute trauma to the foot. Suspect penetrating traumawith a foreign body. Radiographs of the foot are negative. Next imaging study.
B. MRI Foot
Variant 6: Adult or child older than 5 years of age. Acute trauma to the foot. Suspect penetrating traumawith a foreign body. Radiographs of the foot are negative. Next imaging study.
C. US Foot
Summary of Recommendations
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations

Relative Radiation Level*

Adult Effective Dose Estimate Range

Pediatric Effective Dose Estimate Range

O

0 mSv

 0 mSv

☢

<0.1 mSv

<0.03 mSv

☢☢

0.1-1 mSv

0.03-0.3 mSv

☢☢☢

1-10 mSv

0.3-3 mSv

☢☢☢☢

10-30 mSv

3-10 mSv

☢☢☢☢☢

30-100 mSv

10-30 mSv

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”
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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.  Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.