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Ankle and Foot Injuries: Analysis of

MDCT Findings
Ville V. Haapamaki1 OBJECTIVE. The purpose of our study was to assess MDCT findings and the advantages
Martti J. Kiuru1,2 of MDCT compared with radiography in patients referred to a level 1 trauma center for diag-
Seppo K. Koskinen1 nostic evaluation of acute ankle and foot trauma.
MATERIALS AND METHODS. During a period of 37 months, 388 patients underwent
MDCT of the ankle and foot due to an acute trauma. Imaging studies (MDCT and radiogra-
phy) were retrospectively reevaluated with respect to fracture location, fracture type, and
mechanism of injury, and findings from the primary radiographs of the ankle and foot were
compared with MDCT findings.
RESULTS. Of the 388 patients, 344 (89%) had one or more fractures in the ankle or foot.
A total of 517 fractures were found in all anatomic regions: ankle, calcaneus, talus, midfoot,
and forefoot. The three most common occult fractures in the ankle not detected on primary ra-
diography were isolated fractures of the posterior and medial malleolus and Tillaux fractures.
The calcaneus was the most commonly fractured bone, and the sensitivity of radiography in
the detection of calcaneal fractures was 87%. The sensitivity of radiography in the detection
of talar fractures was 78%, whereas it was only 25–33% in the detection of midfoot fractures.
A Lisfranc fracture–dislocation was not detected on primary radiography in five (24%) of 21
cases. The three main injury mechanisms were falling from a height (164 patients [48%]), a
simple fall (68 patients [20%]), and a traffic accident (47 patients [14%]).
CONCLUSION. In patients with injuries from high-energy polytrauma and in those with
complex ankle and foot fractures, the sensitivity of radiography is only moderate to poor; in
these cases, MDCT is recommended as the primary imaging technique.

C onventional radiography has had

Received December 9, 2003; accepted after revision
March 1, 2004.
1 sarily the lower extremities [1].
Department of Radiology, Helsinki University Central
Hospital, Töölö Trauma Center, Topeliuksenkatu 5, Helsinki
FIN-00029, Finland. Address correspondence to
S. K. Koskinen (Seppo.Koskinen@hus.fi).
2
Research Institute of Military Medicine, Mannerheimintie
164, Helsinki FIN-00300, Finland.
AJR 2004;183:615–622
0361–803X/04/1833–615
© American Roentgen Ray Society
and still has an essential and domi-
nant role in the diagnostic evalua-
tion of patients with acute ankle and foot
trauma. In patients with complex ankle and
foot fractures, however, CT is a commonly
used imaging technique after radiography. The
prevalence of complex injuries of the ankle
and foot seems to be increasing as a result of
the increased use of automobile safety devices,
such as seat belts and air bags, that decrease
mortality and protect the trunk but not neces-
As a result of technical breakthroughs,
MDCT is faster and has better temporal, spa-
tial, and contrast resolution than conventional
helical CT [2]. Also, 2D reformats (multipla-
nar reconstructions) and 3D surface renderings
are of excellent quality; and because the image
processing is fast, these images can be made
almost instantly. The purpose of our study was
to assess the MDCT findings and the advan-
tages of MDCT compared with radiography in
patients referred to a level 1 trauma center for
evaluation of acute ankle and foot trauma.
Materials and Methods
This retrospective study took place at the Töölö
Trauma Center in Helsinki, Finland. It serves as
the only level 1 trauma center for a population of
1.4 million people and is the leading level 1
trauma center in Finland. In addition, some of the
most difficult cases of orthopedic and neurosurgi-
cal trauma are referred to the Töölö Trauma Cen-
ter from all over the country. Pediatric patients,
those under the age of 16 years, are primarily
taken to Children’s Hospital and therefore were
not included in the present study.
Using the PACS at our hospital, we retrieved all
emergency department CT requests dating from
the installation of a 4-MDCT scanner in August
2000 to the end of August 2003. A total of 7,139
MDCT examinations were performed during this

AJR:183, September 2004 615

 Haapamaki et al.

37-month period at the request of emergency de-
partment physicians. Patients with an acute ankle
and foot injury and who underwent ankle and foot
MDCT in the primary phase were included in the
study. The ankle and foot MDCT examinations
were requested by emergency department physi-
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formats were performed in standard coronal and
sagittal planes with a slice thickness of 1.0 mm
and a reconstruction increment of 1.0 mm.
In this study, the diagnosis of acute traumatic
ankle or foot fracture was based on MDCT, which
was regarded as the gold standard. Two radiolo-
Results
Of the 388 patients, 344 (89%) had one or
more fractures in ankle or foot. A total of 517
fractures were found in all five anatomic re-
gions: ankle, calcaneus, talus, midfoot (na-
vicular, cuboid, or cuneiform bones), and

cians mainly to reveal complex fracture anatomy gists experienced in musculoskeletal imaging re-
or to rule out a fracture. evaluated retrospectively and by consensus the forefoot (metatarsal bones). The number of
Of these patients, 388 patients (282 males and imaging studies (MDCT and radiography) by the patients and number of fractures accord-
106 females; age range, 16–89 years; mean age, fracture location, fracture type, and injury mecha- ing to anatomic location are shown in Table
40 years) met the inclusion criteria. All patients nism. Primary radiographs of the ankle (antero- 1. Nine patients (3%) had a talocrural frac-
underwent CT on a 4-MDCT scanner (LightSpeed posterior, 20° internal oblique [mortise], and ture–dislocation, and 12 patients (3%) had
QX/i, GE Healthcare). Routine MDCT examina- lateral views) and of the foot (anteroposterior, ob- luxation of Chopart’s joint (one case was bi-
tions of the ankle and foot were performed as fol- lique, and lateral views), when available, were re- lateral). Twenty-four patients (7%) had a Lis-
lows: 4 × 1.25 mm collimation, 0.625-mm evaluated by consensus and were then compared
franc fracture–dislocation and two of these
interval, and 3.75-mm table speed. Routine 2D re- with MDCT images.
patients also had a bilateral tarsometatarsal
fracture–dislocation.
Primary radiographs were available for
Number of Patients and Number of Fractures Related to Anatomic 296 patients (86%) with fractures. The num-
TABLE 1
Location
ber of the fractures detected on MDCT ver-
Patientsa Bilateral Fractures Fracturesb sus on primary radiography is shown
Location
No. % No. % No. % according to location in Table 2. The three
most common occult fractures in the ankle
Ankle 117 34 4 3 121 23 not detected on primary radiography were
Talus 70 20 3 4 73 14 the isolated fractures of the posterior and
Calcaneus 169 49 18 10 187 36 medial malleolus and the lateral margin of
Midfoot 66 19 4 6 70 14 the distal tibia (Tillaux fracture), for which
Forefoot 62 18 4 6 66 13 the sensitivity of primary radiography was
aTotal = 344. 50–72% (Figs. 1 and 2). The calcaneus was
bTotal = 517. the most commonly fractured bone in the
present study, and the overall sensitivity of
primary radiography compared with MDCT
Number of Fractures Detected on MDCT Versus Primary Radiography was 87% in this fracture group (Table 2). Es-
TABLE 2
Related to Location pecially in cases of complex intraarticular
Radiography fracture patterns, MDCT with coronal and
Fractures on
Location sagittal multiplanar reconstructions revealed
MDCT Available True-Positive Sensitivity (%) the extent of the fractures and the position of
Lateral malleolus 30 25 22 88 the dislocated posterior calcaneal facet better
Medial malleolus 20 18 13 72 than conventional radiography (Fig. 3).
Posterior malleolus 18 16 10 63 The overall sensitivity of conventional ra-
Anterior tibia 8 5 4 80 diography for the detection of talar fractures
was 78% compared with MDCT (Table 2).
Bimalleolara 14 10 8 80
MDCT with multiplanar reconstructions was
Medial malleolus 14 10 9 90
most helpful in detecting isolated fractures of
Lateral malleolus 14 10 8 80
the talar trochlea because these fractures
Trimalleolara 16 16 13 81 were shown on conventional radiographs in
Medial malleolus 16 16 15 94 only 34 (68%) of 50 cases. Eight talar frac-
Lateral malleolus 16 16 15 94 tures (11%) were associated with a subtalar
Posterior malleolus 16 16 15 94 joint dislocation, and the intraarticular frac-
Tibial pilon 30 27 26 96 ture was detected in seven of eight cases on
Tillaux 15 14 7 50 primary radiography. The total number of
Talus 73 67 52 78 luxations of Chopart’s joint was 13 (3%),
Calcaneus 187 149 129 87 and five cases were associated with navicular
intraarticular fracture; no fractures of the
Navicular bone 34 30 10 33
corresponding talar joint facet were seen in
Cuboid bone 27 24 6 25
the patients with Chopart’s joint luxation.
Cuneiform bones 37 33 8 24
Only one of four intraarticular navicular
Metatarsal bones 66 57 48 84 bone fractures was shown on conventional
aFindings of primary radiography were classified as negative if all fractured malleoli were not shown.
radiographs. Therefore, intraarticular frac-

616 AJR:183, September 2004

 MDCT of Ankle and Foot Injuries

tures in subtalar or talonavicular dislocations
were seen on conventional radiography in
eight of 12 cases.
In the detection of midfoot fractures, the
sensitivity of primary radiography was 24–
33% compared with MDCT (Table 2). The
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with multiplanar reconstructions provided
better visualization of the complex fracture
anatomy and of even minimal joint malalign-
ment of the Lisfranc joint without superim-
posed structures. The extent of the fractures
and of the dislocated joint facets of all Lis-
height (164 patients [48%]), a simple fall (68
patients [20%]), and a traffic accident (47 pa-
tients [14%]). Eighty-eight patients (26%)
also had serious injuries in other parts of the
body. The three most common injuries else-
where were thoracic fractures with hemo- and

total number of Lisfranc fracture–disloca-
tions was 26 (5%), and an occult Lisfranc
fracture–dislocation was detected in five
cases (24%) on MDCT because primary ra-
diographs were available in 21 cases. MDCT
franc fracture–dislocations was better evalu-
ated on multiplanar reconstructions than on
radiographs (Fig. 4).
In our patient population, the three main
injury mechanisms were falling from a
pneumothorax and pulmonary contusions (29
patients [33%] patients), multiple pelvic frac-
tures (24 patients [27%]), and lumbar vertebral
fractures (20 patients [23%]). In these pa-
tients with polytrauma, the injury mecha-

A B C

D E F

Fig. 1.—66-year-old woman with right ankle injury due to simple fall.
A–C, Conventional radiographs in anteroposterior (A), mortise (B), and lateral (C) views show bimalleolar fracture (arrows, A).
D–F, Coronal and sagittal multiplanar reconstructions from MDCT images reveal bimalleolar fracture (arrows, D and E) and occult posterior malleolus fracture (arrow, F)
that involves more than one third of articular surface. Also, occult Chaput-Tillaux fracture (arrowhead, E) is shown in anterolateral part of tibia. Note significant tibial meta-
physeal osteoporosis.

AJR:183, September 2004 617

 Haapamaki et al.

nism was associated more frequently with
falling from a height or traffic accidents.
Fractures in 223 patients (65%) were surgi-
cally managed, and ankle fractures were the
most common type of fracture to be surgi-
cally treated. A fall from a height was the
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tures in 11 patients (11%), and talus and cal-
caneus fractures in 10 patients (10%).
Forty-four patients (11%) had negative
MDCT findings. In 29 patients (7%) a frac-
ture was suspected on the primary radio-
graph, but these cases were proven to be
Discussion
The ankle is the most commonly injured
joint in the body, and ankle fractures are the
most common types of fractures treated by
orthopedic surgeons [3]. An occult posterior
malleolus fracture can be potentially harmful

main single injury mechanism in all fracture
groups, especially for the talus, calcaneus,
and midfoot fractures (Table 3).
Ninety-nine patients (29%) had multiple
fractures of the ankle or foot. The four most
common combinations of multiple fractures
were forefoot and midfoot fractures in 21 pa-
tients (21%), ankle and calcaneus fractures
in 12 patients (12%), ankle and talus frac-
false-positive on the basis of MDCT find-
ings. A suspected fracture of the talus was
the most common false-positive diagnosis on
primary radiography in 12 patients (41%).
Fifteen patients (4%) with no fractures in the
ankle or foot underwent MDCT because
clinical and primary radiographic signs were
inconclusive and the surgeon wanted to rule
out an occult fracture.
and can cause complications if not detected
and accurately managed because internal fix-
ation of the posterior malleolus is recom-
mended if the reduced fragment constitutes
more than one fourth to one third of the tibial
articular surface [1]. Obtaining an internal
oblique view in addition to the anteroposte-
rior and lateral projections increases the sen-
sitivity of conventional radiography in the

A B C

Fig. 2.—50-year-old woman with distortion injury in ankle due to simple fall.
A–C, Conventional radiographs in anteroposterior (A), mortise (B), and lateral (C) views show no fractures.
D, Coronal multiplanar reconstruction from MDCT images shows dislocated Chaput–Tillaux fracture (arrow) in an-
terolateral part of tibia.
D

618 AJR:183, September 2004


detection of ankle fractures [4], but in pa-
tients with polytrauma and in those with se-
vere comminuted ankle fractures, the
appropriate positioning of the ankle is diffi-
cult. On MDCT, the position of the ankle is
not crucial because of the high quality of the
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reformats. The patterns of articular fracture
in the distal part of the tibia, especially in
comminuted pilon fractures, can be difficult
to manage and therefore MDCT scans with
multiplanar reconstructions enhance the pre-
operative assessment of the fracture and op-
erative decision making.
The calcaneus is the most commonly frac-
tured foot bone [5]. Calcaneal fractures are
the result of high-energy trauma, usually due
to a fall from a height or to a motor vehicle
accident [6], which was also seen in the
present study. Nonoperative treatment is best
reserved for nondisplaced calcaneal frac-
tures; however, for patients who have dis-
placed intraarticular fracture fragments,
nonoperative treatment offers little chance of
a return to normal function because a calca-
neal malunion will develop [6–8]. In intraar-
ticular calcaneal fractures, the degree of the
A B
Fig. 3.—45-year-old man with calcaneal fracture due to fall from height.
A–C, Conventional radiographs in anteroposterior (A) and lateral (B) views from ankle and calcaneal view (C) reveal fracture line through calcaneal body and lateral mal-
leolus avulsion fracture.
(Fig. 3 continues on next page)
AJR:183, September 2004
MDCT of Ankle and Foot Injuries
depression of the posterior calcaneal facet
may often be underestimated on lateral ra-
diographs and also on coronal CT images [9,
10]. Multiplanar reconstructions in sagittal
and coronal planes show the exact position
of the posterior facet and joint malalignment
without superimposed structures, thus help-
ing decision making between operative and
nonoperative treatments.
Fractures of the talus, constituting 3–6%
of all foot fractures according to the litera-
ture [11, 12], are relatively rare. In the
present study, talar fractures constituted 14%
of all fractures. This difference is probably
because our study population was composed
of patients being treated at a level 1 trauma
center for injuries caused by high-energy
trauma and because patients with more sim-
ple foot injuries are treated on the basis of
conventional radiographs and do not undergo
MDCT. Subtalar joint dislocation is not a
common injury [13], but this finding was
seen in 11% of all talus fractures in our
study; again, this unexpected finding is best
explained by the majority of high-energy
trauma patients in this study. Subtalar joint
dislocations with associated intraarticular
fractures involving the subtalar or talonavic-
ular joints can lead to significant subtalar
joint arthrosis [14]. The overall sensitivity of
conventional radiography in the detection of
talar fractures is only moderate, and making
the diagnosis of associated intraarticular
fractures of the subtalar or talonavicular joint
with a subtalar joint dislocation is even more
difficult on conventional radiographs [15], as
was also seen in our study. The presence of
an intraarticular fracture worsens the progno-
sis [13], and MDCT with multiplanar recon-
structions is a recommended complementary
examination to reveal a possible occult in-
traarticular fracture of the talus if subtalar
joint dislocation or subluxation is suspected.
In the detection of midfoot fractures, the
sensitivity of primary radiography was weak
compared with MDCT. These fractures may
be potentially harmful and can cause compli-
cations if not detected and accurately man-
aged. In the Lisfranc joint, the minimal
tarsometatarsal malalignment and fracture
lines are difficult to detect on conventional
radiographs [16–20], and as many as 20% of
C
619
 Haapamaki et al.
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D E

Fig. 3. (continued)—45-year-old man with calcaneal fracture due to fall from height.
D–H, Sagittal and coronal multiplanar reconstructions from MDCT images show
large defect in posterior calcaneal facet (arrows, E and G) and that comminuted
fracture also involves anterolateral facet and calcaneocuboid joint (arrowheads, D
and H).

G H

Lisfranc joint injuries are estimated to be
missed on primary anteroposterior and ob-
lique radiographs [21–23]. In the present
study, the percentage of radiographs with
false-negative findings was slightly higher.
This difference may be because of the patient
population: weight-bearing images cannot
usually be obtained in patients with poly-
trauma, and appropriate positioning is also
difficult in patients with severe ankle and
foot trauma. Operative treatment is usually
needed in patients with a Lisfranc fracture–
dislocation to achieve anatomic reduction
and fixation. Multiplanar reconstructions re-
veal the extent of the fractures and even min-
imally dislocated joint facets in these
complex fractures better than radiographs,
thus helping surgical planning.

620 AJR:183, September 2004

 MDCT of Ankle and Foot Injuries
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A B C

Fig. 4.—20-year-old man with foot injury due to fall from height.
A and B, Anteroposterior (A) and lateral (B) radiographs show comminuted calcaneal fracture and cuboid bone
fracture (arrow, A).
C and D, Coronal (C) and sagittal (D) multiplanar reconstruction images from MDCT images show tonguelike calcaneal
fracture that involves posterior talocalcaneal facet (arrow, D) and Lisfranc fracture–dislocation between fourth meta-
tarsal base and cuboid bone (arrowheads, C and D). Note fractured lateral aspect of cuboid bone (arrow, C).

Number of Surgically Treated Fractures and Associated Injuries in Other Parts of the Body and Distribution of Injury
TABLE 3
Mechanism, by Anatomic Location

No. Surgically Mechanism of Injury

Location No. of Fractures Other Injuries
Treated Fall from a Height Simple Fall Traffic Accident Blunt Injury
Anklea 121 81 (67) 31 (26) 41 (34) 36 (30) 19 (16) 4 (3)
Talus 73 37 (51) 19 (26) 32 (44) 17 (23) 15 (21) 3 (4)
Calcaneus 187 107 (57) 54 (29) 126 (67) 10 (5) 19 (10) 9 (5)
Midfootb 70 27 (39) 24 (34) 31 (44) 5 (7) 13 (19) 11 (16)
Forefootc 66 40 (61) 17 (26) 19 (29) 6 (9) 17 (26) 9 (14)
Note.—Numbers in parentheses are percentages.
aAll malleolar, tibial pilon, and Tillaux fractures.

bNavicular, cuboid, and cuneiform bone fractures.

cMetatarsal bone fractures.

AJR:183, September 2004 621


CT is a commonly used imaging technique
after radiography in the setting of ankle and
foot fracture. Compared with conventional he-
lical CT, MDCT is faster and has fewer motion
artifacts. It offers reduced partial volume ef-
fects, decreased image noise, high-quality
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multiplanar reconstructions, and isotropic
viewing, all of which increase its diagnostic
power and benefit patients who present to the
emergency department with trauma [2, 24].
The position of the ankle or foot is not crucial
because the reformats are of excellent quality.
The high-quality multiplanar reconstruction
capability is especially useful in analyzing
complex ankle and foot fractures. Therefore, in
our hospital, sagittal and coronal reformats are
routinely included; CT technologists make
these standard multiplanar reconstructions;
and radiologists, if needed, make the addi-
tional multiplanar reconstructions. The aver-
age effective radiation dose for an MDCT
examination of the extremities, such as ankle
and foot, is 1 mSv [25], which of course de-
pends on the size and length of the body part
examined and scanning parameters (slice
thickness, kilovoltage, current). The effective
dose for radiography of the extremities is ap-
proximately 0.01 mSv [26]. The radiation dose
is higher for the MDCT examination than for
the conventional radiography examination, but
MDCT examination of the extremities can still
be considered a low-dose examination [26].
The sensitivity of conventional radiography
is only moderate in the detection of serious an-
kle and foot injuries. MDCT is an accurate and
reliable imaging technique in evaluating pa-
tients with ankle and foot traumas. Multiplanar
reconstructions are helpful in disclosing frac-
ture patterns, particularly in complex fractures
of the ankle and foot, where they enable com-
prehensive evaluation of fracture components
and also reveal occult fractures. These frac-
tures may be potentially harmful and can cause
complications if not detected and accurately
managed. The degree of dislocated joint facets
is better evaluated on MDCT with multiplanar
reconstructions than on radiography. Patients
622
Haapamaki et al.
known to have multiple injuries from high-en-
ergy trauma usually have multiple fractures;
therefore, the whole ankle and foot should be
scanned if an MDCT examination is planned.
As shown in this study, MDCT reveals occult
fractures and depicts the exact fracture anat-
omy in ankle and foot fractures, such as tibial
pilon and complex calcaneal fractures.
In conclusion, radiography remains the pri-
mary imaging technique in evaluating patients
with ankle and foot trauma; however, in pa-
tients with multiple injuries from high-energy
trauma and in patients with complex fracture
patterns the sensitivity of conventional radiog-
raphy is only moderate to poor. In these cases,
MDCT of the whole ankle and foot is recom-
mended as the primary imaging technique.
References
1. Vander Griend R, Michelson JD, Bone LB. Frac-
tures of the ankle and the distal part of the tibia.
Instr Course Lect 1997;46:311–321
2. Rydberg J, Buckwalter KA, Caldemeyer KS, et al.
Multisection CT: scanning techniques and clinical
applications. RadioGraphics 2000;20:1787–1806
3. Bauer M, Bengner U, Johnell O, Redlund-Johnell
I. Supination-eversion fractures of the ankle joint:
changes in incidence over 30 years. Foot Ankle
1987;8:26–28
4. Rogers LF. Radiology of skeletal trauma, 2nd ed.
Los Angeles, CA: Churchill Livingstone,
1992:1319–1427
5. Atkins R. Pathology of calcaneal fractures. J
Bone Joint Surg Br 2001;83:326–327
6. Sanders R. Displaced intra-articular fractures of
the calcaneus. J Bone Joint Surg Am
2000;82:225–250
7. Darder Prats AD, Silvestre Munoz A, Segura Llo-
pis F, Baixauli Perello E, Darder Garcia A. Sur-
gery for fracture of the calcaneus: 5 (2-8) year
follow-up of 20 cases. Acta Orthop Scand
1993;64:161–164
8. Sanders R. Radiological evaluation and CT clas-
sification of calcaneal fractures. In: Jahss M, ed.
Disorders of the foot and ankle, 3rd vol. Philadel-
phia, PA: W. B. Saunders, 1990:2326–2354
9. Ebraheim NA, Biyani A, Padanilam T, Paley K. A
pitfall of coronal computed tomographic imaging
in evaluation of calcaneal fractures. Foot Ankle
Int 1996;17:503–505
10. Rosenberg ZS, Feldman F, Singson RD. Intra-artic-
ular calcaneal fractures: computed tomographic
analysis. Skeletal Radiol 1987;16:105–113
11. Adelaar RS. The treatment of complex fractures of
the talus. Orthop Clin North Am 1989;20:691–707
12. Kuner EH, Lindenmaier HL, Munst P. Talus frac-
tures. In: Tscherne H, Schatzker J, eds. Major
fractures of the pilon, the talus, and the calca-
neus: current concepts of treatment. Berlin, Ger-
many: Springer-Verlag, 1993:71–85
13. Bohay DR, Manoli A. Occult fractures following
subtalar joint injuries. Foot Ankle Int
1996;17:164–169
14. Delee JC, Curtis R. Subtalar dislocation of the
foot. J Bone Joint Surg Am 1982;64:433–437
15. Ebraheim NA, Skie MC, Podeszwa DA, Jackson
WT. Evaluation of process fractures of the talus
using computed tomography. J Orthop Trauma
1994;8:332–337
16. Faciszewski T, Burks RT, Manaster BJ. Subtle in-
juries of the Lisfranc joint. J Bone Joint Surg Am
1990;72:1519–1522
17. Foster SC, Foster RR. Lisfranc’s tarsometatarsal
fracture-dislocation. Radiology 1976;12:79–83
18. Lu J, Ebraheim NA, Skie M, Porshinsky B, Yeast-
ing RA. Radiographic and computed tomo-
graphic evaluation of Lisfranc dislocation: a
cadaver study. Foot Ankle Int 1997;18:351–355
19. Norfray JF, Geline RA, Steinberg RI, Galinski
AW, Gilula LA. Subtleties of Lisfranc fracture–
dislocations. AJR 1981;137:1151–1156
20. Preidler KW, Brossmann J, Daenen B, Goodwin
D, Schweitzer M, Resnick D. MR imaging of the
tarsometatarsal joint: analysis of injuries in 11 pa-
tients. AJR 1996;167:1217–1222
21. Englanoff G, Anglin D, Hutson HR. Lisfranc
fracture-dislocation: a frequently missed diagno-
sis in the emergency department. Ann Emerg Med
1995;26:229–233
22. Mantas JP, Burks RT. Lisfranc injuries in the ath-
lete. Clin Sports Med 1994;13:719–730
23. Trevino SG, Kodros S. Controversies in tar-
sometatarsal injuries. Orthop Clin North Am
1995;26:229–238
24. Novelline RA, Rhea JT, Rao PM, Stuk JL. Heli-
cal CT in emergency radiology. Radiology
1999;213:321–339
25. Nagel HD. Dose values from CT examinations.
In: Nagel HD, ed. Radiation exposure in com-
puted tomography. Hamburg, Germany: CTB
Publications, 2002:15–24
26. European Commission. Optimizing radiation
dose. In: Dixon A, ed. Radiation protection 118
referral guidelines for imaging. Luxembourg:
Office for Official Publications of the European
Communities, 2001:19–22
AJR:183, September 2004