Initial imaging. Multiple conditions or scenarios preclude the use of the Ottawa rules for determining if imaging is necessary [5,6]. It has been reported that the Ottawa rules for the foot should not be used or should be used with great caution in the following clinical situations: penetrating trauma, pregnancy, any skin wound, transferred with radiographs already taken, >10 days after trauma, a return visit for continued traumatic foot pain, in the setting of polytrauma, altered sensorium, neurologic abnormality affecting the foot, or underlying bone disease [7]. Radiography Foot If a foot fracture is suspected in a neurologically compromised patient, including patients with diabetic neuropathy, the foot should be radiographed. The Ottawa rules should not be applied in this clinical setting because pain perception may be diminished, no point tenderness will be elicited with palpation, and the patient may be able to ambulate even if a fracture is present [5]. Polytrauma and penetrating trauma also constitute exceptions to the implementations of the Ottawa rules. Both radiographs and US are useful imaging tools to exclude a foreign body in the setting of penetrating trauma to the foot [24]. The best initial imaging study for a foreign body in the foot depends on whether or not the suspected foreign body is radiopaque (eg, gravel, both leaded and nonleaded glass, or metal). Radiographic evaluation for a radiopaque foreign body has approximately 98% sensitivity [25]. If an unembedded fragment of the foreign body is available, then imaging it alongside the foot might provide more information as to the morphology and density of the foreign body. CT Foot CT is commonly used in evaluating the true extent of osseous injury in complex fractures and at times is used as the initial imaging study in polytrauma patients and in complex regions such as the midfoot [21,22]. In the polytrauma patient, approximately 25% of midfoot fractures identified on CT are overlooked on radiographs [21].
Acute Trauma to the Foot. Initial imaging. Multiple conditions or scenarios preclude the use of the Ottawa rules for determining if imaging is necessary [5,6]. It has been reported that the Ottawa rules for the foot should not be used or should be used with great caution in the following clinical situations: penetrating trauma, pregnancy, any skin wound, transferred with radiographs already taken, >10 days after trauma, a return visit for continued traumatic foot pain, in the setting of polytrauma, altered sensorium, neurologic abnormality affecting the foot, or underlying bone disease [7]. Radiography Foot If a foot fracture is suspected in a neurologically compromised patient, including patients with diabetic neuropathy, the foot should be radiographed. The Ottawa rules should not be applied in this clinical setting because pain perception may be diminished, no point tenderness will be elicited with palpation, and the patient may be able to ambulate even if a fracture is present [5]. Polytrauma and penetrating trauma also constitute exceptions to the implementations of the Ottawa rules. Both radiographs and US are useful imaging tools to exclude a foreign body in the setting of penetrating trauma to the foot [24]. The best initial imaging study for a foreign body in the foot depends on whether or not the suspected foreign body is radiopaque (eg, gravel, both leaded and nonleaded glass, or metal). Radiographic evaluation for a radiopaque foreign body has approximately 98% sensitivity [25]. If an unembedded fragment of the foreign body is available, then imaging it alongside the foot might provide more information as to the morphology and density of the foreign body. CT Foot CT is commonly used in evaluating the true extent of osseous injury in complex fractures and at times is used as the initial imaging study in polytrauma patients and in complex regions such as the midfoot [21,22]. In the polytrauma patient, approximately 25% of midfoot fractures identified on CT are overlooked on radiographs [21].