Carefully check the cortical edge of all bones on all views available
Always check for alignment of bones at the mid-forefoot junction (tarsometatarsal joints)
Injury to the Lisfranc ligament may not be visible on initial X-ray - follow up may be necessary
Metatarsal stress fractures are subtle and may not be visible on the initial X-ray
Fractures and dislocations of the forefoot (metatarsals and phalanges) are usually straightforward to identify, so long as the potentially injured bone is fully visible in 2 planes. The contour of the bone cortex of all bones must be checked carefully.
Dorsal-Plantar (DP) and Oblique - are standard projections of the forefoot. If only a phalangeal fracture is suspected then DP and oblique views of the toe(s) can be acquired. Lateral views can also be helpful.
Left image - The fracture line passes transversely across the bone
Right image - A normal unfused 5th metatarsal base apophysis is aligned more longitudinally along the bone
Metatarsal stress fractures
Stress fractures of the metatarsals are common in athletically active individuals. These may not be visible on initial X-rays but follow up images show periosteal stress reaction. This has the appearance of fusiform bone expansion.