Toes & Calcaneus Study Notes

OBJECTIVES

  • Foot Anatomy Review
  • Positioning of the Toes
    • AP Forefoot
    • AP Axial
    • Oblique
    • Lateral
  • Positioning of the Calcaneus
    • Lateral
    • Plantodorsal Axial
    • Dorsoplantar Axial

ANATOMY REVIEW

  • Twos & Calcaneus (fall 2025)

PATIENT PREPARATION

  • Artifact Removal:
    • Shoes
    • Socks, stockings, pantyhose, etc.
    • Roll up pants or remove & gown
  • General Patient Positioning:
    • Seated or supine on x-ray table
    • Affected extremity resting on the image receptor (IR) on tabletop
    • Adjust patient position for trauma scenarios
  • Other Considerations:
    • 40-48" Source-to-Image Distance (SID)
    • Technical Factors?

POSITIONING OF THE TOES

AP Toes (Forefoot)

  • Patient/Part Position:
    • Same patient position as AP foot
    • Toes centered to IR, may be elevated on a 15-degree sponge
  • CR/IR/Collimation:
    • Tabletop IR
    • If foot is flat on IR: CR angled 15 degrees towards the heel (cephalic)
    • If toes are elevated on a 15-degree sponge: CR perpendicular to IR
    • CR entering 3rd MTP joint
    • Collimate to borders on each side & 1" of MTs

Structures Shown (AP Toes - Entire Forefoot)

  • 14 phalanges
  • 2nd DIP joint
  • 2nd PIP joint
  • 2nd MTP joint
  • Distal MTs
  • IP joints open

Evaluation Criteria

  • Proper collimation (phalanges & distal MTs)
  • Correct side marker (not in anatomy)
  • No rotation
  • Equal concavity on each side of phalanx
  • Even soft tissue borders on each side
  • Open IP & MTP joint spaces
  • Bony trabeculae & soft tissue detail seen

Consequence of Incorrect CR Angle

  • If CR isn't angled or toes aren't elevated 15 degrees:
    • IP joints will be closed off (not open)

AP Toe (Single Digit)

  • Patient/Part Position:
    • Same as for AP Forefoot
  • CR/IR/Collimation:
    • If foot is flat on IR: Angle CR 15 degrees cephalic (towards the heel)
    • If toes are on 15-degree wedge: CR perpendicular
    • CR entering MTP joint of digit of interest
    • Collimate to include 1" on each side of digit of interest & distal half of MT

Anatomy Demonstrated (AP Toe - Single Digit)

  • Entire digit of interest & distal half of MT

Evaluation Criteria

  • Entire digit & distal half of MT seen
  • No overlap of soft tissue
  • IP & MTP joints open
  • Bony trabeculae & soft tissue detail
  • Correct side marker (not in anatomy)

OBLIQUE TOE

  • Patient/Part Position:
    • Supine/seated on table
    • Knee flexed, plantar surface on IR
    • Rotate leg & foot 30-40 degrees:
    • Medially for digits 1-3
    • Laterally for digits 4-5
  • CR/IR/Collimation:
    • Tabletop IR
    • CR perpendicular, entering MTP joint of digit of interest
    • Collimate to include 1" border on each side

Anatomy Demonstrated (Oblique Toe)

  • Entire digit of interest
  • Half of the MT of digit of interest

Evaluation Criteria

  • Correct rotation (increased concavity on one side of phalanges)
  • Overlap of soft tissue
  • Heads of MTs only minimally overlapping
  • Proper collimation & marker placement
  • Bony trabeculae & soft tissue detail seen

LATERAL TOE

  • Patient/Part Position:
    • Lateral recumbent
    • Foot/toes placed in lateral position
    • Lateromedial for digits 1-2
    • Mediolateral for digits 3-5
    • Toes parallel to IR
    • Unaffected toe separated from other toes (using gauze, tape, etc.)
  • CR/IR/Collimation:
    • Tabletop IR
    • CR perpendicular
    • Enters IP joint for the great toe
    • Enters PIP joint for digits 2-5
    • Collimate to digit of interest

Anatomy Demonstrated (Lateral Toe)

  • Phalanges of digit of interest free of superimposition
  • At least distal phalanx

Evaluation Criteria

  • Entire toe seen
  • True lateral position
  • Concavity of plantar (posterior) surfaces of phalanges
  • Open IP joint spaces
  • Proper collimation & marker placement
  • Bony trabeculae & soft tissue detail

TANGENTIAL SESAMOIDS

  • Patient/Part Position:
    • Lewis Method: Patient prone with dorsiflexed foot & great toe on IR
    • Holly Method: Patient seated, dorsiflex foot with positioning aid pulling toes towards leg
  • CR/IR/Collimation:
    • Tabletop IR
    • CR perpendicular, tangential to 1st MTP joint
    • Tight collimation for sesamoids

Structures Shown (Tangential Sesamoids)

  • Tangential projection of MT head & sesamoids

Evaluation Criteria (Tangential Sesamoids)

  • Sesamoids free of superimposition
  • Proper collimation & marker placement
  • Bony trabeculae & soft tissue detail

POSITIONING OF THE CALCANEUS

LATERAL CALCANEUS

  • Patient/Part Position:
    • Recumbent on affected side
    • Foot in lateral position
    • Calcaneus centered to IR
  • CR/IR/Collimation:
    • Tabletop IR
    • CR perpendicular, entering 1” distal to medial malleolus

Structures Shown (Lateral Calcaneus)

  • Ankle joint
  • Calcaneus in lateral profile

Evaluation Criteria

  • Entire calcaneus seen
  • Ankle joint & tarsals seen
  • No rotation
  • Tuberosity in profile
  • Sinus tarsi open
  • Calcaneocuboid & talonavicular joints open
  • Proper collimation & marker placement
  • Bony trabeculae & soft tissue detail

PLANTODORSAL AXIAL CALCANEUS

  • Patient/Part Position:
    • Supine or seated
    • Leg fully extended
    • Foot dorsiflexed & perpendicular to IR
  • CR/IR/Collimation:
    • Tabletop IR
    • CR angled 40 degrees cephalic, entering plantar surface of foot at base of 3rd MT

Structures Shown (Plantodorsal Axial Calcaneus)

  • Axial projection of calcaneus
  • Talocalcaneal joint
  • Sustentaculum tali in profile

Evaluation Criteria

  • Calcaneus and talocalcaneal joint seen
  • No rotation of calcaneus
  • Sustentaculum tali in profile
  • 1st & 5th MTs not visible
  • Proper marker placement & collimation
  • Bony trabeculae & soft tissue detail

DORSOPLANTAR AXIAL CALCANEUS

  • Patient/Part Position:
    • Prone
    • Ankle elevated on sponge
    • Foot dorsiflexed (vertical)
    • Plantar surface of foot against IR
  • CR/IR/Collimation:
    • IR vertical in IR holder
    • CR angled 40 degrees caudal, entering posterior ankle
    • Collimate to Region of Interest (ROI)

Structures Seen & Evaluation Criteria (Dorsoplantar Axial Calcaneus)

  • Same as for Plantodorsal Axial Calcaneus

SUMMARY OF POSITIONING TOES

  • AP Toes (Forefoot)
  • AP Toe (Single Digit)
  • AP Oblique Toe
  • Lateral Toe
  • Tangential Sesamoids

QUESTIONS??