The added value of cross-sectional imaging
in the detection of additional radiographically occult fractures
in the setting of a Chopart fracture
Renata R. Almeida
David K. Tso
Anne H. Johnson
Michael H. Lev
Ajay K. Singh
Efren J. Flores
Received: 4 May 2018 /Accepted: 30 May 2018
American Society of Emergency Radiology 2018
Purpose Radiography has a low sensitivity for the detection of fractures related to the talonavicular and calcaneocuboid artic-
ulations, also known as Chopart fractures. The purpose of this study is to determine the sensitivity of radiographs for detecting
additional foot and ankle fractures related to Chopart fracture using CT or MRI as the reference standard.
Method We performed an IRB-approved, retrospective review of radiology reports between 2010 and 2014. Inclusion criteria
were (1) diagnosis of a Chopart fracture and (2) at least one radiograph and subsequent cross-sectional imaging (CT or MR). CT
or MRI was considered the diagnostic reference standard. Results were stratified by the energy of trauma and by type of
radiograph performed (weight-bearing (WB) versus non-WB).
Results One hundred eight patients met the inclusion criteria. The calcaneocuboid articulation was the most commonly involved
type of Chopart fracture, seen in 75% of cases (81/108). Chopart fractures were detected on the initial radiographs in 67.6% of
cases (73/108). Additional fractures of the ankle and midfoot were diagnosed in 34.2% of cases (37/108), with 56.7% (21/37) of
these cases having at least one additional fracture seen on CT or MRI that was not seen on the initial radiographs, with fractures of
the midfoot most often missed. In 56.7% (17/30) patients whose radiographs detected Chopart fractures, at least one additional
fracture was missed; 30% of them demonstrated intra-articular extension and 56.7% were considered displaced. High-energy
trauma was related to higher incidence of additional fractures. There was no significant difference in the sensitivity of radiographs
to detect additional fractures between high versus low-energy trauma (p = 0.3) and WB versus non-WB radiographs (p =0.5).
Most patients were treated nonoperatively (56.5%, 61/108), with surgical intervention more frequent in patients with a high
energy of trauma (51.7% versus 33.3%, p =0.05).
Conclusion In the setting of a Chopart fracture, CT or MRI can add significant value in the detection of additional ankle or
midfoot fractures, irrespective of the energy of trauma. Since additional fractures can have important management implications,
CT or MRI should be considered as part of the standard workup for all midfoot fractures.
The Chopart joint (Fig. 1) is comprised of the talonavicular and
calcaneocuboid articulations and represents the anatomical
border of the hind- and midfoot, allowing the mid- and fore-
foot to move in three dimensions as a unit while the hindfoot
remains stationary [1–3]. This joint is essential for normal foot
function and biomechanics by providing flexibility during
heel strike to adapt to uneven surfaces, and by facilitating
inversion, eversion, pronation, and supination [1, 2, 4].
* Renata R. Almeida
Emergency Radiology, Radiology Department, Massachusetts
General Hospital – Harvard Medical School, 55 Fruit St,
Boston, MA 02114, USA
Foot & Ankle Center, Orthopaedics, Massachusetts General Hospital
– Harvard Medical School, Boston, MA, USA