I had fractured my ankle by the fracture of the fourth metatarsal was not seen in two X-rays that were taken. Only CT-scan revealed the cracks. Why is this the case? I was seen by an doctor who dismissed me after seeing nothing wrong with the x-rays. However, the pain persisted and I got the Ct scan only upon much hard work of visiting my GP and revisiting the radiology departments.

  • Diagnostic sensitivity isn't perfect. The CT probably has higher sensitivity, but may cost more or give more false positives as an initial test.
    – jiggunjer
    Jul 8 '16 at 17:01

It is difficult to judge, as we don’t know whether your fracture resulted from an acute direct trauma or whether it is a so called “stress fracture” (due either to an abrupt increase in activity or to chronic overload).

While most of the acute fractures (in particular shaft fractures) are visible on lateral view Rx (+/- oblique or modified lateral views Rx), stress fractures are frequently not detected with conventional Rx. It’s only about 10-14 days after the onset of symptoms (some studies even report from 2 weeks to 6 weeks after the onset of symptoms), that repeated Rx show a radiolucent resorption gap around the fracture that helps to confirm the diagnosis.

Finally, as suggested in the comment, in some cases, the sensitivity (= the capacity of a test to correctly identify the cases) of conventional radiography to detect metarsal fractures is not sufficient enough and further studies (CT or MRI) are needed when the clinical suspicion for a fracture is high.


  • Metatarsal fractures. Rammelt, Stefan et al. Injury, Volume 35, Issue 2, 77-86
  • Hatch RL et al, Diagnosis and Management of Metatarsal Fractures, Am Fam Physician. 2007 Sep 15;76(6):817-826.
  • Stress fractures in the lower extremity. The importance of increasing awareness amongst radiologists. Berger, FH, de Jonge, MC and Maas, M. European Journal of Radiology 62 (2007), 16-26.*

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