Ortho Hors D'oeuvres (Answer):
To review, this is a 33 year-old man with right foot pain after fall from roof height.
Questions and Answers:
1) What is the injury and what is its eponym?
There is a disruption of the tarsal-metatarsal joints of the foot caused by ligamentous injury to the lisfranc joint complex. These injuries are typically caused by axial loading on a plantar flexed foot. As you can see below, the second metatarsal typically articulates with all three cuneiforms as well as the first metatarsal. A disruption of these ligamentous connectis is known as a Lisfranc injury. This patient has a obvious dislocation between the medial cuneiform and the second metatarsal, but patients often present to the emergency department after a spontaneous relocation and radiographs can appear normal. For patients who have pain to the base of the first and second metatarsal with surrounding swelling or bruising and negative x-rays, a weight-bearing film should be obtained to evaluate any inappropriate flexibility of the tarsal-metatarsal joint.
2) What are the consequences of missing this injury?
Because these midfoot injuries involve multiple joints and are often unstable, there is a a high risk of chronic pain and functional disability if they go undiagnosed and hence untreated. Emergency physicians should maintain a high index of suspicion for these injuries. It is estimated that the Lisfranc injuries are missed on initial presentation to the ED in roughly 20% of cases.
3) What are the next steps in management of this injury?
In the emergency department, the foot should be elevated and iced, and the patient should not bear weight. Orthopedic surgery should be consulted immediately, as many of these injuries will require open reduction in the operating room, as they can be quite unstable. If no orthopedic surgeon is available, an attempt should be made to reduce the foot using traction in finger traps. The foot can then be placed in a posterior slab splint. The patient should be made nonweight bearing and follow up with orthopedic surgery as soon as possible.
References:
Burroughs KE, Reimer CD, Fields KB: Lisfranc injury of the foot: A commonly missed diagnosis. Am Fam Phys 1999;58:118-124
Gaines, Sarah, Handel, Daniel, and Ramsey, Peter. Foot Injuries. In: Tintinalli JE et al. Tintinalli Emergency Medicine 7th ed. New York: McGraw-Hill; 2011:1875-1880.
Perron, Andrew D., William J. Brady, and Theodore E. Keats. American Journal of Emergency Medicine 19.1 (2001): 71-75.
