Lisfranc fracture and transverse ligament rupture

Members do not see these Ads. Sign Up.

Just saw a patient 1 hour ago for the 1st time.... Sorry for the long story..

31st April 2009 feel down some stairs while working on a cruiseliner. Huge amount of pain and swelling on the whole foot could not walk. Bone xrays taken nothing noted ( Ive not seen them but they would not have been able to see anything from the amount of swelling the patient describes) Went to a Dr in Burmuda given some advice and crutches sent via plane back to Sweden.

Foot and whole leg very swollen, black and blue. MRI taken 2 weeks after fall. Orthopeadic surg looked at MRI and X-rays- given advice you will be fine put away your crutches take some painkillers and call me in 3 weeks if your still in pain.

Patient did as was told pain through the roof, very swollen, walking just on heel. Rang 1st Dr he "had moved on". Saw a new Orthopeadic surg she looked at same MRI and noted a Lisfranc Fracture and a rupture of (what I can gather from the patient) the transverse ligament near 1st metatarsal head.

Told to use crutches again come back in a month. Returned in 1 month for new X-rays. No change come back in a month, this went on for 6-8 months with the same Dr.

In Jan of 2010 saw a new Orthopeadic surgeon who took new X-rays and MRI who told her I can operate but 50% chance that you will never walk on the foot again after the operation.

Patient says I´ll think about it, is there anything else I can do , NO says Dr number 4. Call me when you want the op.

Now things get really messy. The patient was employed by a US company and the insurance is paying the medical bills, so the patient sends over the DR notes, it appears someone has been changing the patients notes to make the whole thing look better. I´ve not seen the MRI or X-rays and may never due to the paperwork trail, so I only have what the patient tells me and what I found during the assessment.

361 days post fall patient enters walking with a very supinated foot, weight on heel.
Pain very much Dorsal Left medial area of foot, over the Lisfranc joint on palpation ( very light touch).
Foot swollen
pain shoots distal to toes on palpation of dorsal midfoot.
Pain on dorsiflexion of 1st, 2nd,3rd metatarsal.
ROM of 1st ray, MTJ not able to be assessed due to pain, STJ on pain on passive movement.
a FF equinus postion non weightbearing was noted affected side only.

* I had had a phone call with the patient 10 days before I saw her a she had began icing 2-3 times a day which helped her to sleep at night but made the day pain worse.

So I´ll try and get hold of some pictures.

Today I have instructed the patient to begin NSAID´s ( 1st person to suggest this !!)
continue with ice
rest as much as possible
wear very stiff sole shoes
I changed the lacing system in her runners to reduce pressure over painful dorsum area
heel lifts added to shoes
Low dye tape with arch fill

pain on walking went from a 10 to a 6.5.

My plan now is a higher arch device with heel lift, stiffer materal device and a FF valgus post.
Anything Ive missed from the info we have ?

 

You do get some interesting cases don't you!

Sounds good so far to me (but I'm no expert) - I'm assuming you've got the patient doing some simple NWB calf muscle stretches or is the pain too severe at the moment and they'll come later?

Just out of curiousity - What finally made the patient come to a Podiatrist after seeing so many other medical experts? I like to know how people make these decisions so hopefully we can better understand them and provide better community education.

(Right off the topic - it would be interesting if you could relate some of your experiences in starting different podiatry jobs/practices in different countries)

Cheers
RStone
(By the way I loved the photos you posted on the volcano - spectacular photography)

 

The xrays and MRI should tell the story.
If there is a lis franc fracture the treatment generally is surgery. The surgeons have either not suggested this, or the patient has chosen not to hear it...
Are the surgeon looking at this foot and ankle specialists?

 

Michael,

From reading your case description, I couldn't help think 'Complex Regional Pain Syndrome'.

Cheers,
Ian

 

Hi Craig as I said

as for foot and ankle specialists Ive no idea but you hope 1 out the 4 might have been.

I´m pretty sure that surg is off the cards for this patient so I need to do what I can.

 

Hi R

No stretching as loading forefoot increased pain levels.

I´ve just started one day a week at a Physio center the other side of Stockholm
( to increased patient base) and she was seeing a physio for a shoulder problem that developed from using crutches, the physio popped in asked a few questions having not heard of Podiatry and got the patient to ring....

as for the different country question maybe for another thread.

ps I think those photo were Mark Russell, but they were great.

 

Hi Ian, there is specific mechancial pain, but I will keep that in mind. I also had to work on the mental side of things today, a very down patient, until the walking test and a big smile which was nice.

 

Mike,

What was the original mechanism of injury?

Ian

 

Hi Ian,

She feel down some stairs so trauma from many angles I guess.

 

I only ask as personally in all of the Lisfranc fracture dislocations I have seen (only about 3 or 4) the mechanism of injury was rotation of the rearfoot on a fixed forefoot (usually cyclists whose cleats didn't dettach from the pedal during a fall). Seems an unlikely scenario in a stair fall?

Get the X-Rays up when you have them - be really interested to see them mate.

Ian

 

Hi Mike

When are you seeing this patient again?

Cheers
RStone

 

First job: exlcude RSDS/CRPS. IF positive, this needs to be managed first.

If negative, fit a CAM walker with perhaps a total contact orthosis. Pain should reduce markedly. Remove CAM walker after 6-8 weeks and see how he goes without it and an appropriate shoe + orthosis.

After 12 weeks, if not significantly better, then Lisfranc joint arthrodesis will be indicated. The extent of which (eg 1-3, 1-5) will be determined by clinical findings (ie piano key test) and imaging (CT is best, + standard and PA plain films).

Hope this helps,

LL

 

Hi Mike

My comments were more that I am surprised that surgery was not suggested first up with the diagnosis- . I understand all too well that there are different approaches around the world, but I thought that this is a pretty standard protocol. My understanding is that the consequence of not stabilising a lisfranc rupture can be pretty catastrophic.
Obviously the decision is not your call and it does not mean that this person cannot be managed conservatively. Your plan sounds like you are more on the right track than the surgeons in this regard.
It will be interesting to see the response of the surgeons who are already 'managing' this case- they may see you as interfering- particularly if you do something highly visible such as the CAM walker, or, they may see you as a valuable asset to help them manage orthopaedic foot problems... When the patient improves it won't really matter...

I had a case here which was similar with respect to history, but I saw it within a few days of it occuring. The origin xrays were reported as normal- we took some more pictures-
What do you think? anyone? anyone?
I was partly correct with my assessment at the time... (I will post the answer a little later...)

 

Hi Craig thanks for that. Its a bit of nightmare, but there has no phone call today. The old no news is good news was discussed with the patient.

If no real improvement when I see the patient next camwalker sounds the go, from you and LL.

R: I see the patient next Wednesday. I´ll keep you posted and any X-rays get a few more eyes looking at it.

Craig as for your X-rays - I´ll go for fractures base of mets 3 and 4 and dislocation/subluxation cuniforms 2 and 3 ( intermediate and lateral) ?

 

Hi Craig

Re X-ray - I would have said fracture at base of 3rd and 4th metatarsal and something weird going on around 3rd or lateral cuneiform - (lateral/3rd cuneiform almost looks like a crush injury I saw once).

Also query fracture at base of 2nd met at joint interface.

Look forward to the answer.
RStone

 

Pretty good Mike and RStone-
I picked the lisfranc injury, and suspected something fishy around the base of the MTs.
It was reported as a suspected lisfranc rupture and then subsequently a trans tarsal dislocation following an MRI. The visiting Foot and Ankle Trauma surgeon picked it on plain film. Observe the step in the line along the 3rd cuneiform and 3rd met and along the cuboid to the 4th met on the oblique view.
The patient had the dislocation reduced while having the lisfranc joint fixated surgically.

 

Nice and how they end up after surg, rehab and pod care ?

 

At this stage I believe she is coming along nicely- she is about 5 months post surgery, but I have not seen her for about 6 weeks.
This is a bit different to your case particularly as I first saw here within 5 days of the injury, and she had the surgery about a week or so later...

 

Hi Folks update time if your intersted.

Patient is still hunting down Xrays, the series will be posted up as soon as I get them.

Patients pain levels reduced to a 5/10 for the 1st 2 days of tape. Friends and Family were making comments about the 1st time in a year she has walked without a limp.

Dorsal swelling has reduced a little with ice and NSAID´s
ROM levels before pain have increased.

today retaped - review on Monday for total contact device as LL suggested.
Hopefully will have the x-rays on Monday.

 

I call it the 'magic tape'- gets them every time.
Actions speak louder than words and decreasing this persons pain significantly should lead to them being a very compliant patient who will tell their friends about you... good job!

 

Here is the X-ray. Ive zoomed in. Its a mirror image so have marked left/injured foot. It doesn´t seem as bad as I expected. Saw the patient today pain continues to reduce.

 

Good work on the pain reduction - I'm assuming this patient is pretty happy with you at the moment

Just curious - what was your assessment of the x-rays?

Going out on a limb (maybe a lower limb ) before the more qualified respond I would probably say - damage/narrowing of Lisfranc joints, widening of IM space 1/2 with associated instability and damage to ligaments, also damage between 1st/medial cuneiform and 2nd/intermmediate cuneiform. Clinically I'd still be expecting swelling and reduced ROM across base of metatarsal and tenderness/pain on palpation. I would expect ongoing instability of the 1st ray once swelling subsides and "more normal" movement becomes possible and also long term ache/tenderness laterally across base of metatarsals. So long term I'd try and support 1st ray and stabilise lateral side of midfoot.

Mike - please don't take this as advice, I'm just trying to be brave and stretch myself professionally a little - I await the response of those who specialise in biomechanics to see if I'm anywhere near the ball park or shot down over enemy lines!

Cheers
RStone

 

Michael

They're non-WB. Not very helpful (unless you have a PA view).

LL

 

Hi LL there the best I have and this is what they( the DR´s) were assessing the patient with, as a Pod I´m not allowed to order Xrays- Welcome to socialism heathcare. I will try and get the patient to get some weightbearing DP views done on both feet.

I noted a bone fragment near the base of the 1st metatarsal and some slight different joint spaces, but as I said was a bit suprised. Maybe more will be seen weightbearing.

Thanks LL

 

Next update for anyone who still intersted.

Weightbearing x-ray request was shoot down by the head Xray Dr at the hospital as " it was not necessary and a waste of money" how I long for the same treatment and assessment conditions as Australia sometimes.....

anyway on a positive note.

Pt´s ROM has imporoved, swelling is down and propulsion phase of gait on the effected side showing signs of improvement pain now at 3-4 and no night pain for the last 3 weeks.

Pt is going to sit on a beach for a month and visit family so next update will not be for awhile.

But we have a happy patient.