Case Diagnosis: Left Lisfranc fracture
Case Description: A 66-year-old male presented to inpatient rehabilitation after sustaining a crush by a cabinet. He had multiple injuries to his thorax, lumbar spine, pelvis and also underwent a right below knee amputation. On day 12 of his rehabilitation admission, he reported intermittent band-like left foot pain located at the medial malleolus which radiated to the midfoot. Physical exam was unremarkable apart from tenderness to palpation of the medial malleolus. Left foot x-ray revealed a Lisfranc fracture. Left foot Computer Tomography confirmed the diagnosis. Podiatry was consulted and recommended a walking boot and non-weight bearing on the left lower extremity. He elected for non-operative management and completed his rehabilitation program at wheelchair level.
Discussions: A Lisfranc fracture is a tarsometatarsal fracture characterized by the disruption of the medial cuneiform-base of second metatarsal joint. It occurs from trauma or from an axial load onto a plantar-flexed forefoot. In this case, the fracture occurred during the crush. Lisfranc fractures are rare, accounting for less than 1% of all fractures and nearly 20% are missed on initial imaging. This was the situation in this report, where the fracture was identified in a subsequent left foot x-ray series. Early identification of the fracture is important as it guides treatment options (non-operative and operative) based on ligament and bony injury patterns. The consequences of a non-treated Lisfranc fracture include osteoarthritis and chronic midfoot pain syndrome.
Conclusions: This case highlights the importance of considering a Lisfranc fracture as a cause of foot pain in a multi-traumatic injury patient. Although this patient had a delayed presentation of a Lisfranc fracture, work up with imaging was key in it’s identification. Communication between the rehabilitation and podiatry teams was important for acute management and for outpatient follow up given the known sequelae of a missed Lisfranc fracture.
Alexandre Mazar– PMR resident, Beaumot Hospital-Taylor
Riley Smith– Physician, Beaumont Hospital-Taylor Physical Medicine and Rehabilitation
Robert Gapinski– Resident Physician, Beaumont-Taylor Hospital Physical Medicine and Rehabilitation
P. Tyler Roskos– Clinical Neuropsychologist, Beaumont-Hospital Taylor Physical Medicine and Rehabilitation
Rizwan Alvi– Resident Physician, Beaumont Hospital-Taylor Physical Medicine and Rehabilitation