Working Diagnosis:
Complete Five Digit Lisfranc Fracture-Dislocation

Treatment:
Orthopedic surgery evaluation in the Emergency
Department
Surgical correction consisting of:
- closed reduction with percutaneous pinning of the right midfoot.
- Internal fixation with four K-wires were used to stabilize the Lisfranc joint obliquely, laterally, and vertically.
Case Photo #4 Case Photo #5

Outcome:
No post-operative complications.
12 weeks of casting and non weight bearing then transitioned to 7 weeks in a walking boot.
The patient was able to progress to full weight bearing activity with the assistance of physical therapy and customized orthotics.
Ligamentous strength and stability remained a concern
with increasing activity.
To monitor the need for possible reconstruction, follow-up X-rays were completed every 4-6 weeks for 6 months. Case Photo #6 At that time, x-rays continue to show anatomic alignmen of the tarsometatarsal joints.

Author's Comments:
The patient was allowed to return to weight lifting six months after surgical correction.
She is without complaints and participating in activities as tolerated.
With continued progression, she is hopeful to begin competing in spring softball approximately nine months post-operatively.

Editor's Comments:
This is a case of an obvious and severe injury, however Lisfranc injuries are often more sublte and require a high index of suspician in order to make the appropriate diagnosis.
Injury mechanisms include direct trauma, as seen in this case; twisting injury while in the tip toe position, common in dancers and force applied to the heel of a plantar-flexed forefoot, common in football players.
Initial work up should include bilateral weight bearing foot films to evaluate for diastasis between the base of the first and second metatarsals, using radiographs of the uninjured foot for comparison. CT can offer a more detailed view of involved fractures and MR can more accurately define ligamentous injury, particulary in partial tears where radiographs may be normal.
Stable injuries can be treated conservatively with non-weight bearing immobilization followed by physical therapy and unstable injuries require surgical referral.

References:
Coetzee JC. Making sens of lisfranc injuries. Foot Ankle Cln.2008;13:695-704
DeCrio M. Lisfranc injuries in sport. Foot Ankle Clin. 2009;14:169-186
Crim J. MR imaging evaluation of suble Lisfranc injuries: the midfoot sprain. Magn Reson Imaging Clin N Am. 2008;16:19-27

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