A Patient with Persistent Midfoot Pain; following a fall

HPI: The patient is a 57-y/o who presents with persistent pain in right midfoot following a fall approximately seven months ago. The patient was evaluated by a local orthopedist, who diagnosed a 2nd metatarsal fracture and elected to treat the patient conservatively with cast immobilization for a period of six weeks....

PMH: Diabetes mellitus, HTN         PSH: Hysterectomy ’99, right wrist ORIF ‘02
Meds: Ibuprofen for pain, HCTZ, Glipizide        ALL: NKDA
Social: The patient relates to social consumption of alcohol, denies tobacco or drug usage.

Physical Exam: Upon physical exam, the patient demonstrates Pedal pulses are palpable and graded +2/4 bilaterally with CFT <3 seconds, with no varicosities noted. There is hair growth noted on the leg to the distal 1/3 of the tibia bilaterally...

Considering the history, radiographic data, and clinical exam, how would you proceed in the management of this challenging patient?

Lis Franc fracture dislocation was obviously missed in this patient. The persistent pain and disability would be expected with this choice of treatment. ORIF should have been done seven months ago. At this stage the patient has or is likely to develop tarso-metatarsal arthrosis with chronic pain and disability.  Arthrodesis of the 1st, 2nd and 3rd TMJs should be offered to the patient. Osteosynthesis and a bone stimulator will help in the repair process.  At least 4 weeks NWB cast then 4 weeks FWB cast, and physical therapy.  Initially or later, weightbearing or stress x-rays would be helpful. It will take the good part of a year for this patient to recover. And, orthotics will be essential long term.

   Communited fracture 2nd metatarsal. ORIF followed by non-weight bearing cast immobilization.

  Innitially, would order an MRI/CT to evaluate Lis Franc joint .

Agree with arthrodesis of 1st, 2nd and 3rd  and bone stim. but with diabetic history would keep NWB for 6+ weeks and would use locking plate/lag screw combo to reach out on to 2nd met.  Agree on orthosis  longterm/lifetime.

If the broken bone wasn't set right I would suggest a resetting and then apply a proper alignment cast  insuring the bones of the foot are in proper alignment with each other..      

Currently, I looks to me that the calcaneus, is malaligned with the tarsas, creating a twisting effect,Thus causing pain!  This twisting effect,Also allows weekness in the mid arch creating a stretching of the planter surface thus colaping the longitudal arch. Although not surgical, nor mainstream, I lwould suggest a conservitive approach first before, proceeding to any surgical  methods.

I would apply aseries of figure 8 manipulation in combination with phisical therepy to strengthen the ligiments to hold the adjustment over a period of 8 weeks. Having a manipulation first and then physical therepy to follow.  If the foot does not respond, than more aggressive mesures would be in order.. 

- Marlietta Schock
Pedorthist./thereputic Last Maker
 

Nothing better than a high index of suspicion and concern for a potentially debilitating injury. MRI and CT will show how disruptive this type of injury can be relative how uncomplicated it may present initially on x-ray and clinically.  I might add this type injury to the five most commonly missed foot and ankle fractures:
 
FLOAT

1. 5th metatarsal
2. Lateral talar process
3. Os trigonum or posterior malleolus
4. Anterior calcaneal process
5. Talar dome

There are lessons to be learned from cases as such presented here.

As for fixation, TriMed makes a nice  saucer-shaped radiolucent plate (Xpode) for fusion of the TMJ, allowing for fusion/alignment under radiological control.  I also agree that it may take longer for this patient to consolidate the fusion.  All the more reason to use biologic enhancements for osteosynthesis and a bone stimulator.

As noted above there appears to be a oblique fracture of the 2nd metatarsal shaft with lateral cortical disruption, On the AP there is an increase in the normal articulation between the 1st and 2nd metatarsal bases Lis Francs Joint Diastasis, On lateral there is dorsal dislocation at the talonavicular joint. As for repair I would precede with ORIF of Lis Francs joint with screw fixation to recreate the joint and normal anatomy, I would leave the 2nd metatarsal shaft fracture alone. After Lis Francs is restored if needed adress the dorsal dislocation of the TN.

Nice try. Some docs are missing the point.  This patient limps into your office today, not 7 months ago.  Read carefully the question again.  This might be a good surgery board certification oral question.  What do you do now?!  Next case.

 I believe in this case , the fact that the Pt now complains of pain around the 1 MPJ even though the original X-Ray only reported a shaft Fx on 2 met is giving us a clue that we are now dealing with a "DISSOCIATIVE TYPE OF LISFRANC INJURY" due to inadequate original Treatment. I would keep in mind that i am now dealing with 3 problems : Number 1: Loss of stability of both transverse and Longitudinal arch, Pain Deformity and Arthrosis. Based on the current X-Ray, I should know now that I am dealing with a mixed Ligamentous/Fracture/Dislocated Injury, therefore that would be my logic for ordering the CT/MRI

Next Step: Surgical therapy: Medial to Lateral reduction in the following order:

1. Reduce 1 met to medical cuneiform in both sagital and transverse plane
2.Address intercuneiform instability 
3.Debride any bone debris and ligament remnants
4.Second met base reduction

--The key would be here to use K Wire with  Neutralization Screw fixation of 1+2+3  tarsometatarsal joint with single intercuneiform Screw 

Post-Op Tx: Rigid Splinting/Casting with Ankle plantigrade x 6 weeks, Suture removal x 2 weeks, K-Wire removal x 6 weeks, remove pt to removable walker after 6 weeks to be considerate for the DM status, start the physical therapy. 

I am not a fan of the idea that removal of the Screw improves long-term outcome(it is becoming popular from what I have seen ), I don't believe that would be the case in any Diabetic pt or any pt older than 40, there has also been studies that shows a possible miscalculated Screw removal time can lead to recurrent midfoot subluxation 

Based on the X-rays, the patient has a lisfranc's fracture dislocation. The lesser mets have shifted laterally, making it a hardcastle type 2B.

The patient does need an MRI/CT to evaluate the extent of the injury before any planning is made.

After the results are obtain, there are different things that could be done surgically to repair this injury. Couple of mini rails could be used, Tight rope from arthrex has worked well in the past for me, or the ORIF which can be a plate, screws or combination of these.

With the patient being diabetic, she must be followed very closely for any post op complications. She would probably need shoe modification of some sort once all said and done, such as an orthotic

7 months out makes this a neglected injury.  At this point, the proponents for fusion are presenting the best long term option.  Pain is from early post traumatic arthritis and attempting to perform ORIF at 7 months, is  going to be technically very difficult (i.e. 15 minutes into the procedure you would have wished you consented the patient for a fusion).  In fact, recent studies are demonstrating that primary fusion of acute Lisfrancs fracture dislocations are associated with higher long term functional outcome scores than ORIF.  This is likely due to the congruous and limited excursion of the Lisfranc complex difficult to achieve complete anatomic reduction with our conventional methods of imaging (fluoroscopy and radiographs since we dont get CTs pre and postop).  I agree with Dr. Bottle this is a good board case.  

Prediction of Midfoot Instability in Subtle Lisfranc Injury
Journal of Bone and Joint Surgery, 04/10/09

Raikin SM et al. - Magnetic resonance imaging is accurate for detecting traumatic injury of the Lisfranc ligament and for predicting Lisfranc joint complex instability when the plantar Lisfranc ligament bundle is used as a predictor. Rupture or grade-2 sprain of the plantar ligament between the first cuneiform and the bases of the second and third metatarsals is highly suggestive of an unstable midfoot, for which surgical stabilization has been recommended.