Imaging Case of the Week 8

It is 2am and there is a trauma patient in the resus area. Primary survey does not reveal any injuries. On secondary survey, you note that the patient has a swollen left foot and your next step is obviously to x-ray the area of interest to look for any fractures. In the meantime patient wants to know if he can be discharged as he has to fly out to a remote area for work soon. The x-rays are here. Would you let him go? What do the x-rays show?

Answer
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3 thoughts on “Imaging Case of the Week 8

  1. Hi,

    Plain xray of the left foot in two projections, AP and lateral.
    Adequate exposure and quality
    Markedly widening of the space between the base of the first and second metatarsal bones, about 4mm, with lateral type (divergent) dislocation of the lateral 4 metatarsal bones.
    Fractured medial cuneiform and likely the lateral cuneiform as well.
    Soft tissue edema
    No other bone injuries
    Lateral film shows no significant abnormalities.

    Summary:
    Significant left foot xray findings in the form of widening of the first metatarsal and tarso metatarsal joint which is highly suggestive of Lis franc joint # dislocation.
    In the setting of trauma of this patient:
    1. Painful distracting injury, should not clear C spine clinically.
    2. Significant force, look for other injuries.
    3. Foot threatening injury, significant morbidity associated with this type of injury. Check neurovascularity. Therefore, the condition should be explained to the patient in details.

    Management:
    1. Analgesia
    2. Back slab & RICE
    3. CT foot
    4. Admission & Ortho consultation, emergency .

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    • Hi

      Thank you for your extensive coverage of Lisfranc`s.

      On the CT scans,this patient had associated cuboid and medial cuneiform fractures.

      C Spine clearance in the right context though. If the injury is secondary to fall of heavy object on the foot, I wouldn`t chase the c spine for a fracture. And in regards to mechanism of Lisfranc`s it is not always high impact injury that causes it. In people who sustain simple plantar flexion injuries, the tarsometatarsal ligaments can `snap` and cause Lisfranc`s.

      Tethering/tenting of the skin on the dorsum of foot is another indication for emergent reduction. In the absence of any neurovascular, fascial compartment or pressure area catastrophies, I do not think orthopaedic surgeons are going to rush the patient to theatre at 3 am!

      Regards
      Prathibha

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  2. Thanks for your thoughts.
    1. Mechanism of injury: you are right it can result from forced planterflexion. However, given the stem trauma I presumed multisystem trauma. Just trying to make the answer exam palatable
    2. Main aim of admission is RICE to prevent further tissue swelling/compartment syndrome, not necessary ortho intervention per say.

    Thanks once again 🙂

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