Treating An Acute Lisfranc Fracture With ORIF

These authors discuss the use of open reduction and internal fixation in the treatment of a 20-year-old patient with a Lisfranc injury.

A 20-year-old African-American woman presented to the emergency department with left foot pain after going on a waterslide at an amusement park. She stated that, hours after the incident, the pain was very severe and was accompanied by swelling and throbbing pain. According to her mother, the patient tried placing an ice pack at home and her symptoms worsened. Her past medical history is significant for controlled asthma and treated sinusitis. The patient did not smoke. She was also allergic to sulfur and penicillin.

The patient appeared to be alert and oriented, but had decreased range of motion of the left foot. There was a weakly palpable left dorsalis pedis pulse in comparison to the right. Her pain was severe when the left foot was everted. Swelling was visible at the first metatarsal of the first digit with tenderness to palpation of the entire foot. No additional signs, such as erythema, drainage or acute infections, were present.

We obtained lateral, frontal and oblique radiographs of the left foot. There was a significant finding of an oblique fracture at the lateral aspect of the base of the first metatarsal bone. There was a comminuted fracture at the base of the second metatarsal bone with an intra-articular extension. Mild spatial widening was significant between the first and second metatarsal bone, a suspected Lisfranc injury. Lastly, moderate generalized soft tissue swelling was also visible.

After thorough review, the next step was to apply a Jones compression with a posterior split to stabilize the joint and prevent further exacerbation. We scheduled surgical intervention for 10 days later. Upon discharge from the emergency department, the patient took oral analgesics for pain management.

Two days after the initial emergency room visit, the patient followed up in the outpatient clinic. A left foot computed tomography (CT) scan in the axial plane demonstrated an avulsion fracture at the lateral base of the first, second and third metatarsal bones. A non-displaced fracture at the medial base of the fourth metatarsal bone was also present. However, the midfoot alignment appeared intact.

Pertinent Insights On The Surgery And Post-Op Course

Eight days later, we repaired the Lisfranc complex with open reduction and internal fixation (ORIF) along with implanted hardware (plates, screws, pins) as planned.

After sedation of the patient with general anesthesia, we proceeded to perform the left Lisfranc repair with the Charlotte Lisfranc Reconstruction System (Wright Medical). We utilized two K-wires and two screws, which measured 3.7 mm x 30 mm and 3.7 mm x 40 mm. After performing subsequent anatomic closure, we used a bivalve plaster cast to cover the operated foot.

Postoperatively, the patient remained stable without complications. Upon discharging the patient from the surgical suite, we advised her to ambulate with crutches, elevate her foot when resting and intermittently place an ice bag behind the knee of the operated limb. We instructed the patient to contact the emergency room if complications arose after discharge from the hospital.

On the ninth postoperative day, we reevaluated the patient in the outpatient clinic. She denied symptoms of fever, nausea, vomiting and/or dyspnea. The patient also denied left foot pain. She ambulated with crutches and the cast over the left foot appeared clean and intact. Upon examination of the foot, no signs of infection were visible. The two K-wires were intact within the third and fourth metatarsals. Upon discharge of the patient from the clinic, we advised her to have physical therapy to regain normal function. She had follow-up in the clinic two weeks later to remove the K-wires.

Dr. Shah is an MD graduate of the class of 2016 from the American University of Antigua.

Dr. DeMeo is the Director of Foot and Ankle Surgery at Interfaith Medical Center in Brooklyn, NY.