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Lisfrancs Fractures
Lisfranc's Foot Fractures in the Foot: An Injury That Gets Missed Often and Won’t Get Better Without Treatment - By San Francisco’s Foot Fracture Specialist
What is a Lisfranc's Injury?
A Lisfranc’s Fracture is an injury to the midfoot where the Lisfranc’s ligament tears (called a ligament rupture by podiatrists or foot doctors). In some cases, the ligament doesn’t really tear but it yanks off a small piece of bone where the ligament is anchored. In this case doctors call it an “avulsion fracture.” Because Lisfranc’s ligament is one of the primary structures stabilizing the bones in the midfoot, a Lisfranc’s fracture has to be treated correctly to heal correctly. Otherwise continued foot pain, arthritis and loss of foot function may result.
 
As a foot surgeon, what makes me think you might have a Lisfranc’s Fracture?
The classic story of the patient we see with a missed Lisfranc’s fracture is one who had some kind of injury. Maybe they were in a minor car accident where they rear-ended another vehicle. Maybe the twisted the foot playing soccer. Or perhaps they just tripped over a root while trail running. 
Regardless of the specific way the foot injury happened, these patients usually have a couple of things in common. First, they have aching or throbbing pain in the midfoot, most often across the top of the foot. They usually remember having some swelling in the foot and possibly even some bruising right after the initial accident.
They may have applied some ice, rested and even worn an Ace wrap or ankle brace, but the pain in the foot just isn’t getting any better. The foot still aches when walking and throbs after even a short run. But the other thing that is key about people with a missed Lisfranc’s fracture is that the person had x-rays and were told by the doctor “it’s just a midfoot sprain.” 
Here’s a just one real world example of I patient I saw. A young woman was riding on the back of a motorcycle that was involved in a minor accident. Her foot was bruised, swollen and aching so she went to the hospital to get it checked out by the emergency room doctor. While she was there, she had 9 (not one, not two, not three, but NINE) xrays of her right foot. 
Now, given that they took 9 x-rays in the E.R., the doc in the Emergency Room must have been very suspicious something was wrong. The reason I say this is that in most cases with only 3 standard views of the foot, the doctor should see pretty much everything in the foot necessary to tell whether or not anything is broken. 
Interestingly the radiologist also looked at those 9 films dictated a “Radiology Report” that said. “9 views right foot. Normal right foot.”  Wrong!!!!!!
I looked at her xrays and guess what?  Broken right foot, not “normal right foot.”
So after a week of hobbling around on that aching, swollen foot she showed up in my office and said “MY FOOT IS BROKEN! They said it was just a sprain, but I know something is wrong.” And she was right. She had a Lisfranc’s fracture that was simply not going to get better without surgery.
Why Won’t a Lisfranc’s Fracture Get Better?
The problem with Lisfranc’s injuries (also called Tarsaometatarsal Fracture/Dislocation) is that the joint and any associated fractures simply cannot heal if you walk on them. This is because of two basic reasons.
The first reason is that when you walk, all of the metatarsal bones are moving against the tarsal bones in the midfoot at Lisfrancs joint (the tarso-metatarsal complex). This motion alone is enough to keep the injury from healing.
The second reason is when these injuries happen, the ligaments that tear can actually get stuck between these bones and act as a physical barrier to healing. Simply put, you have to clear any debris before the area can heal. 
How are Lisfranc’s Fractures Diagnosed?
The first part of diagnosing a subtle fracture like a Lisfranc’s injury is to be aware of the possibility when listening to the patient’s story of how the injury happened. There is a saying in medicine that “The eyes see what the mind knows.” So if the doctor isn’t really aware of this injury, it might get missed. A podiatrist who is thinking of a Lisranc’s fracture can easily poke and prod on a couple of areas to either determine that it is or is not likely to have occurred. 
Foot X-rays are also an diagnostic important tool. With 3 views of the foot, we should be able to tell with relative certainty whether or not one of these injuries happened. In defense of the E.R. docs, the midfoot has a lot of bones overlapping and it can be tricky to look for just the right clues. 
How Do You Really Know Lisfranc’s Injuries are Often Misdiagnosed?
While I was in the beginning of my foot and ankle surgery residency, I saw several Lisfranc’s fractures that other doctors missed. So I did I research study to investigate how often the “clues” that we know show up on x-rays get missed by the doctors who would be likely to see people with foot injuries. 
What we found was that Family Practice Physicians failed to recognize 98.4% of one of the clues on x-ray. Emergency Room Physicians missed 96.7% of another of these x-ray clues to a broken foot. Theses findings were presented at the Annual Scientific Conference of the American College of Foot and Ankle Surgeons and won 2nd Place for the research.
Why are the So Frequently Misdiagnosed?
Part of the reason these fractures are so often missed it that the midfoot and Lisfranc’s joint in particular is very complicated. It is no surprise that a Podiatric Foot Surgeon is 80 times more likely to notice this fracture pattern. 
Lets face it, if you have a foot injury, you want a foot specialist. But of you have a heart attack, you really don’t want a foot surgeon reading your EKG and figuring out whether or not you need heart surgery.
What Can I Do If My Lisfranc’s Fracture Was Misdiagnosed? 
The good news is that Lisfranc’s fractures that are missed can still heal. But they must be treated. The place to start is with an expert second opinion. Even if you have an HMO and have been told nothing is wrong, you still should get a second opinion. 
Look at this way… if you get some expert advice in the form of a second opinion it can save you a huge amount of trouble later. Even if you have been walking on it for several weeks it can still be repaired and allowed to heal. 
But if you ignore it hoping it will go away, bad things happen. Over time, the extra motion that happens because of the torn ligament leads to arthritis. The midfoot becomes more painful. Eventually, the entire arch can collapse at the whole Lisfranc’s joint complex falls apart and dislocates. But all this is preventable if you know what needs to be treated. The best part is that you can get the second opinion and have that doctor send a letter to your HMO so that your HMO doctors (who’s costs are covered under your insurance plan) can then fix the injury if surgery is required. 
The bottom line is that foot pain is never normal. Bruising in foot is also a very bad sign and one that often suggests a fracture of some type. If you think you might have a Lisfranc’s injury, you owe it to yourself to get an expert to look at your foot and your x-rays.

Dr. Christopher Segler is a San Francisco foot surgeon and nationally recognized foot and ankle fracture specialist. He won awards from the American College of Foot and Ankle Surgeons two years in a row for his research on diagnosing difficult to identify foot and ankle fracture patterns. He offers second opinion consultations for people in the San Francisco Bay Area who have foot pain that just isn't getting better. In most cases he can even evaluate your foot problem during a house call appointment at your home or office. If you have a question about your foot or ankle injury and would like to speak with him, you can reach him at (415) 308-0388.
 

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