(Kiosk 2) Lisfranc Injury, the Hidden Fracture: A Case Report

Case Diagnosis: Lisfranc Injury

Case Description: 73-year-old female with a history of coronary artery disease, lower extremity deep venous thrombosis, type 2 diabetes, vitamin D deficiency, and iron deficiency anemia, was admitted to our inpatient rehabilitation service following a ground level fall from standing. Resulting injuries included fractures to the right femoral neck, left metatarsal base, and left fibula. She required closed reduction and percutaneous pinning of her femoral fracture while other injuries were managed non-operatively. On day two of her rehabilitation stay, she developed acute pain and swelling involving her right foot without any inciting event.

Discussion: Lisfranc injury is a cause of midfoot pain and can involve the metatarsals, cuneiform bones, navicular, cuboid tarsal bones, and interconnecting ligaments. Often missed, injury to the Lisfranc joint complex can lead to chronic arthritis, pain, and disability in patients without appropriate and timely intervention. Injuries commonly occur following high-energy trauma such as vehicular collisions or falls from a height. Low-energy injuries may occur in sports when an axial or rotational force is applied during plantar flexion.

Setting: Academic inpatient rehabilitation hospital

Assessment/Results: On exam, patient had swelling around the lateral and medial malleolus of the right ankle. Furthermore, there was notable swelling and erythema of the forefoot along with exquisite tenderness to palpation of the navicular. Non-weight bearing x-rays of the foot and ankle six days prior were without acute findings involving the right foot. Follow-up computed tomography scan demonstrated Lisfranc fracture pattern involving the medial cuneiform and bases of the first through third metatarsals with adjacent callus formation, as well as a non-displaced fracture of the medial base of the navicular. Ultimately, she required open reduction and internal fixation with orthopedic surgery.

Conclusion: This case illustrates an atypical presentation of Lisfranc injury after ground level fall and a reminder that providers should be cognizant of this often missed diagnosis.