Lisfranc injury ends NFL season potentially

Matt Schaub of the NFL's Houston Texans, sustained a midfoot sprain to the right foot, notably called a "Lisfranc" injury in last week's game. This is considered a "significant injury" which has the potential to end his season in 2011.







Why is that?








Most players require lateral movement and the ability to jump and stop suddenly after sprinting. These are all functions that the midfoot complex will play a significant role in accomplishing. The injury itself is a complicated one, with numerous variations that each have a significant prognosis in longterm funcion. This injury may have a pure ligamentous tear, or even a fracture component with the ligament tear. With this, some orthopedic literature has condoned the possibility that with regards to athletes, surgery may be indicated in more cases to realign the foot and promote more stability longterm. Other studies have shown that if the alignment is maintained with the bones of the midfoot, a cast or walking boot may be sufficient for a minimum of 6 weeks followed by progressive weight bearing.


Classification
There are three classifications for the fracture:

1) Homolateral: All 5 metatarsals are displaced in the same direction. Lateral displacement may also suggest cuboidal fracture
2) Isolated: 1 or 2 metatarsals are displaced from the others
3) Divergent: metatarsals are displaced in a sagittal or coronal plane. May also involve intercuneiform area and a navicular fracture.

Treatment
Treatment options include operative or non-operative treatment. If the dislocation is less than 2 mm, the fracture can be managed with casting for 6 weeks. The patient's injured limb cannot bear weight during this period. For operative treatment, screws +/- k-wire will be used for internal fixation of the fracture after closed or more likely open reduction. Again, the patient's injured limb should not bear weight for approximately 6–12 weeks. The screws/k-wires are usually removed later, sometimes before weight bearing.

At FFLC, we find this injury to be a relatively underdiagnosed entity, and have had to treat numerous late onset arthrosis, as well as acute injury patients with this mechanism of injury. If you are on the field, and you twist your foot and it remains painful, it is not a straightfoward injury and should be followed by a foot and ankle surgeon.

Even with that being said, the possibility of late onset arthrosis and deformity can ensue without proper diagnosis, and in the NFL the players are fortunate to have medical professionals there to diagnose them right at the time of injury.

Is MRI really being overutilized?

So often in this litigious society, practitioners are being scrutinized by lawyers for malpractice. This includes lacking diagnostic information to either support or negate a diagnosis. That is why wounds are cultured without looking "infected" and why radiographs are done even after soft tissue surgery. So often are practitioners forced to practice "defensive medicine" that the costs for health care are going to rise simply because of these examinations. Without these tests to "confirm" a diagnosis, surgery may not be authorized by an insurance company, or if someone is injured on the job or as part of a traffic accident, the extent of damage may be overlooked.

This is in my opinion, that these tests need to be done. MRI should be ordered to confirm or negate osteomyelitis in the presence of diabetic foot wounds. Also with severe ankle sprains to rule out underling ligamentous damage or cartilage lesions. Without the tests, even in the presence of clinically suspicious findings, there will always be a malpractice lawyer who will ask you, "why didn't you get the test, Dr?"

In the case of MRI, there are few to no real risks, as there are no radiation exposures for this exam. Also, for patients that are not able to have this test (ie. pacemaker,etc) it is usually determined by CT scan for whatever the reason for the advanced imaging. In other words, these tests are available and although not entirely necessary, they are invaluable to not only diagnose with more certainty, but also allow for surgical planning and provide further means to demonstrate pathology leading towards surgical intervention in the case of malpractice depositions.

The coutnter argument is that over-utilization of MRI is expensive and wasteful, according to researchers. For example, the information needed to diagnose knee OA can be obtained using x-ray. While an x-ray can cost less than $150, the cost of an MRI is about $2,500.
Medical imaging accounts for 10 to 15% of Medicare payments to physicians. Ten years ago, medical imaging accounted for less than 5%. The cost of medical imaging is expected to continue soaring at an annual rate of at least 20%. Suffice to say, it's an expensive business.

And sometimes, MRI findings may be overly sensitive, leading to incorrect diagnosis, or over diagnosis of tendon pathology.

This nails home another concept I have discussed on here on many occasions. We treat the patients, not the MRI findings. We need to understand the personality of the injury and how that injury is presenting itself in you, how your lifestyle or quality of life is affected, and whether or not the findings that we have identified on the MRI are in fact the competent producing cause of your discomfort — and then come up with an appropriate treatment plan that will likely involve a period of nonsurgical management— which, if unsuccessful perhaps might lead to an indicated surgical procedure, if your lifestyle changes and quality-of-life dictates that this is in fact an option.