Lisfranc Injury of the Foot: A Commonly Missed Diagnosis

Lisfranc Injury of the Foot: A Commonly Missed Diagnosis

Case Study Example:

The patient presented to the Emergency Department with a limp, following a twisting injury to the left foot. After being briefly examined, an x-ray revealed no fracture and the patient was subsequently discharged with crutches and advised to follow up with their GP.

A few weeks later after being referred to the fracture clinic by their GP, further x-rays were performed, along with an urgent CT scan which revealed a Lisfranc injury to the left foot. This is where bones in the midfoot have become detached following trauma. The patient subsequently underwent Open Reduction and Internal Fixation surgery to treat the injury.

How to Improve Patient Safety and Reduce the Risk of Litigation

TMLEP would like to raise awareness of the importance of correctly diagnosing Lisfranc fractures to improve patient care and avoid the risk of potential litigation.

  • It is recommended that clinicians have a high index of suspicion for Lisfranc injuries when patients present with midfoot pain following trauma. Lisfranc injuries are more often associated with a significant trauma mechanism, but can also occur with low energy injuries; in this case, a twisting injury resulted in a Lisfranc injury. Clinicians should be mindful of this when examining foot injuries to help prevent misdiagnosis.

  • Clinicians should ensure that a comprehensive and thorough examination is completed and documented. This should include the location of any tenderness, whether bruising is present or not, whether swelling is present or not, whether the patient can weight bear or not. This is recommended for all potential fractures.

  • It is important that clinicians are aware of the pitfalls of plain film radiography. Inadequate films can obscure changes associated with a Lisfranc injury. The second tarsometatarsal joint line must be visible. These are weightbearing films which are often difficult to obtain in the acutely injured foot. Where the index of suspicion is high, the patient should either have CT imaging or a follow up plain film if symptoms are not settling.

  • It is further recommended when diagnosing a midfoot sprain, a careful explanation is given to the patient. They should be informed of the likely timeline for function to be regained. If they are not improving as expected, they should be advised to seek further help from their GP or Urgent/Emergency care and this should be documented in the notes. It is recommended that the clinician is confident that the patient has fully understood the explanation.

To Summarise

Lisfranc injuries are uncommon and can be difficult to diagnose which can put patients at risk of unnecessary harm and clinicians at risk for potential claims.

A high index of suspicion for Lisfranc injuries and a thorough clinical and radiographic assessment can result in earlier detection of these injuries and lead to a better outcome. Furthermore, clinicians should acknowledge the possibility of Lisfranc injuries, even in low energy injuries.

The guidance above is designed to help improve patient safety, reduce the possibility of misdiagnosis, and the risk of potential litigation.

References

  • Co-written by TMLEP’s Patient Safety Publishing Group, Charlotte Wilson-Holliday, TMLEP Analyst and Dr David Hodgson, Consultant in Emergency Medicine. (2020). Lisfranc Injury of the Foot: A Commonly Missed Diagnosis. TMLEP Clinical Risk Case Studies. 4 (7), 1.

Important Note

This article is intended to raise awareness to clinical risk issues in an effort to reduce incidence recurrence and improve patient safety. This is not intended to be relied upon as advice. Facts have been altered to ensure this case is non-identifiable, albeit clinical learning points remain applicable. To request an independent clinical review, please contact admin@tmlep.com or call +44 (0) 203 355 9796.