Lisfranc Injuries

LIsfranc…just another one of these obnoxiously named orthopedic injuries? Actually, its named after this guy: 

Jacques Lisfranc de St. Martin, who actually was a gynecologist, with a side-gig as one of Napoleons battlefield surgons. Less obnoxious now?

Why does it matter:

• if undiagnosed, it can cause chronic instability, deformity, functional deficiency and pain
• not common (1:55.000), but frequently missed (appr 20% of cases)
• x-ray findings are often subtle or even absent on standard views. 

Basic anatomy:

• the Lisfranc joint is a name for all the tarsometatarsal joints,
• the joint separates the forefoot from the midfoot (there is also a hindfoot, if you’re wondering)
• the Lisfranc ligament secures the second metatarsal to the medial cuneiform, serving as a mortise joint anchoring the entire complex and preventing medio-lateral or plantar displacement.
• fractures and concomitant disarticulations of this joint are termed Lisfranc fracture-dislocations

How does it happen:

• often high-energy trauma, such as MVAs, falls from height, and athletic injuries, but can be low-energy rotations, especially in elderly individuals 
• most often axial load through hyperplantar flexed forefoot 

How do we diagnose it?

• suspect for anyone with severe midfoot pain, tenderness to palpation over midfoot, unable to bear weight. If complete ligamentous tear, ecchymosis on the plantar surface for the foot can sometimes be seen
• stress examination of the midfoot is positive
• the “Piano Key” test: Exacerbation of pain with dorsal and plantar flexion of each digit 
• findings may be subtle
• regular XR for foot does not rule out Lisfranc injury, so weight bearing XR or CT is essential if strong suspicion
• XR of foot may show obvious fracture, but other subtle findings may require bilateral weight bearing XRs. Findings include:
  • loss of the smooth alignments at the medial border of the second metatarsal with the medial cuneiform and/or the medial border of the fourth metatarsal with the cuboid
  • diastasis of the space between the bases of the 1st and 2nd metatarsals (>2mm in a normal foot, or >1mm relative to the contralateral foot)
• CT will give diagnosis if XR is equivocal

Treatment and folllow-up

• if strong suspicion, ortho or podiatry consult if they are in-house
• a significantly displaced injury or dislocation (>2mm widening at the Lisfranc joint) – immediate orthopedics referral in the ED is required for urgent surgical intervention.
• if no ortho in house, give posterior splint and strict non-weight bearing on crutches
• ortho or podiatry f/u within a week
• some of these patients will require operative management

Sources: Orthoinfo

CoreEM

Orthobullets

Emergency Medicine Cases

Rosens

Hyphema

Facial Trauma: Hyphema

Hyphema

Hyphema results from ocular trauma that causes bleeding into the anterior chamber. The bleeding originates from vessels in the ciliary body or iris. The blood tends to layer over time, and left undisturbed, will form a visible meniscus when the patient sits upright. Patients typically complain of pain, photophobia, and possibly blurred vision secondary to obstructing cells. Intraocular pressure should be measured because acute glaucoma may be caused by RBC clogging of the trabecular meshwork with impedance to aqueous outflow. Prevention of further hemorrhage is the principal treatment goal. Most rebleeding occurs within the first 72 hours and, when present, tends to be more extensive than the initial event. Patients should be instructed to rest in the supine position with their head slightly elevated. In addition, carbonic anhydrase inhibitors should be avoided in patients with sickle cell anemia because they can cause RBCs to sickle in the anterior chamber, which can lead to increased IOP.

There are 4 grades of Hyphema. Below is an image showing the grades and 

 

 

Evaluation - Best done under a slit-lamp exam. Watch the videos below for  

 

Dr. Anna Pickens has great videos on the slit-lamp exam and hyphema, please watch below: 

 

1. Slit Lamp: https://emin5.com/2016/02/07/slit-lamp-anatomy/

2. Hyphema: https://www.youtube.com/watch?v=vQG9kL7mpyA 

• Blood in anterior chamber
  • May only see difference in color of irises if patient is supine because blood layering is gravity dependent
  • Blood in anterior chamber only visible on slit lamp is a microhyphema
• Vision loss / Acuity changes
• Inspect the lids, lashes, lacrimal ducts, and cornea
  • Corneal abrasions often co-exist
• Assess direct and consensual pupillary response for the presence of a relative afferent pupillary defect
• Assess for Ruptured Globe which is associated with high energy mechanisms (shrapnel, BB guns, paint balls, etc)
• Check intraocular pressure after Globe Rupture is excluded
• Inquire about bleeding diathesis, anticoagulant/NSAID/aspirin use

 

Management

 

• Elevate head of bed and upright position to layer blood by gravity, open visual field while blood resorbs
• Eye shield
• Pharmacologic control of pain and emesis
• Weigh risks and benefits of stopping NSAIDs, ASA, anticoagulants
• If IOP elevated (>22) the treatment is similar to glaucoma management except if there is also a concern for a retrobulbar hematoma as a result of trauma. Topical and oral treatments include
  • Timolol
  • Topical α-adrenergic agonist
  • Carbonic anhydrase inhibitors
• Consult ophtho regarding:
  • Dilation of pupil to avoid "pupillary play" -constriction and dilation movements of the iris in response to changing lighting, which can stretch the involved iris vessel causing additional bleeding
  • Use of topical α-agonists and/or acetazolamide to decrease intraocular pressure
• Cycloplegic can be given for comfort and to decease pupillary play if globe rupture has been excluded. Options include:
  • Tropicamide (Mydriacyl)
  • Homatropine
  • Cyclopentolate (Cyclogyl, Cylate, Pentolair)
  • Scopolamine
• Topical steroid
• Treat any underlying coagulopathy

Disposition

• Should be made by the ophthalmologist after examining the patient
  • Hyphemas <33% of anterior chamber are frequently managed as outpatients
• Patients being managed as an outpatient should have ophthalmologist referral and consider outpatient screening for spontaneous hypthemas due to the association with sickle cell disease and hemophilia
• Patients on anticoagulation or anti-platelets agents should be admitted for reversal and observation.

Discharge Instructions

• No reading (accommodation may further stress injured blood vessels)
• Avoid NSAIDs
• Wear hard shield at all times
• Return to ED if rapid increase in size of hyphema or large increase in pain

Prognosis

• Rebleeding worsens prognosis as patients are at higher risk of permanent vision loss.
  • Occurs 3-5 days after initial incident
  • Complicates ~30% of cases
  • Populations at highest risk:
    • Sickle cell disease or sickle cell trait
    • Bleeding dyscrasia (including aspirin, NSAID, or anticoagulant use)
    • Initial intraocular pressure >22 mmHg
    • Pediatric patients

Grade	Anterior Chamber Filling	Normal Vision Prognosis
I	<33%	90%
II	33-50%	70%
III	>50%	50%
IV	100%	50%

Sources: EM in 5, Rosh Review, Wikem.

Pelvic Binder Placement

We recently had a sim where only one person was confident in placing a pelvic binder. So this is basic but it should be reviewed, particularly for interns, in a trauma you may be asked to place one. So if you don't read anything, please watch the 2 very short videos below: a 1 minute video on pelvic binder placement - this I believe is the same binder we have in our ed, and a 3 min video on pelvic fractures. Afterward go find the pelvic binder on your next Northside shift and take a look at it.

 

1. Pelvic Binder Placement: https://www.emrap.org/episode/pelvicbinder/pelvicbinder

2. Pelvic Fractures: https://www.emrap.org/episode/pelvicfractures/pelvicfractures

 

For binders classically an open book fracture and an unstable patient will require a binder. A open book fracture results from Anteroposterior (AP) compression forces, which cause disruption near the symphysis pubis and sacroiliac joint opening resulting in the “open-book” pelvic injury. This injury can be diagnosed on an AP pelvic X-ray if the diastasis of the pubic symphysis is >2.5 cm. The high-forces from the injuries cause shearing and tearing of blood vessels leading to hemorrhagic shock. Examination of the pelvis will reveal gross instability. “Rocking” of the pelvis is discouraged as this force may dislodge clots that have formed. Instead, the greater trochanters should be grasped with both hands and gently squeezed together. Any movement with this procedure indicates an unstable pelvic fracture. Once an unstable pelvic fracture is recognized, it should immediately be stabilized with either a properly applied sheet and towel clamps or a commercial pelvic binder -over the greater trochanters not iliac crests. Patients who have immediate stabilization have been found to have lower transfusion requirements. Additionally, the AP injury pattern stands to benefit the most from external stabilization.

 

 

More on Pelvic Fractures, types, evaluation, and management:

 

Pelvic Fractures. There are 3 types based on mechanism. 

1. Lateral Compression

• Most common
• Often T-bone MVC/pedestrian hit from side
• Usually stable as affected hemipelvis is crushed inward, reducing pelvic volume
• Associated with the unstable wind-swept pelvis fracture
• Severe cases usually associated with bladder rupture; consider CT or retrograde cystography

2. Anteroposterior Compression

• Usually unstable as the iliac wings are forced outward, increasing pelvic volume
• Often head on MVC
• Often assocciated with pelvic and retroperitoneal hemorrhage
• Coincident injuries of the thorax and the abdomen are the rule
• Associated with the unstable open book fracture
• Urethral disruption should also be considered

3. Vertical Shear

• Result from vertically oriented force (fall) delivered to the pelvis via the extended femurs
• Unstable; pelvic volume is increased
• Associated with the unstable Malgaigne fracture or bucket handle fracture

 

Evaluation: 

XR, US, CT/MRI, Retrograde cystourethrogram

1. CXR: AP - Obtain in all unconscious blunt trauma patients

2. CT

• Obtain in all hemodynamically stable blunt trauma patients with pelvic fracture on x-ray
• Exceptions include isolated pubic rami fracture, avulsion fracture

3.Retrograde cystourethrogram

• Obtain (before foley) if blood at meatus, high riding prostate, or gross hematuria

 

Management: 

Classify fracture pattern as "stable" or "unstable"

• • If unstable pelvis:
    • Wrap with sheet or pelvic binder: Place pelvic binder over greater trochanters
    • Do not over-reduce a lateral compression fracture (places increased strain on post pelvis)
    • Placing pelvic binder in vertical shear injury may worsen fracture
• Anticipate hypotension: 80-90% Venous plexus bleeding, 10-20% Arterial bleeding

 

FAST Exam

• • If hemoperitoneum is present→ OR
  • If vital signs are unstable→ OR for damage control laparotomy, not CT
  • If vital signs are stable and no hemoperitoneum→ CTAP with IV contrast
    • Contact IR for possible pelvic angiographic embolization
• Pre-peritoneal packing can rescue failed angiography (usually in venous bleeding)
  • Also an option for primary hemorrhage control
• Look for vaginal or rectal bleeding, suggests open fracture (uncommon)

 

Specific Fractures

Open Book:

• Disruption of pubic symphysis >2.5cm and the pelvis opens like a book and may be accompanied by sacroilial joint disruption
• External rotation of the hemipelvis requires binding and likely surgical fixation

Straddle Pelvic Fracture: 

• Unstable
• Both rami fractured on both sides or both rami on one side with pubic symphysis diastasis
• High rate of urinary tract and bowel injury

Pelvic Avulsion Fracture: 

• Anterior superior iliac spine
  • Occurs from forceful sartorius muscle contraction (adolescent sprinters)
  • Bed rest for 3-4 wk with hip flexed and abducted, crutches, ortho follow up in 1-2wk
• Anterior inferior iliac spine
  • Occurs from forceful rectus femoris muscle contraction (adolescent soccer players)
  • Bed rest for 3-4 wk with hip flexed, crutches, ortho follow up in 1-2wk

Sources: Rosh Review, Uptodate, EMRAP, Wikem