Lisfranc's Injury

With the NFL season approaching, a lot of fan talk is about who will be the starting quarterbacks of their favorite teams. The Las Vegas Raider's have signed veteran quarterback Jimmy Garoppolo in the off season. But didn't he have a potentially career threatening foot injury last season? It was reported initially that he had sustained the dreaded Lisfranc's joint fracture/dislocation. The Lisfranc's joint is located in the center of the foot where the 5 metatarsal bones meet the rest of the foot. This complex joint is a key component to the structure and stability of the arch of the foot. Injury to this area usually occurs in contact sports when there is force applied to the foot when is is pinned to the ground. Fractures of the metatarsal bones as well as the tarsal bones in the area can occur. The more significant structures that can be injured in this area are the ligaments that hold this complex joint together. Rupture of some of these ligaments can result in instability of the entire joint complex. Dislocation of the joint can occur leading to loss of structure and function of the foot. Ligament injury cannot bee seen on regular x-rays. If a dislocation of the joint is seen on x-rays, ligament injury can be presumed. Instability cannot be easily assessed clinically because of the swelling in the area and pain from the trauma. MRI examination is usually needed to asses the ligaments and to determine if surgery is needed to stabilize the joint. Should MRI be inconclusive, it is better to err on the side of caution and suspect the injury, because improper treatment of this injury can lead to poor outcomes. The most accurate way to assess the stability of Lisfranc's joint is by stress x-rays. This is where stress is applied to the joint while viewing it with real time floroscopic x-rays. This often requires general or regional anesthesia for accurate examination due to the pain and muscular splinting that occurs after injury. Lisfranc's injuries that are not dislocated and do not have gross instability can be managed with non weight bearing immobilization for 6-8 weeks followed by a rehabilitation program. Dislocations and instability are treated surgically. This is done 1-2 weeks after injury when the initial swelling has diminished. Most often open reduction with internal fixation/stabilization is performed through 1-3 incisions on the top of the foot. Closed reduction and percutaneous fixation can be used in some cases without associated fractures. Here the joint is relocated through manipulation using floroscopic guidance and pins or screws are inserted across the joints through small incisions on the sides of the foot. Late recognized or neglected Lisfranc's injuries may require primary joint fusion procedures to restore the stability and structure of the foot. After surgery, non weight bearing is required for 8-10 weeks followed by rehabilitation with a return to full return to sports taking up to one year. Fortunately for Jimmy G, his testing showed that the ligaments were stable with only metatarsal fractures to repair. He should be able to return to the field this fall.