lisfranc stress exam?

[sinustarsi]

How many of you guys in private prictice stress your lisfranc injury under General for possible guarding? If CT/xray shows no step off and joints are congruent, but if you have mid-foot fxs, dont we need to do a stress exam? I thought maybe ankle block but general will be ideal. Let me hear how you handle the stress cause I am stressing the question. Thanks.

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[Feli]

Clinical exam, XR, and maybe a CT (esp frontal plane) is about all you should need in most possible lisfranc case workups. I probably ordered about a dozen foot CTs for lisfranc fx/disloc during my pgy-1 year, but they were ordered more for surg planning - diagnosis was already pretty obvious in nearly all based on exam. When you see a Lisfranc in the ER (or in clinic as an ER "ankle sprain" f/u), you will probably know it just from clinical hx/symptoms/exam... they can't walk, massive edema/ecchy if more than a few hours s/p, usually at least some fleck or displacement sign on plain XR, etc.

There are some papers, incl a good one in JBJS 2009, that say MRI is the most accurate (~95% Sen, Spec) since it'll show both the subtle fx and ligament tear in case of a possible pure ligament lisfranc injury, but MRI's also the most expensive (beats CT by a longshot). I've ordered foot MRI in a couple adolescents in whom I saw nothing on XR but the clinical exam was still suggestive of more than just a contusion/sprain after a couple weeks of casting. FWIW, all were negative. That's basically the pattern I've found to work for lisfranc... exam + XR, CT for op plan if it's almost surely a lisfranc, splint a week then poss MRI if it's still ambiguous and it would be potentially detrimental to miss it or treat conservatively (kid, athlete etc).

...Pre-op stress views to "justify" any F&A surgery are pretty much BS, IMO. They are very very subjective, and for many injuries, I'm just not sure they change the treatment in anyways. If the ankle/midfoot/etc is symptomatic, it's painful, unstable when you do drawer tests, it "gives out" and "catches" when the patient walks, etc... then fix it (duh). I don't care what the XR stress test says, and it's a nice way to cause the patient pain of the anesthetic inject and the stress XRs themselves. If the injury's, symptomatic, fix it surgically... obviously lower surg threshold in serious athletes and higher threshold in everyday avg Joes. You always can take pre/post flouro when you do ligament repair/recon or osseous fixation... there's your "stress views" lol.

 

[sinustarsi]

I disagree. I think stress exam is very important. How many of us do order MRI for lis franc and how many radiologist/podiatrist are great at reading lisfranc tear on MRI? If the radiologist does not see it and you dont treat a tear, is that standard of care? plus you did mention the cost!
When you do ankle orif, dont you perform a cotton test? isn't that a stress exam? Do you order MRI before ankle fx to see if the syndesmosis is out? I think you need to stress and if unstable, you need to fix it. I just need to know if I can get a conscious sedation or general early in the exam.

 

[Podfather]

I disagree. I think stress exam is very important. How many of us do order MRI for lis franc and how many radiologist/podiatrist are great at reading lisfranc tear on MRI? If the radiologist does not see it and you dont treat a tear, is that standard of care? plus you did mention the cost!
When you do ankle orif, dont you perform a cotton test? isn't that a stress exam? Do you order MRI before ankle fx to see if the syndesmosis is out? I think you need to stress and if unstable, you need to fix it. I just need to know if I can get a conscious sedation or general early in the exam.

Well in my opinion, if the dislocation isn't clinically or radiographically noted then even with ligamentous disruption, it is non displaced and should be treated non-operatively for the typical patient. MRI or CAT scan may be helpful to determined if there is displacement not apparent on plain films or reveal fractues of the metatarsal bases or cuneiforms. Yes if a ligament is ruptured, stressing it will cause displacement but does that mean surgery? Think if we did that for ankle sprains. All would show displacement/instability with stress but do we fix them in the non elite athlete? I saw a lecture many years ago by an individual who claimed to have done 200 Lis Franc's repairs within a few years. During his presentation 95% were diagnosed with stress testing (some very borderline, how much stretch/dislocation is acceptable? would a ligamentous lax person yield a false positive?) and for me were simple foot sprains.

 

[PADPM]

Well in my opinion, if the dislocation isn't clinically or radiographically noted then even with ligamentous disruption, it is non displaced and should be treated non-operatively for the typical patient. MRI or CAT scan may be helpful to determined if there is displacement not apparent on plain films or reveal fractues of the metatarsal bases or cuneiforms. Yes if a ligament is ruptured, stressing it will cause displacement but does that mean surgery? Think if we did that for ankle sprains. All would show displacement/instability with stress but do we fix them in the non elite athlete? I saw a lecture many years ago by an individual who claimed to have done 200 Lis Franc's repairs within a few years. During his presentation 95% were diagnosed with stress testing (some very borderline, how much stretch/dislocation is acceptable? would a ligamentous lax person yield a false positive?) and for me were simple foot sprains.

I could not agree more. I practice relatively close to a very well known orthopedic group that treats several professional sports teams. I know one of the orthopods and it's amazing how conservative he is when it comes to treating the types of injuries mentioned, including some of the ligamentous injuries above, ankle ligament disruptions, etc, ESPECIALLY in the non elite athlete.

And this seems to really be the new trend.

Some of the best trained and brightest surgeons I know are the most conservative when it comes to bringing these patients to the O.R. That alone should send a message.

There are a LOT of patients out there getting better without going to the O.R.!

 

[newankle]

If subtle I order an MRI. Otherwise I "stress" them by taking a fully weightbearing xray and evaluate for diastasis/separation. If that is present and/or 2nd met base fx at attachment, it is functionally torn indirectly and I will percutaneously reduce and fixate. Less active patients I'm more likely to treat conservatively. Even in the ones I treat conservatively, I do weightbearing views after immobilization to ensure no incongruity.

 

[Feli]

I disagree...
...When you do ankle orif, dont you perform a cotton test? isn't that a stress exam? ...

(ahem)

......Pre-op stress views to "justify" any F&A surgery are pretty much BS, IMO. They are very very subjective, and for many injuries, I'm just not sure they change the treatment in anyways. If the ankle/midfoot/etc is symptomatic, it's painful, unstable when you do drawer tests, it "gives out" and "catches" when the patient walks, etc... then fix it (duh). I don't care what the XR stress test says, and it's a nice way to cause the patient pain of the anesthetic inject and the stress XRs themselves. If the injury's, symptomatic, fix it surgically... obviously lower surg threshold in serious athletes and higher threshold in everyday avg Joes. You always can take pre/post flouro when you do ligament repair/recon or osseous fixation... there's your "stress views" lol.

 

[krabmas]

I could not agree more. I practice relatively close to a very well known orthopedic group that treats several professional sports teams. I know one of the orthopods and it's amazing how conservative he is when it comes to treating the types of injuries mentioned, including some of the ligamentous injuries above, ankle ligament disruptions, etc, ESPECIALLY in the non elite athlete.

And this seems to really be the new trend.

Some of the best trained and brightest surgeons I know are the most conservative when it comes to bringing these patients to the O.R. That alone should send a message.

There are a LOT of patients out there getting better without going to the O.R.!

I respectfully disagree with this. There is a fairly recent article within the past 2 years by Myerson about purely ligamentous injuries doing better with a primary fusion.

Even the Lis Franc fracture dislocations tend to go on to fusions in 5 years or so. Would you want a stable foot that will last a lifetime, instead of needing to go back to the OR and do the NWB --> PT course x 2?

In residency most of my attendings (podiatry and ortho trauma) treated this injury very agressively with surgery, and where I am in fellowship as well is quick to take these pt to the OR for primary fusions for any unstable Lis Franc injury.

 

[Podfather]

I respectfully disagree with this. There is a fairly recent article within the past 2 years by Myerson about purely ligamentous injuries doing better with a primary fusion.

Even the Lis Franc fracture dislocations tend to go on to fusions in 5 years or so. Would you want a stable foot that will last a lifetime, instead of needing to go back to the OR and do the NWB --> PT course x 2?

In residency most of my attendings (podiatry and ortho trauma) treated this injury very agressively with surgery, and where I am in fellowship as well is quick to take these pt to the OR for primary fusions for any unstable Lis Franc injury.

I agree that in the displaced Lis Franc fracture dislocation surgery is indicated. There is controversy as to whether to ORIF or perform a primary fusion. My preference is in severe dislocations, comminution, and cartilage damage arthrodesis makes sense and have performed primary arthrodesis (just like in other severely comminuted intrarticular fractures). For lesser Hardcastle classification patterns I will still do an ORIF. Where I have a problem is with the aggressive treatment of subtle injuries. If there is minimal/no displacement or if ligamentous disruption is only noted on MRI or stress exam then IMO most of these patients only require immobilization.

Another controversy is the acute charcot Lis Francs dislocation. If vascular status is intact, I will treat the charcot until quescence then perform an arthrodesis. Some choose to open the acute charcot and attempt an ORIF.

 

[PADPM]

I respectfully disagree with this. There is a fairly recent article within the past 2 years by Myerson about purely ligamentous injuries doing better with a primary fusion.

Even the Lis Franc fracture dislocations tend to go on to fusions in 5 years or so. Would you want a stable foot that will last a lifetime, instead of needing to go back to the OR and do the NWB --> PT course x 2?

In residency most of my attendings (podiatry and ortho trauma) treated this injury very agressively with surgery, and where I am in fellowship as well is quick to take these pt to the OR for primary fusions for any unstable Lis Franc injury.

You may have misunderstood the context of my post, or I simply didn't make it clear. Podfather had discussed ankle injuries in his post and I was refererring to ankle ligamentous injuries, not unstable midfoot/Lis-Franc's injuries.

I was referring to my experience with some very well known orthopedic groups in my area who treat professional sports teams, and the way they treat ligamentous injuries of the ANKLE.

Hopefully, my point is now a little "clearer"!

 

[krabmas]

You may have misunderstood the context of my post, or I simply didn't make it clear. Podfather had discussed ankle injuries in his post and I was refererring to ankle ligamentous injuries, not unstable midfoot/Lis-Franc's injuries.

I was referring to my experience with some very well known orthopedic groups in my area who treat professional sports teams, and the way they treat ligamentous injuries of the ANKLE.

Hopefully, my point is now a little "clearer"!

yes, you are right, I misunderstood. My apologies. some ligamentous injuries of the ankle def do not require surgery until after failing conservative care.