Midfoot fracture-dislocations are difficult to treat, often lead to multiple procedures, and lifetime functional impairment and disability. These injuries are often the product of high-speed motor vehicle accidents and associated with multiple life threatening injuries in a ‘polytrauma patient’. The two most described midfoot injuries in the literature are the Lisfranc fracture-dislocation and Chopart fracture- dislocation and there is ample evidence documenting the poor prognosis and the necessary treatments for these complex injuries. Contrary to previously held beliefs that metatarsal shaft fractures lead to little long-term disability, a recent study indicates that patients with three or more metatarsal shaft fractures in the forefoot actually have a worse functional outcome than the Lisfranc and Chopart fracture-dislocations.
The Lisfranc dislocation refers to ligament disruptions between the first and second metatarsals and the medial and middle cuneiform bones of the midfoot. This injury is associated with fracture-dislocations at the junction of the forefoot and the midfoot. Studies indicate that twenty percent of Lisfranc fracture-dislocations are missed during the initial evaluation. X-rays often will not reveal the fracture-dislocation and may require weight-bearing x-ray views to show the instability related to this injury. In the polytrauma patient standing is not possible, and therefore either CT scan or MRI are the necessary diagnostic tests if this injury is suspected. Currently the standard of care is operative management with either primary fusion of the unstable Lisfranc complex or internal fixation with pins or screws. If an internal fixation patient remains symptomatic with pain limiting function, a salvage fusion of the involved joints will be recommended.
Chopart fracture dislocations are again injuries of the midfoot that may be missed initially in the polytrauma patient and are products of high force trauma related to motor vehicle or motorcycle accidents. Early diagnosis is necessary and treatments include closed reduction, closed reduction with internal fixation, or open reduction and internal fixation. Again like the management of the Lisfranc fracture-dislocation, those with an unacceptable outcome will likely require a salvage fusion.
Historically, it has been a common belief in the field of orthopedic trauma that metatarsal shaft fractures healed with little disability. A study published in 2014 indicated that is not the case. The study involved measuring the functional outcome, quality of life, and dynamic functional assessments via 3D gait analysis, velocity, and step counting in patients with either a Lisfranc fracture-dislocation, a Chopart fracture-dislocation, or in a patient with three or more metatarsal shaft fractures. Surprisingly this study indicated that the individuals with multiple metatarsal shaft fractures of the forefoot had worse outcomes than the expected poor outcomes of the Lisfranc and Chopart fracture-dislocations.
Case managers and Life Care Planners must understand that the complexity of the anatomy of the foot leads to great diversity of potential injuries. Post-traumatic arthritis related to high velocity foot trauma often leads to disability and impairment. Patients with three or more metatarsal fractures, Lisfranc fracture-dislocations, and Chopart fracture-dislocations will require ongoing physician care, medication management, laboratory testing, diagnostic imaging, and orthotic management to the injured patient’s life expectancy to prevent complications and maintain function.
http://www.krankenhaus-rummelsberg.de/uploads/tx_templavoila/chopart.pdf
