foot fracture

Monday, November 14, 2011

Big hits make the highlights after every NFL game and often they show a quarterback absorbing the brute force of an attacking rusher. While significant injury can occur (check out Tony Romo and Michael Vick’s rib fractures). Most often they get up, dust themselves off and call the next play. Sometimes, though, it’s damage done in the pile that puts the quarterback, or any other player for that matter, on the sideline. And so goes the story of Matt Schaub who broke his foot on a quarterback sneak, hurt in a pile of three hundred pound linemen.

Schaub sustained a Lisfranc injury of the metatarsal tarsal joints of the mid foot. A quick anatomy lesson: the metatarsals are the long thin bones that connect each toe to the midfoot, where the tarsal bones are located. Dr. Jacques LisFranc de St. Martin was a 19th century surgeon who describe the anatomy of the 2nd metatarsal bone and the ligaments that connect it to the tarsal bone and keep the joint stable. This joint is put under great stress when the foot flexes down as the body falls forward, think of stepping into a hole falling forward. In football, the injury occurs when the foot is pointing downwards and somebody falls onto the heel.

Lisfranc fractures can be subtle and hard to diagnose. Often the patient can’t remember the exact mechanism of injury but knows that walking is either very difficult or impossible because of the pain. Physical exam shows swelling on the top of the foot and pain with foot movement. X-rays are important to do but they are often difficult to interpret. The fracture may not be recognized on initial reading.. More importantly, there can be subtle changes in alignment of the metatarsal and the tarsal bones at the joint that may be missed. Some studies suggest that only 60% of fractures are accurately diagnosed. This is important because missing this injury and failing to repair it can lead to arthritis in the joint and chronic pain. It’s important to remember that the foot absorbs the force and shock of every footstep and solid architecture and anatomy is needed for the foot to do its job. CT scan of the foot may be needed to get accurate images and make a firm diagnosis.

Treatment of Lisfranc fracture depends upon the stability of the injury. Stable sprains and fractures that are not displaced potentially can be treated conservatively. That means a non-weight bearing cast for at least 6 weeks. Gradual weight bearing occurs until the patient can walk normally without pain. If there is any displacement of the joint, surgery is required to place screws across the joint to allow the bones to heal in appropriate alignment. Even with the best of care, arthritis can chronic pain can be a complication in 25% of patients.

It often takes time for pro quarterbacks to mature. Game time experience allows instincts to develop and help recognize and react to situations as they present themselves. The same is true for doctors. Good clinicians learn from each patient and develop instinct and pattern recognition. When a blood test r x-ray doesn’t fit the patient’s situation, it’s often the patient that has the clue that will lead to the diagnosis. The Lisfranc fracture is just one example where technology sometimes may take a back seat to a doctor listening to the patient and trusting the physical examination.

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foot fracture

Big hits make the highlights after every NFL game and often they show a quarterback absorbing the brute force of an attacking rusher. While significant injury can occur (check out Tony Romo and Michael Vick’s rib fractures). Most often they get up, dust themselves off and call the next play. Sometimes, though, it’s damage done in the pile that puts the quarterback, or any other player for that matter, on the sideline. And so goes the story of Matt Schaub who broke his foot on a quarterback sneak, hurt in a pile of three hundred pound linemen.

Schaub sustained a Lisfranc injury of the metatarsal tarsal joints of the mid foot. A quick anatomy lesson: the metatarsals are the long thin bones that connect each toe to the midfoot, where the tarsal bones are located. Dr. Jacques LisFranc de St. Martin was a 19th century surgeon who describe the anatomy of the 2nd metatarsal bone and the ligaments that connect it to the tarsal bone and keep the joint stable. This joint is put under great stress when the foot flexes down as the body falls forward, think of stepping into a hole falling forward. In football, the injury occurs when the foot is pointing downwards and somebody falls onto the heel.

Lisfranc fractures can be subtle and hard to diagnose. Often the patient can’t remember the exact mechanism of injury but knows that walking is either very difficult or impossible because of the pain. Physical exam shows swelling on the top of the foot and pain with foot movement. X-rays are important to do but they are often difficult to interpret. The fracture may not be recognized on initial reading.. More importantly, there can be subtle changes in alignment of the metatarsal and the tarsal bones at the joint that may be missed. Some studies suggest that only 60% of fractures are accurately diagnosed. This is important because missing this injury and failing to repair it can lead to arthritis in the joint and chronic pain. It’s important to remember that the foot absorbs the force and shock of every footstep and solid architecture and anatomy is needed for the foot to do its job. CT scan of the foot may be needed to get accurate images and make a firm diagnosis.

Treatment of Lisfranc fracture depends upon the stability of the injury. Stable sprains and fractures that are not displaced potentially can be treated conservatively. That means a non-weight bearing cast for at least 6 weeks. Gradual weight bearing occurs until the patient can walk normally without pain. If there is any displacement of the joint, surgery is required to place screws across the joint to allow the bones to heal in appropriate alignment. Even with the best of care, arthritis can chronic pain can be a complication in 25% of patients.

It often takes time for pro quarterbacks to mature. Game time experience allows instincts to develop and help recognize and react to situations as they present themselves. The same is true for doctors. Good clinicians learn from each patient and develop instinct and pattern recognition. When a blood test r x-ray doesn’t fit the patient’s situation, it’s often the patient that has the clue that will lead to the diagnosis. The Lisfranc fracture is just one example where technology sometimes may take a back seat to a doctor listening to the patient and trusting the physical examination.

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