A 28 y.o. male comes to the ED with severe foot pain after dropping a heavy weight on his foot

Why would you do a standing xray of the foot? He states he cannot bear weight on the L foot.

Our patient had  a Lisfranc injury.  A Lisfranc injury if the most common type of dislocation of the foot and can be subtle on xray.  The Lisfranc ligament attaches the medial cuneiform to the second metatarsal base.  The ligament helps wedge the base of the 2nd metatarsal between the medial and lateral cuneiforms creating a keystone-like configuration and  acts as a transverse stabilizer of the foot.   If this injury.  If the injury is missed it can result in disabling pain and arthritis.  If a distance between the first and second metatarsals s more than 2 mm is seen on a weight bearing view, the injury should be suspected.  The weight bearing view also gives you the opportunity to compare the space to the unaffected foot.

If the Lisfranc ligament is torn it often requires surgical repair.

Of course Lisfranc  fractures can be more obvious.  Severe injuries can result in a compartment syndrome of the foot.  

This midfoot injury is a bit more obvious

In addition to the Lisfranc fracture, fractures of the talus, calcaneus and navicular bone can also be easily missed.  The anterior process of the calcaneus can be fractured with a flexion and inversion injury. It is often missed initially because the location of pain mimics an anterior talofibular ligament strain.

fracture of the anterior process of the calcaneus

the injury to the anterior process of the calcaneus can mimic an ankle sprain

The fracture of the lateral process of the talus is known as the snowboarder’s fracture and occurs when a blow occurs while the foot is dorsiflexed and everted. This jams the talus into the fibula. It is also easily missed.

the snowboarder’s fracture.

Our patient underwent internal fixation of the injury and is recovering.

Ei C, Tsai W, Tiu C, et al. Systematic analysis of missed extremity fracture in emergency radiology Acta Radiol 2006;47:710717

Dhinsa B, Lotif A, Walker R, et al. Fractures of the anterior process of the calcaneum;a review and proposed treatment algoritm. Foot and Ankle surgery, Vol 25(3) 2019:258-261

 Lisfranc Injuries - Everything You Need To Know - Dr. Nabil Ebraheim. Avalaible from:https://www.youtube.com/watch?v=f26KukNYsWA [last accessed:15/01/17]