Lisfranc injuries and commonly missed diagnosis
When a Lisfranc fracture dislocation injury is sustained, a person will commonly develop severe clinical symptoms very quickly including swelling of the foot, severe pain and an inability to weight bear on the affected foot. Also, characteristic bruising will often develop on the sole of the foot. After the injury is sustained, an individual can also be unable to stand on tiptoes.
Unfortunately, Lisfranc injuries are quite commonly misdiagnosed or missed. I have acted for several clients who, following an injury to their foot, have presented to an A&E department and had a non weight bearing x-ray taken of their foot, only to be told that there is no fracture present and soft tissue damage only. The clients are commonly advised to rest and ice the foot, take pain relief and return to walking on the foot as soon as they are able and with no follow up in place. This can even be the case when the client's pain and clinical symptoms are entirely disproportionate to a simple soft tissue injury.
However, clients commonly find that if there is a failure to diagnose and treat a Lisfranc injury, their symptoms do not improve, they continue and often, will get worse. This can interfere greatly with clients being able to return to work and go about their daily activities due to severe pain and swelling in the foot.
If a Lisfranc injury is correctly identified at the outset, treatment options include conservative management with close follow up (if the injury is at the more subtle end of the spectrum) or surgery to perform open reduction and internal fixation (ORIF) to restore the integrity and function of the midfoot. If a patient requires surgery, this will usually be performed within 14 days of the injury and the patient should be advised not to weight bear on the foot pending surgery. Following timely surgery, the vast majority of patients will have a good recovery from the Lisfranc injury and return to normal activities.
Unfortunately, if the Lisfranc injury is missed, it is generally accepted that the longer the delay in treating the injury, the worse the outcome can be and the patient may require surgery to fuse the midfoot which is a more major procedure than the surgery that would have been required with timely diagnosis. A missed Lisfranc injury can result in the patient developing early onset osteoarthritis in the midfoot and walking on the injured foot can cause further damage to the affected joint and adjacent joints. In worst case scenarios, the arch of the foot can collapse.
When fusion surgery is required to treat a missed Lisfranc injury, the surgery may reduce the pain in the foot, however, the fusion alters the mechanics of the midfoot as the joints no longer move in a normal anatomical way. This in turn can cause the load through the foot to be transferred to adjacent joints which can result in degeneration in those joints, pain and further disability. In the longer term, further fusions of adjacent joints may be required. Following fusion surgery for a Lisfranc injury, many patients continue to experience some pain and swelling of the foot, particularly following activity and this can interfere with their ability to undertake activities of daily living. Even with 'successful' fusion, patients may need to modify their activities due to pain and their ability to undertake certain types of employment, such as those involving standing or walking for long periods or manual, physical jobs may be curtailed.
In cases involving missed Lisfranc injuries, breach of duty can often be admitted by the Defendant NHS Trust, particularly if the injury was evident on an x-ray and missed. However, causation, namely proving that the outcome for the patient is worse due to the delay in treatment, is sometimes strongly defended.
Read about Helen's recent settlement following delayed diagnosis at Bedford Hospital.