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A 64 year old woman was brought to the accident and emergency department after a head on road traffic accident with a combined speed of both cars approximating to 80 mph. The patient had not been able to free herself from the car and was amnesic for the events. Initial assessment revealed an alert and talking patient with grade II hypovolaemic shock. Fluid resuscitation was started. Secondary survey revealed a stable pelvic fracture and a knee effusion. It was also noted that both feet appeared to have step deformities although relatively less painful. The main complaint was of knee pain. The first impressions of both the admitting senior house officer and specialist registrar was that the feet were unlikely to be injured given the symmetrical distribution of the apparent deformities. However, radiographs were performed and revealed Lisfranc fracture dislocations (fig 1). Closed reduction and internal fixation using Kirschner wires was performed. The patient made a good recovery from her injuries and was discharged two weeks later with continuing rehabilitation.
Lisfranc fractures have a reported incidence of 1 per 55 000 people per year and a prevalence of 0.2 % of all fractures.1 Some authors suggest that the “rarity” of these injuries may be attributable in part to doctors missing them, particularly in the context of polytrauma.2 Overlooked Lisfranc fractures may lead to limb loss or more probably may predispose the patient to chronic pain and debilitation. This case illustrates how in a case of major trauma the initial examination may overlook the seemingly less important foot injuries and also the difficulty in clinically assessing painless symmetrical injuries. Moreover, this is a rare case of bilateral Lisfranc fractures, only previously reported bilaterally as occult injuries in non-trauma patients with diabetic neuropathic feet.3
Conflicts of interest: none.
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