What Is: The LisFranc Injury?
Medicine is full of conditions with eponyms. Trauma is no exception. There’s the Mattox maneuver and the Cushing response, to name two. Many times, the name is just a kind of vanity plate for the discoverer of the condition. But in the case of the LisFranc injury (or fracture), it makes some sense. This injury is tough to describe in a sentence or two, let alone a few words.
Jacques LisFranc de St. Martin was a French surgeon and gynecologist (!) who described this condition in about 1815. It entails the fracture of the heads of the metatarsal bones and possible dislocation from the tarsals (the cuboid, navicular, and three cuneiform bones). This area is known as the LisFranc joint complex.
The injury can involve any or all of the metatarsals. The typical mechanism applies high energy across the midfoot, which can often be seen in head-on motor vehicle crashes. Crush injury to the proximal foot can also do this, such as running the foot over with a car. Occasionally, this injury pattern is produced with lower energy during sports play. In this case, the top of the foot is typically contacting the ground, plantar flexing it. At the same time, another player steps on the heel, grinding the foot into the ground (ouch). Interestingly, LisFranc did not describe the injury pattern or mechanism. His name is associated with the joint complex, and it is an injury to his joint complex.
Most of the time, the injury is obvious. There is usually notable pain and swelling of the foot. X-ray findings are generally not subtle. However, lower energy mechanisms may not cause much displacement, and initial imaging may not show the injury. If your patient starts to complain of pain in the midfoot when they begin to ambulate, think of LisFranc.
Treatment depends on the degree of displacement and the amount of disruption of the tarso-metatarsal joints. If minimal, a trial of nonoperative, non-weight bearing may be sufficient. But frequently, surgical reconstruction is required.
The Value of Protocols in Trauma
Most trauma centers have a book of practice protocols or guideleines. Actually, it is required by the American College of Surgeons verification standards. All centers must have a massive trauma protocol. Many have pain management or alcohol withdrawal or a number of other protocols. The question sometimes arises: why do we need another protocol? Can we show some benefit to using a protocol?
I’ve looked at the literature, and unfortunately there’s not a lot to go on. Here are my thoughts on the value of protocols.
In my view, there are a number of reasons why protocols need to be developed for commonly encountered issues.
- They allow us to build in adherence to any known practice guidelines or literature.
- They help conserve resources by standardizing care orders and resource use.
- They reduce confusion. Nurses do not have to guess what cares are necessary based on the specific admitting surgeon.
- They reduce errors for the same reason. All patients receive a similar regimen, so potential errors are more easily recognized.
- They promote team building, particularly when the protocol components involve several different services within the hospital.
- They teach a consistent, workable approach to our trainees. When they graduate, they are familiar with a single, evidence based approach that will work for them in their practice.
A number of years ago, we implemented a solid organ injury protocol here at Regions Hospital. I noted that there were large variations in simple things like time at bedrest, frequency of blood draws, how long the patient was kept without food and whether angiography should be considered. Once we implemented the protocol, patients were treated much more consistently and we found that costs were reduced by over $1000 per patient. Since we treat about 200 of these patients per year, the hospital saved quite a bit of money! And our blunt trauma radiographic imaging protocol has significantly reduced patient exposure to radiation.
Bottom line: Although the proof is not necessarily apparent in the literature, protocol development is important for trauma programs for the reasons outlined above. But don’t develop them for their own sake. Identify common problems that can benefit from consistency. It will turn out to be a very positive exercise and reap the benefits listed above.
… And The Ultimate Retained Foreign Bodies
Sponges are unfortunately one of the most common retained foreign bodies. This is due to their small, flimsy nature. The surgeon usually looks at the obviously visible areas of the abdomen or other body cavity before closing. She can also feel around in the “nooks and crannies”, but sponges feel very similar to the other organs surrounding it.
But what about more substantial items, like surgical instruments? Surely these are so obvious as to not leave behind?
Unfortunately, not so. Take a look at these items. This is a large pari of surgical forceps.
This is a malleable retractor, a long, thin sheet of pliable metal that can be bent to any desired shape.
And finally, a pair of Metzenbaum scissor, a common surgical instrument for cutting tissue.
Bottom line: It doesn’t matter how small or large, anything can and will be left behind in emergent and trauma cases. Recognizing that this can occur, no matter how confident you are that it has not, is the key. Always count, but followup with an x-ray that covers all areas of the surgical field before closing.
What Does A Retained Surgical Sponge Look Like?
It’s the bane of any surgeon’s existence. And the reason why OR personnel take such great pains to account for everything in the room. It is a catastrophe, and always a preventable one, when some piece of equipment goes missing and ends up left inside a patient.
A number of methods have been developed to try to eliminate this problem. They include careful counts, having someone record anytime anything is placed inside, x-rays, and most recently, RFID tags.
After counting, x-ray is the most common way to try to find missing objects. One would think that these foreign bodies would be easy to see. Metallic instruments are rather easy to spot. But many trauma professionals, even those who work in the OR, have never seen what a positive image of a sponge actually looks like. So here they are. You should never miss one on an xray now.
Surgeons typically use two types of sponges in the OR: Ray-Tec sponges and standard lap pads. Ray-Tecs look like a 4x8 piece of gauze with a mysterious blue string woven throughout it. The string is the only part that shows up on x-ray, and it is very thin and somewhat hard to see. Here are some Ray-Tec sponges outside the body:
And here’s one that was left inside. Note the little squiggle in the left lower quadrant and how easy it is to over look.
On the other hand, a laparotomy pad is a 4x4 folded cloth pad that unfolds into a larger pad. It has a blue tag sewn in the corner, extending along one edge of the pad. Here’s what they look like:
And here’s one inside a patient. Note the irregular object in the right upper quadrant.
Bottom line: It’s important for anyone who works in the OR on any body part to be familiar with the appearance of these tags on x-rays. Since it’s generally impossible to get accurate counts before or after a trauma procedure, always image the involved body cavity looking for these telltale signs before closing the patient.
Note: These images taken from the internet. Patients not treated at Regions Hospital.