A Pirouette Gone Wrong: Can A Ballerina Stay On “Pointe” To Recover From A Complex Foot Injury?

HISTORY: A 52-year-old female, longstanding recreational ballet dancer, presented to sports medicine clinic 4 days after awkwardly falling forward while en pointe and pirouetting, twisting her foot. She felt a pop, swelling, immediate bruising, pain localized in her midfoot and inability to bear weight. She had xrays at urgent care, was placed in a posterior splint and crutches. She denies any tingling, numbness or ankle pain. She has been a dancer almost all her life without any major injuries resulting in time away from dance. She is very active, currently swims a mile 1-2/week. Dances 1-2/week for 1-2 hrs. She does not run however, walks and bikes to work and to run errands. PHYSICAL EXAMINATION: Thin female who appears her stated age. 157 cm (5’2”) and 47 kg (104 lb). Left foot exam-Significant soft tissue swelling and diffuse ecchymosis over the TMT and MTP’s dorsally and entire plantar arch. Normal ROM at the ankle and IP joints. Diffusely tender over the midfoot, 2nd to 4th TMT junctions and base of MT’s dorsally and plantar surface. SILT for tibial, sural and CP nerves. Unable to bear weight on the left foot. DIFFERENTIAL DIAGNOSIS: 1.Metatarsal fracture(s) 2.LisFranc injury 3.Muscle strain/sprain/tears 4.DJD of midfoot TEST AND RESULTS: Foot Xrays:Day of injury NWB xrays showed comminuted and displaced fracture base of 2nd MT.4 days later WB xrays showed mildly displaced comminuted fx base 2nd MT with mild lateral subluxation of fx fragment. Lisfranc space measures 2.5 mm. Additional non-displaced fx seen base of 3rd MT.CT foot: same as xrays with additional small linear fx fragment seen within 2nd webspace. TMT joint alignment maintained. Lisfranc space widened along plantar aspect but normal alignment along dorsal aspect. No DJD noted. FINAL/WORKING DIAGNOSIS: Left 2nd MT base intra articular comminuted and 3rd MT base intra articular fractures with possible Lisfranc injury TREATMENT AND OUTCOMES: CAM boot NWB. Referral to foot and ankle surgeon. ORIF for Left foot 2nd MT intraarticular comminuted fracture using joint spanning plate and +/- Lisfranc injury. Nonsurgical treatment for 3rd MT fracture. Postop immobilization in a posterior splint for 2 weeks and short leg case for 4 weeks. NWB for 8 weeks. Trial aqua therapy in 4 weeks. Follow up in 4 months. May return to dance in 4 to 5 months. High risk of post traumatic arthritis.