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Chapter 194 Lisfranc Injuries

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Chapter 194 Lisfranc InjuriesHany El-Rashidy and Anand Vora

ICD-9 CODE838.03 Lisfranc(Tarsometatarsal)

Fracture-Dislocation

Key Concepts

● TheLisfrancjointrepresentsthejunctionbetweenthemidfootandforefoot.

● Threemetatarsal-cuneiformarticulations(first,second,and third tarsometatarsal joints)and twometatarsal-cuboid articulations (fourth and fifth tarsometatarsaljoints)(Fig.194-1).

● Proper alignment and stability of these joints areessentialfornormalfootfunction.

● The Lisfranc joint is very stablebecauseof its bonyanatomy and strong ligamentous attachments. Thebaseofthesecondmetatarsal(“keystone”)isrecessedandlocksbetweenthemedialandlateralcuneiforms.Plantarligamentsarestrongerthandorsalligaments.

● The Lisfranc ligament is the strongest ligament andruns from thebaseof the secondmetatarsal to themedialcuneiform.

● Injuriestothisjointrangefrommildsprainstowidelydisplaced,unstable,debilitatinginjuries.● Injuries can be bony, ligamentous, or a

combination.● Asmanyas20%ofLisfrancinjuriesinitiallygounrec-

ognized. When suspected, weight bearing and/orstressradiographsarecritical.

● Injuries to the tarsometatarsal joints require earlyaccurate diagnosis with prompt anatomic reductionand internal fixation foroptimal results.Severe long-term morbidity may occur if not properly treated atinitialpresentation.

History

● Mild to severe pain in the midfoot at rest and withweightbearing;maybeunabletobearweight

● Acuteinjury;maybedirectorindirect(Fig.194-2)● Direct:crushinjury● Indirect(morecommon):axialloadinfixedplanted

foot(football,missedstepoffcurb,landingdancejump)or twisting injurywith forcefulabductionofforefootonmidfoot(MVC)

● Any traumatic mechanism with significant midfootpain should raise suspicion of a possible Lisfrancinjury.

Physical Examination

● Observation● Abrasions,lacerations● Bruising (especially medial plantar surface of the

foot)● Swellingarounddorsalmidfoot● Lossofnormalarchormidfootcontourwithweight

bearing● Palpation

● Painwithpalpationormanipulationof the tarso-metatarsaljoints

8

Figure 194-1 Normalanatomyoftarsometatarsaljoints.

Metatarsalbones

Lisfranc joint

Tarsalbones

Metatarsalbones

Lisfranc joint

Tarsalbones

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8 Section 8 The Ankle and Foot

194-�

● Rangeofmotion● Passivedorsiflexionandplantarflexionofmetatar-

salselicitspain.● Specialtests

● PainatmidfootwithattemptedsinglelegheelrisesuggestsaLisfrancinjury.

● Careful neurovascular examination emphasizingsensationandperfusionisessential.Lisfrancdis-location can be associated with impingement orlacerationofabranchofthedorsalispedisarteryor thedeepperonealnerve,bothofwhichcrossdorsallybetweenthebaseofthefirstandsecondmetatarsals.

● Severeswelling,especiallyinhigh-energymecha-nisms,shouldalertthephysiciantopossiblecom-partmentsyndromeofthefoot.

Imaging

● Radiographs: anteroposterior, lateral, and obliqueviewsofthefoot(Fig.194-3).● Shouldbeweightbearing if possible to load the

ligaments and test their integrity. If not possible,obtainstressviews.

● Anteroposterior view: The medial border of thesecond metatarsal should align with the medialborderofthemiddlecuneiform.

● Oblique view: The medial border of the fourthmetatarsalshouldalignwithmedialborderofthecuboid.

● Lateralview:Thesuperiorborderofthemetatarsalbase should align with superior border of themedialcuneiform.

Figure 194-2 Commonmechanismsofinjury.Axialloadinaplantedfoot(1),MVCtrauma(2),directcrushinjury(3).

1 2

3

1 2

3

Figure 194-3 Normalbonyrelationshipsaswouldappearonanteroposterior(AP)andobliqueradiographs.ThesecondmetatarsalshouldalignwiththemedialborderofthemiddlecuneiformontheAPviewandthemedialborderofthefourthmetatarsalshouldalignwiththecuboidontheobliqueview.

Normal alignmentof 2nd metatarsal

and middle cuneiform

Normal alignment of4th metatarsaland cuboid

AP Oblique

Normal alignmentof 2nd metatarsal

and middle cuneiform

Normal alignment of4th metatarsaland cuboid

AP Oblique

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Chapter 194 Lisfranc Injuries

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● Disruption of any these defined relationships isindicativeofaLisfrancinjury(Fig.194-4).

● Stress views help reveal displacement in subtlecases with spontaneous reduction (Fig. 194-5).Ankleblockorsedationmayberequired.

● Computedtomography● Betterfordiscerningminordisplacement,associ-

atedfractures,comminution,anddislocations● Magneticresonanceimaging

● Toassesssoft-tissuedamage

Additional Tests

● Compartment pressure monitoring in selectedcases

Differential Diagnosis

● Tarsal,metatarsal,orphalangealfracturesofthefoot● LigamentousinjuryoutsidetheLisfrancjoint

● Soft-tissue damage around foot without fracture orligamentinjury

Treatment

● Atdiagnosis● InitialtreatmentofaLisfrancinjuryfocusesonsoft-

tissue evaluation and diagnosing instability andassociatedfractures/dislocations.

● For truly nondisplaced, stable injuries (negativeweightbearingandstressradiographs)withnormalsoft-tissue/neurovascularexamination,castimmo-bilizationcanbeused.

● A non-weight bearing short leg cast for 6weeks is followedbyawalkingcast foranaddi-tional 6 weeks until pain and tenderness haveresolved.

● Allotherinjuriesshouldbereferredacutely(seethefollowing).

Figure 194-4 Lisfrancinjury.A,Ontheanteroposteriorview,notetheabnormalalignmentbetweenthemedialbordersofthesecondmetatarsalandmiddlecuneiform(circle).B,Ontheobliqueview,notetheabnormalalignmentbetweenthemedialbordersofthefourthmetatarsalandcuboid(circle).

A B

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8 Section 8 The Ankle and Foot

194-4

● Later● Forstableinjuries,follow-upweight-bearingradio-

graphsshouldberepeatedat10to14days.Iftheinjury remains stable (<2mm displacement) andpain is decreasing, continued cast managementwith serial repeat radiographs in 2 weeks isrecommended.

● Any evidence of displacement or instability onfollow-upexaminationwarrants immediateortho-paedicreferralforoperativeplanning.

When to Refer

● Any Lisfranc injury with displacement or instabilityrequires operative intervention and anatomic reduc-tionforoptimalresults.

● Urgent/emergentreferralisessentialforanyquestionofcompartmentsyndrome(severeswellingandpain),dislocation,openfracture,orabnormalneurovascularexamination.

Prognosis

● Asmanyas20%ofLisfranc injuriesareoverlooked,especially in polytrauma patients, with severe long-termmorbidity.

● The severity of even subtle Lisfranc injuries is oftenunderestimated,andhealingmaybeprolonged.

● Patientsshouldbeprovidedwithaccurateprognosisatthetimeofdiagnosis.

● The best results (95% good to excellent functionalrecovery) are seen in those patients who undergoopenreductionandinternalfixation.

● Inadequate reduction or initial damage to the jointsurface directly correlates with the development ofposttraumaticarthritis.

● SymptomsafterLisfranc injurymaypersist,butcon-tinuetosubsideforseveralyears.

Troubleshooting

● Compartment syndrome usually occurs only with ahigh-energy Lisfranc fracture-dislocation and shouldbeconsideredinanyinjurywithsevereswellingandapainful,tensefoot.Anysuspicionwarrantsimmediateorthopaedicevaluation.

● Counselpatientsthatposttraumaticarthritisiscommonandrelatedtoboththeinitialinjuryandtheadequacyofreduction.

● Beverywaryofdiagnosingasimplemidfootsprain.Ifapatientwithafootinjuryisunabletobearweightorhasseveremidfootpain,heorsheshouldbereferredfororthopaedicevaluation.

● Standardradiographsmayonlyshowslightincongru-ityof the joint;gross instabilitymayonlybeseenonstressorweight-bearingviews. Inanypatientwithamidfootsprain,itisessentialtoobtainsuchstudiestoavoidmissinganunstableinjury.

Patient Instructions

● Instruct patients on the importance of elevation todecrease swelling, weight-bearing restrictions, andorthopaedicfollow-up.

● AccuratelyoutliningtheprognosisassociatedwithLis-franc injuries, including a likely prolonged recoverytime(immobilizationupto3to4months),isanimpor-tantcomponentofthetreatmentplan.

Considerations in Special Populations

● Athleteswithtraumaticfootinjuryandresultantmidfootpain should be referred to an orthopaedic specialistforappropriateevaluation.

Figure 194-5 A,Toobtainastressviewradiograph,stabilizethehindfootwithonehandandgrasptheforefootwiththeoppositehand.B,Withtheheelstabilized,placeabduction/pronationstressontheforefoot.Wideningofmorethan2mmorseverepainindicatesaLisfrancinjury.

A

B

A

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Chapter 194 Lisfranc Injuries

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8● Diabeticpatientsmayhaveanunderlyingneuropathic

(Charcot’s) arthropathy contributing to the Lisfrancpathology, especially with a history of minimaltrauma.

Suggested ReadingArntzCT,VeithRG,HansenST:Fracturesandfracture-dislocationsofthetarsometatarsaljoint.JBoneJointSurgAm1988;70A:173–181.

CoetzeeJC,LyTV:TreatmentofprimarilyligamentousLisfrancjointinjuries:Primaryarthrodesiscomparedwithopenreductionandinternalfixation.JBoneJointSurgAm2007;89A:122–127.

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DavisE:Lisfrancjointinjuries.Trauma2006;8:225–231.

DesmondEA,ChouLB:Currentconceptsreview:Lisfrancinjuries.FootAnkleInt2006;27:653–660.

KuoRS,TejwaniNC,DiGiovanniCW,etal:OutcomeafteropenreductionandinternalfixationofLisfrancjointinjuries.JBoneJointSurgAm2000;82A:1609–1617.

MulierT,ReyndersP,DereymaekerG:SevereLisfrancinjuries:PrimaryarthrodesisorORIF.FootAnkleInt2002;23:902–905.

RichterM,WippermanB,KrettekC:Fracturesandfracturedislocationsofthemidfoot:Occurrence,causes,andlong-termresults.FootAnkleInt2001;22:392–398.

SandsAK,GroseA:Lisfrancinjuries.Injury2004;35:71–76.

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AUTHOR qUeRy fORMDear Author,

During the preparation of your manuscript for publication, the questions listed below have arisen. Please attend to these matters and return this form with your proof.Many thanks for your assistance.

MeO_194

Query Description Your Response

1 AU: Pls spell out MVC

2 AU: Pls spell out MVC

3 AU: OK as edited?

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