Lisfranc InjuryLisfranc InjuryAn In-depth StudyAn In-depth Study

By: Jeff FreshourBy: Jeff Freshour

History of LisfrancHistory of LisfrancThe Lisfranc joint, or tarsometatarsal articulation The Lisfranc joint, or tarsometatarsal articulation of the foot, is named for Jacques Lisfranc (1790-of the foot, is named for Jacques Lisfranc (1790-1847), a field surgeon in Napoleon's army. 1847), a field surgeon in Napoleon's army. Lisfranc described an amputation performed Lisfranc described an amputation performed through this joint because of gangrene that through this joint because of gangrene that developed after an injury incurred when a soldier developed after an injury incurred when a soldier fell off a horse with his foot caught in the stirrup. fell off a horse with his foot caught in the stirrup.

The incidence of Lisfranc joint fracture The incidence of Lisfranc joint fracture dislocations is one case per 55,000 persons each dislocations is one case per 55,000 persons each year. Thus, these injuries account for fewer than year. Thus, these injuries account for fewer than 1 percent of all fractures. As many as 20 percent 1 percent of all fractures. As many as 20 percent of Lisfranc joint injuries are missed on initial of Lisfranc joint injuries are missed on initial anteroposterior and oblique radiographs.anteroposterior and oblique radiographs.

Mechanisms of InjuryMechanisms of InjuryLisfranc joint complex injury can Lisfranc joint complex injury can occur as a result of direct or occur as a result of direct or indirect trauma. Lisfranc joint indirect trauma. Lisfranc joint fracture dislocations and sprains fracture dislocations and sprains can be caused by high-energy can be caused by high-energy forces in motor vehicle crashes, forces in motor vehicle crashes, industrial accidents and falls from industrial accidents and falls from high places. Occasionally, these high places. Occasionally, these injuries result from a less stressful injuries result from a less stressful mechanism, such as a twisting fall.mechanism, such as a twisting fall.

Since Lisfranc joint fracture Since Lisfranc joint fracture dislocations and sprains carry a dislocations and sprains carry a high risk of chronic secondary high risk of chronic secondary disability, physicians should disability, physicians should maintain a high index of suspicion maintain a high index of suspicion for these injuries in patients with for these injuries in patients with foot injuries characterized by foot injuries characterized by marked swelling, tarsometatarsal marked swelling, tarsometatarsal joint tenderness and the inability joint tenderness and the inability to bear weight. to bear weight.

Anatomy of the Lisfranc JointAnatomy of the Lisfranc Joint

The Lisfranc Joint is comprised of articular The Lisfranc Joint is comprised of articular surfaces between the base of all 5 metatarsals, surfaces between the base of all 5 metatarsals, the 3 cuneiforms and the cuboid.the 3 cuneiforms and the cuboid.

Anatomy of the Lisfranc JointAnatomy of the Lisfranc Joint

First metatarsal base(1), medial cuneiform(2), second metatarsal First metatarsal base(1), medial cuneiform(2), second metatarsal base(3), intermediate cuneiform(4) and distal extent of navicular(5).base(3), intermediate cuneiform(4) and distal extent of navicular(5).

Radiographic StudiesRadiographic Studies

Anteroposterior non weight-bearing radiograph of the left foot.

Note that this view shows no evidence of malalignment or any other joint disruption

Radiographic StudiesRadiographic Studies

Figure 1. Lateral non weight-bearing radiograph showing dorsal displacement of the proximal base of the second metatarsal in the left foot of the patient in the illustrative case. The arrow points to the "step-off" point (i.e., the dorsal surface of the second metatarsal is higher than the dorsal surface of the middle cuneiform).

Radiographic StudiesRadiographic Studies

Figure 2. Anteroposterior weight-bearing radiograph of the left foot of the patient in the illustrative case. The medial margin of the second metatarsal base and the medial edge of the middle (second) cuneiform are malaligned (triangles). A fleck sign (arrow) is

also present.

Figure 3. Enlargement of the radiograph shown in Figure 2. Note the fleck sign (arrow), which is a bony fragment indicating severe disruption of the Lisfranc joint. The triangles indicate the malalignment of the proximal base of the second metatarsal and

the medial margin of the middle cuneiform.

Clinical DiagnosisClinical Diagnosis

PresentationPresentation

Apart from a crush injury with marked Apart from a crush injury with marked swelling and radiographic changes, the swelling and radiographic changes, the Lisfranc joint injury can be difficult to Lisfranc joint injury can be difficult to diagnose. Gross subluxation or lateral diagnose. Gross subluxation or lateral deviation of the forefoot is rare. Swelling in deviation of the forefoot is rare. Swelling in the midfoot region and an inability to bear the midfoot region and an inability to bear weight may be the only findings that suggest weight may be the only findings that suggest the diagnosis. Lisfranc joint injury should be the diagnosis. Lisfranc joint injury should be suspected when the mechanism of injury is suspected when the mechanism of injury is consistent with this traumatic injury and soft consistent with this traumatic injury and soft tissue edema or pain in the foot persists five tissue edema or pain in the foot persists five or more days after the initial injury.or more days after the initial injury.

Clinical DiagnosisClinical DiagnosisPhysical ExaminationPhysical Examination

When Lisfranc joint complex injury is suspected, palpation of When Lisfranc joint complex injury is suspected, palpation of the foot should begin distally and continue proximally to each the foot should begin distally and continue proximally to each tarsometatarsal articulation. Tenderness along the tarsometatarsal articulation. Tenderness along the tarsometatarsal joints supports the diagnosis of midfoot sprain tarsometatarsal joints supports the diagnosis of midfoot sprain with the potential for segmental instability.with the potential for segmental instability.

Pain can localize to the medial or lateral aspect of the foot at Pain can localize to the medial or lateral aspect of the foot at the tarsometatarsal region on direct palpation, or it can be the tarsometatarsal region on direct palpation, or it can be produced by abduction and pronation of the forefoot while the produced by abduction and pronation of the forefoot while the hindfoot is held fixed.4 Another diagnostic clue is the patient's hindfoot is held fixed.4 Another diagnostic clue is the patient's inability to bear weight while standing on tiptoe.inability to bear weight while standing on tiptoe.

The dorsalis pedis pulse and capillary refill should also be The dorsalis pedis pulse and capillary refill should also be evaluated. The dorsalis pedis artery courses over the proximal evaluated. The dorsalis pedis artery courses over the proximal head of the second metatarsal. Thus, it is susceptible to head of the second metatarsal. Thus, it is susceptible to disruption in a severe dislocation.disruption in a severe dislocation.

TreatmentTreatment

Early diagnosis of a Lisfranc joint injury Early diagnosis of a Lisfranc joint injury is imperative for proper management is imperative for proper management and the prevention of a poor functional and the prevention of a poor functional outcome. With a general knowledge of outcome. With a general knowledge of both conservative and operative both conservative and operative treatment options, the primary care treatment options, the primary care physician can decide whether to treat physician can decide whether to treat the injury nonoperatively or refer the the injury nonoperatively or refer the patient to an orthopedist. patient to an orthopedist.

TreatmentTreatmentNonoperative Treatment Nonoperative Treatment

If the clinical evaluation indicates the probability of a mild or If the clinical evaluation indicates the probability of a mild or moderate sprain and the radiograph shows no diastasis, moderate sprain and the radiograph shows no diastasis, immobilization is suggested. Treatment with a short-leg immobilization is suggested. Treatment with a short-leg walking cast,6 a removable short-leg orthotic or a non walking cast,6 a removable short-leg orthotic or a non weight-bearing cast4 is continued for four to six weeks or weight-bearing cast4 is continued for four to six weeks or until symptoms have resolved. The potential for disability until symptoms have resolved. The potential for disability following a Lisfranc joint injury justifies the use of a non following a Lisfranc joint injury justifies the use of a non weight-bearing cast.weight-bearing cast.

After the period of immobilization, ambulation and After the period of immobilization, ambulation and rehabilitation exercises should be progressive. If the rehabilitation exercises should be progressive. If the symptoms persist up to two weeks after rehabilitation has symptoms persist up to two weeks after rehabilitation has begun, a repeat weight-bearing radiograph must be obtained begun, a repeat weight-bearing radiograph must be obtained to evaluate the joint articulation for instability5 and evidence to evaluate the joint articulation for instability5 and evidence of delayed separation (i.e., disarticulation worsened after of delayed separation (i.e., disarticulation worsened after weight-bearing).weight-bearing).

TreatmentTreatmentOperative TreatmentOperative Treatment

If surgical repair is warranted, it should be done within the first 12 If surgical repair is warranted, it should be done within the first 12 to 24 hours after the injury. Alternatively, surgery can be to 24 hours after the injury. Alternatively, surgery can be performed after 7 to 10 days to allow the reduction of swelling.performed after 7 to 10 days to allow the reduction of swelling.

While some orthopedists prefer closed fixation with percutaneous While some orthopedists prefer closed fixation with percutaneous K-wires, others report that this method does not hold anatomic K-wires, others report that this method does not hold anatomic reduction and fixation. An alternative method involves the use of reduction and fixation. An alternative method involves the use of open reduction and internal fixation. An open surgical field allows open reduction and internal fixation. An open surgical field allows easier removal of fragments or soft tissue that may be hindering easier removal of fragments or soft tissue that may be hindering reduction of the dislocation.reduction of the dislocation.

After open reduction and internal fixation, most orthopedists After open reduction and internal fixation, most orthopedists suggest that the foot be immobilized in a cast for 8 to 12 weeks suggest that the foot be immobilized in a cast for 8 to 12 weeks with minimal (toe-touch) weight-bearing. Noncasted, full weight-with minimal (toe-touch) weight-bearing. Noncasted, full weight-bearing usually is not allowed until the AO screw or similar device bearing usually is not allowed until the AO screw or similar device is removed at 8 to 12 weeks. For three months after cast removal, is removed at 8 to 12 weeks. For three months after cast removal, the patient should wear a protective shoe with a well-molded the patient should wear a protective shoe with a well-molded orthotic.orthotic.

TreatmentTreatment

ORIFORIF (open reduction internal fixation)(open reduction internal fixation)

OPERATIVE CONSIDERATIONSOPERATIVE CONSIDERATIONS

PATIENT POSITIONING: supine with ipsilateral sandbag.PATIENT POSITIONING: supine with ipsilateral sandbag.

TOURNIQUET: thigh at 300mmHgTOURNIQUET: thigh at 300mmHg

ANAESTHESIA: GeneralANAESTHESIA: General

NERVE BLOCK: femoral and sciaticNERVE BLOCK: femoral and sciatic

INSTRUMENTS REQUIRED: lambotts fine osteotomes, 5mm INSTRUMENTS REQUIRED: lambotts fine osteotomes, 5mm high speed burr, Charlotte staples, 4.0mm cannulated ACE high speed burr, Charlotte staples, 4.0mm cannulated ACE screws screws

Treatment-ORIFTreatment-ORIFProximal instability - This includes tarsal instability and Proximal instability - This includes tarsal instability and longitudinal impaction injuries that can disrupt the normal arcade longitudinal impaction injuries that can disrupt the normal arcade of the TMT joints. Openly reduce and hold with fixation screws of the TMT joints. Openly reduce and hold with fixation screws any instability between tarsal bones. If necessary, a mini-external any instability between tarsal bones. If necessary, a mini-external fixator can be used to control proximal migration and fixator can be used to control proximal migration and comminution. Anatomically restore any shortening of the tarsals, comminution. Anatomically restore any shortening of the tarsals, and graft the defect with a structural graft from the iliac crest or and graft the defect with a structural graft from the iliac crest or proximal tibia. If more than 50% of the joint surface is destroyed, proximal tibia. If more than 50% of the joint surface is destroyed, perform primary fusion among the involved bones to preserve perform primary fusion among the involved bones to preserve long-term stability. Treatment then can proceed as it would for a long-term stability. Treatment then can proceed as it would for a pure dislocation pure dislocation

Treatment-ORIFTreatment-ORIFDistal fractures - MT fractures distal to the Lisfranc joint Distal fractures - MT fractures distal to the Lisfranc joint sometimes can interfere with stable fixation. In these sometimes can interfere with stable fixation. In these instances, use intramedullary K-wires in conjunction with open instances, use intramedullary K-wires in conjunction with open reduction to anatomically realign the foot.reduction to anatomically realign the foot.

Outcome StudiesOutcome StudiesStable anatomic alignment is the best predictor of outcome. The presence of Stable anatomic alignment is the best predictor of outcome. The presence of fractures and/or articular destruction leads to poorer results, regardless of fractures and/or articular destruction leads to poorer results, regardless of alignment. Incidence of posttraumatic arthritis reportedly ranges from 0-58%.20 alignment. Incidence of posttraumatic arthritis reportedly ranges from 0-58%.20  One study reported that up to 25% of patients develop posttraumatic arthritis  One study reported that up to 25% of patients develop posttraumatic arthritis even after fixation. even after fixation.

In 2006, Ly and colleagues reported the results of their study comparing primary In 2006, Ly and colleagues reported the results of their study comparing primary arthrodesis with ORIF in primarily ligamentous Lisfranc injuries. Twenty patients arthrodesis with ORIF in primarily ligamentous Lisfranc injuries. Twenty patients were treated with ORIF, and 21 were treated with arthrodesis of the medial 2 or were treated with ORIF, and 21 were treated with arthrodesis of the medial 2 or 3 TMT joints, with an average follow-up period of 42.5 months. Using outcome 3 TMT joints, with an average follow-up period of 42.5 months. Using outcome measures, the authors reported that the members of the arthrodesis group measures, the authors reported that the members of the arthrodesis group reached a postoperative activity level that was an estimated 92% of their pre-reached a postoperative activity level that was an estimated 92% of their pre-injury activity level, while in the ORIF group, members achieved an activity level injury activity level, while in the ORIF group, members achieved an activity level that was only 65% of their pre-injury level. The authors concluded that a stable, that was only 65% of their pre-injury level. The authors concluded that a stable, primary arthrodesis seemed to have better short- and medium-term outcomes. primary arthrodesis seemed to have better short- and medium-term outcomes. Whether this improves long-term results is not yet known.Whether this improves long-term results is not yet known.

In 2002, Thordarson and colleagues reported results from 14 patients at an In 2002, Thordarson and colleagues reported results from 14 patients at an average follow-up of 20 months. At this short-term follow-up they determined average follow-up of 20 months. At this short-term follow-up they determined that bio-absorbable screws are safe and that they eliminate the need for screw that bio-absorbable screws are safe and that they eliminate the need for screw removal. Larger studies with long-term follow-up are needed to determine the removal. Larger studies with long-term follow-up are needed to determine the true efficacy.true efficacy.

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