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Mid foot lisfranc fracture
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Mid foot lisfranc fracture

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  • 1.  Any bony or ligamentous injury involving the tarsometatarsal joint complex.  Where the metatarsals dislocate from their normal articulation with the mid-tarsal bones  Most commonly involves the 1st and 2nd  Metatarsals and the medial cuneiform  Incidence is 1 in 55,000 people each year  Easily missed on initial x-rays  Can be difficult to diagnose
  • 2.  Named after the Napoleonic-era surgeon who described amputations at this level without ever defining a specific injury › Dr. Lisfranc › Injury was common in cavalry troops › Due to design of the stirrup › Severe vascular complications › Amputation was performed
  • 3.  Lisfranc’s joint: articulation between the 3 cuneifoms and cuboid (tarsus) and the bases of the 5 metatarsals  Osseous stability is provided by the Roman arch of the metatarsals and the recessed keystone of the second metatarsal base
  • 4.  Lisfranc’s ligament: large oblique ligament that extends from the plantar aspect of the medial cuneiform to the base of the second metatarsal (there is no transverse metatarsal ligament from 1 to 2)
  • 5.  Interosseous ligaments: connect the 2nd to 5th metatarsal bases both dorsal and plantar (stronger and larger)  Secondary stabilizers: plantar fascia, peroneus longus, and intrinsincs
  • 6.  Four Major Units * 1st MT – Medial Cuneiform : 6 degrees of Mobility * 2nd MT – Middle Cuneiform : Firmly Fixed * 3rd MT – Lateral Cuneiform : Firmly Fixed * 4th – 5th MT – Cuboid : Mobile
  • 7.  Associated Structures: 1. Dorsalis pedis artery – courses between 1st and 2nd metatarsal bases 2. Deep peroneal nerve: runs alongside the artery
  • 8.  Lisfranc’s joint: › Key to the transverse arch of the foot  Lisfranc’s ligament attaches the medial cuneiform to the base of the 2nd metatarsal  Continued ligamentous support linking the bases of the 2nd-5th metatarsals  No ligamentous connection between the 1st and 2nd metatarsals › Allows for frequently seen divergent injury  Dorsalis pedis dives between bases of 1st & 2nd
  • 9.  2nd MT is recessed between the medial and lateral cuneiforms: › “Keystone” mortise that greatly adds stability in transverse plane
  • 10.  Cuneiform, tarsal bones, and medial 3 MT bases: › Have a trapezoidal configuration that is wider on the dorsal aspect › Effect of a Roman arch; resisting collapse
  • 11.  Hyper-extending the forefoot Catching the forefoot in a hole in the ground Horseback rider falling and hanging the forefoot in the stirrup  Commonly seen as a Charcot’s Joint in diabetic patients  RTA – especially when foot is trapped in dorsi-flexion under the foot pedal  Crush injuries
  • 12.  Trauma: motor vehicle accidents account for one third to two thirds of all cases (incidence of lower extremity foot trauma has increased with the use of air bags)  Crush injuries  Sports-related injuries are also occurring with increasing frequency
  • 13. Placing the foot into extreme plantar flexion with an axial load.
  • 14.  Typical of athletic injury  Axial loading to plantar flexed foot results in hyper- plantar flexion and ligament rupture  Rarely associated with open injury or vascular compromise
  • 15. Direct Injuries: force is applied directly to the Lisfranc’s articulation. The applied force is to the dorsum of the foot. Plantar displacement more common
  • 16. Direct Injuries: plantar displacement is more common, but dorsal displacement can also occur. Open fracture/compartment syndrome/soft tissue injury greater
  • 17. Indirect injuries: more common than direct and result from axial loading or twisting. Metatarsal bases dislocate dorsally more often than plantarly. Dorsal displacement more common
  • 18.  Twisting injuries lead to forceful abduction of the forefoot, often resulting in a 2nd metatarsal base fracture and/or compression fracture of the cuboid (“ nut cracker”)
  • 19.  Base of 2nd metatarsal  Avulsion of navicular  Isolated medial cuneiform  Cuboid  Fractures of the shafts of the metatarsals  Dislocations of the 1st(medial) and 2nd (middle) and cuneonavicular joints
  • 20.  Sprains are the most common injury to the tarso-metatarsal ligament.  graded I, II and III  Burroughs et al 1998
  • 21.  Grade I - Pain at the joint, minimal swelling and no instability of the joint
  • 22.  Grade II – Increased pain and swelling of the joint, with mild laxity but no instability
  • 23.  Grade III – Complete ligamentous disruption and may represent a fracture-dislocation
  • 24. HOMOLATERAL: most common
  • 25. ISOLATED
  • 26. DIVERGENT: least commom
  • 27. Homolateral or Total Incongruity: • All 5 metatarsals displace in common direction •Fracture base of 2nd common
  • 28. Isolated Partial Incongruities: • Displacement of 1 or more metatarsals away from the others
  • 29. Divergent: • Lateral displacement of lesser metatarsals with medial displacement of the 1st metatarsal • May have extension of injury into cuneiforms or talonavicular joint
  • 30. Total incongruity – Can be either medially or laterally displaced
  • 31. Partial incongruity – Either medial (Type B1)or lateral (Type B2), the most common type
  • 32. Divergent displacement – Either partial (type C1) or total (type C2)
  • 33.  Diagnosis requires high index of suspicion › Midfoot swelling & tenderness  Often in patients with polytrauma  Vascular status  Assess soft tissues › Open fx › Degloving injuries › Monitor for compartment syndrome
  • 34.  Swelling and large lump in the midfoot  Unable to weight bear  Tenderness along the tarso- metatarsal joints  Tenderness with passive abduction and pronation of the forefoot with the hindfoot held flexed
  • 35.  Ecchymosis may appear late  Local tenderness at tarsometatarsal joints  Gentle stressing plantar/dorsiflexion and rotation will reveal instability
  • 36. AP, Lateral, and 30 Oblique X-Rays are mandatory
  • 37.  To look for alignment  AP : The lateral border of the 1st metatarsal is aligned with The Lateral border of the medial uneiform
  • 38.  AP: the medial border of the 2nd metatarsal is in line with the medial border of the intermediate cuneiform
  • 39.  Medial and lateral borders of the lateral cuneiform should align with the medial and lateral borders of the 3rd metatarsal
  • 40.  Medial border of the cuboid should align with the medial border of the 4th metatarsal
  • 41.  Lateral: The dorsal surface of the 1st and 2nd metatarsals should be level to the corresponding cuneiforms
  • 42.  Standing views provide “stress” and may demonstrate subtle diastasis  Comparison views are very helpful
  • 43.  Additional imaging: 1. True stress views or fluroscopy 2. CT Scans 3. Bone scan – for persistent pain with no radiographic findings 4. If suspicious: repeat x-rays and keep looking
  • 44.  Anteroposterior X-ray presenting a type A (lateral) injury according to Myerson et al. classification
  • 45.  Anteroposterior X-ray presenting a type B2 (partial lateral) injury according to Myerson et al. classification
  • 46.  Anteroposterior X-ray presenting a type C2 (total) injury according to Myerson et al. classification
  • 47. that indicate presence of midfoot instability  disruption of the continuity of a line drawn from the medial base of the second metatarsal to the medial side of the middle cuneiform  widening of the interval between the first and second ray  medial side of the base of the fourth metatarsal does not line up with medial side of cuboid on oblique view  metatarsal base dorsal subluxation on lateral view  disruption of the medial column line (line tangential to the medial aspect of the navicular and the medial cuneiform)
  • 48.  Operative treatment is indicated for displacement > 2mm of the TMT joint  Some argue for ORIF regardless of displacement  Key to successful outcome is anatomic alignment  ORIF can be attempted as late as 8 weeks after injury for pts < 160 lbs; >160lbs arthrodesis of medial three joints  < 2mm of displacement: › NWB SLC for 6 weeks › WB SLC for an additional 4 to 6 weeks › Follow closely with repeat radiographs to ensure no displacement has occurred
  • 49.  Spinal or general anesthesia  Modified finger traps to great toe and one or two adjacent toes  Longitudinal traction with 5 to 10 lbs  Manipulate foot within 5 minute period in either inversion or eversion  Rarely palpable or audible reduction  Verify reduction on fluoroscopy  Maintain reduction with Steinmann pins/cannulated screws  Final routine radiographs PRIOR to leaving OR
  • 50.  Surgical emergencies: 1. Open fractures 2. Vascular compromise (dorsalis pedis) 3. Compartment syndrome
  • 51.  Reduction is easiest if performed within 4 –6 hours  Restoration of circulation is critical for soft tissue healing  Compartment syndrome: › Four fascial compartments  Long medial incision to decompress abductor hallucis & deep compartments  Two dorsal incisions betw 2nd & 3rd and betw 4th & 5th to decompress dorsal intrinsic compartments  Extensive vascular compromise › Midfoot level amputation
  • 52.  Dorsal incision lateral to EHL in the interval between the 1st & 2nd MT  Isolate dorsalis pedis & deep peroneal nerve  Inspect Lisfranc ligament  Reduce cuneiforms if needed › Steinmann pin followed by cannulated screw  Guide wire/drill medial cuneiform to base 2nd MT › Continue fixation as needed to restore anatomic alignment › Multiple constructs  1st MT to medial cuneiform  Cuboid to base of 5th MT
  • 53.  1 – 3 dorsal incisions: 1. 1st incision centered at TMT joint and along axis of 2nd ray, lateral to EHL tendon 2. Identify and protect NV bundle
  • 54.  Reduce and provisionally stabilize 2nd TMT joint  Reduce and provisionally stabilize 1st TMT joint  If lateral TMT joints remain displaced use 2nd or 3rd incision(s) 2nd met. Base unreduced reduced
  • 55.  If reductions are anatomic proceed with permanent fixation: 1. Screw fixation is preferable for the medial column 2. “Pocket hole” to prevent dorsal cortex fracture
  • 56. 3. Screws are positional not lag 4. To aid reduction or if still unstable use a screw from medial cuneiform to base of 2nd metatarsal
  • 57. 5. If intercuneiform instability exists use an intercuneiform screw 6.The lateral metatarsals frequently reduce with the medial column and pin fixation for mobility is acceptable
  • 58. Preop AP Postop AP Postop Lateral
  • 59.  Bulky dressing with posterior splint postoperatively  NWB SLC at 7-10 days postop  PWB at 6-8 weeks  Laterally placed steinmann pins removed at 8 weeks  Medial screws removed at 4 months
  • 60.  Splint 10 –14 days, nonweight bearing  Short leg cast, nonweight bearing 4 – 6 weeks  Short leg weight bearing cast or brace for an additional 4 – 6 weeks  Arch support for 3 – 6 months
  • 61.  Lateral column stabilization can be removed at 6 to 12 weeks  Medial fixation should not be removed for 4 to 6 months  Some advocate leaving screws indefinitely unless symptomatic
  • 62.  Commonly missed injury  Lisfranc joint disruption should be suspected with flake fxs at base of 2nd MT  Anatomic reduction is essential  Nearly all require fixation  ORIF can be carried out with pins, screws or both  Terrible injuries, especially if missed › Debilitating foot pain
  • 63. Thank you
  • 64.  Anatomy: - the 9 compartments of the foot can be placed into 4 groups; - Intrinsic Compartment: - 4 intrinsic muscles between the 1st and 5th metatarsals; - Medial Compartment: - abductor hallucis; - flexor hallucis brevis; - Central Compartment: (Calcaneal Compartment) - flexor digitorum brevis; - quadratus plantae; - adductor hallucis; - Lateral Compartment: - flexor digiti minimi brevis; - abductor digiti minimi;
  • 65.  Appropriate treatment for a suspected compartment syndrome of the foot is immediate and complete fasciotomy;  abductor hallucis longus, central, lateral, and interosseous compartments must be released;
  • 66.  Effective decompression of all 4 compartments can be accomplished thru medial longitudinal Henry approach, or through 2 parallel dorsal incision along the lengths of the second and fourth metatarsals;