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Lis Franc Injury

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  • 1. Lisfranc Injury An In-depth Study By: Jeff Freshour
  • 2. History of Lisfranc
    • The Lisfranc joint, or tarsometatarsal articulation of the foot, is named for Jacques Lisfranc (1790-1847), a field surgeon in Napoleon's army. Lisfranc described an amputation performed through this joint because of gangrene that developed after an injury incurred when a soldier fell off a horse with his foot caught in the stirrup.
    • The incidence of Lisfranc joint fracture­ dislocations is one case per 55,000 persons each year. Thus, these injuries account for fewer than 1 percent of all fractures. As many as 20 percent of Lisfranc joint injuries are missed on initial anteroposterior and oblique radiographs.
  • 3. Mechanisms of Injury
    • Lisfranc joint complex injury can occur as a result of direct or indirect trauma. Lisfranc joint fracture­dislocations and sprains can be caused by high-energy forces in motor vehicle crashes, industrial accidents and falls from high places. Occasionally, these injuries result from a less stressful mechanism, such as a twisting fall.
    • Since Lisfranc joint fracture­dislocations and sprains carry a high risk of chronic secondary disability, physicians should maintain a high index of suspicion for these injuries in patients with foot injuries characterized by marked swelling, tarsometatarsal joint tenderness and the inability to bear weight.
  • 4. Anatomy of the Lisfranc Joint
    • The Lisfranc Joint is comprised of articular surfaces between the base of all 5 metatarsals, the 3 cuneiforms and the cuboid.
  • 5. Anatomy of the Lisfranc Joint
    • First metatarsal base(1), medial cuneiform(2), second metatarsal base(3), intermediate cuneiform(4) and distal extent of navicular(5).
  • 6. Radiographic Studies Anteroposterior non­weight-bearing radiograph of the left foot. Note that this view shows no evidence of malalignment or any other joint disruption
  • 7. Radiographic Studies Figure 1. Lateral non­weight-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).
  • 8. Radiographic 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.
  • 9. Clinical Diagnosis
    • Presentation
    • Apart from a crush injury with marked swelling and radiographic changes, the Lisfranc joint injury can be difficult to diagnose. Gross subluxation or lateral deviation of the forefoot is rare. Swelling in the midfoot region and an inability to bear weight may be the only findings that suggest the diagnosis. Lisfranc joint injury should be suspected when the mechanism of injury is consistent with this traumatic injury and soft tissue edema or pain in the foot persists five or more days after the initial injury.
  • 10. Clinical Diagnosis
    • Physical Examination
    • When Lisfranc joint complex injury is suspected, palpation of the foot should begin distally and continue proximally to each tarsometatarsal articulation. Tenderness along the tarsometatarsal joints supports the diagnosis of midfoot sprain with the potential for segmental instability.
    • Pain can localize to the medial or lateral aspect of the foot at the tarsometatarsal region on direct palpation, or it can be produced by abduction and pronation of the forefoot while the hindfoot is held fixed.4 Another diagnostic clue is the patient's inability to bear weight while standing on tiptoe.
    • The dorsalis pedis pulse and capillary refill should also be evaluated. The dorsalis pedis artery courses over the proximal head of the second metatarsal. Thus, it is susceptible to disruption in a severe dislocation.
  • 11. Treatment
    • Early diagnosis of a Lisfranc joint injury is imperative for proper management and the prevention of a poor functional outcome. With a general knowledge of both conservative and operative treatment options, the primary care physician can decide whether to treat the injury nonoperatively or refer the patient to an orthopedist.
  • 12. Treatment
    • Nonoperative Treatment
    • If the clinical evaluation indicates the probability of a mild or moderate sprain and the radiograph shows no diastasis, immobilization is suggested. Treatment with a short-leg walking cast,6 a removable short-leg orthotic or a non­weight-bearing cast4 is continued for four to six weeks or until symptoms have resolved. The potential for disability following a Lisfranc joint injury justifies the use of a non­weight-bearing cast.
    • After the period of immobilization, ambulation and rehabilitation exercises should be progressive. If the symptoms persist up to two weeks after rehabilitation has begun, a repeat weight-bearing radiograph must be obtained to evaluate the joint articulation for instability5 and evidence of delayed separation (i.e., disarticulation worsened after weight-bearing).
  • 13. Treatment
    • Operative Treatment
    • If surgical repair is warranted, it should be done within the first 12 to 24 hours after the injury. Alternatively, surgery can be performed after 7 to 10 days to allow the reduction of swelling.
    • While some orthopedists prefer closed fixation with percutaneous K-wires, others report that this method does not hold anatomic reduction and fixation. An alternative method involves the use of open reduction and internal fixation. An open surgical field allows easier removal of fragments or soft tissue that may be hindering reduction of the dislocation.
    • After open reduction and internal fixation, most orthopedists suggest that the foot be immobilized in a cast for 8 to 12 weeks with minimal (toe-touch) weight-bearing. Noncasted, full weight-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, the patient should wear a protective shoe with a well-molded orthotic.
  • 14. Treatment
    • ORIF (open reduction internal fixation)
    • OPERATIVE CONSIDERATIONS
    • PATIENT POSITIONING: supine with ipsilateral sandbag.
    • TOURNIQUET: thigh at 300mmHg
    • ANAESTHESIA: General
    • NERVE BLOCK: femoral and sciatic
    • INSTRUMENTS REQUIRED: lambotts fine osteotomes, 5mm high speed burr, Charlotte staples, 4.0mm cannulated ACE screws
  • 15. Treatment-ORIF
    • Proximal instability - This includes tarsal instability and longitudinal impaction injuries that can disrupt the normal arcade of the TMT joints. Openly reduce and hold with fixation screws any instability between tarsal bones. If necessary, a mini-external fixator can be used to control proximal migration and comminution. Anatomically restore any shortening of the tarsals, 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, perform primary fusion among the involved bones to preserve long-term stability. Treatment then can proceed as it would for a pure dislocation
  • 16. Treatment-ORIF
    • Distal fractures - MT fractures distal to the Lisfranc joint sometimes can interfere with stable fixation. In these instances, use intramedullary K-wires in conjunction with open reduction to anatomically realign the foot.
  • 17. Outcome Studies
    • Stable anatomic alignment is the best predictor of outcome. The presence of fractures and/or articular destruction leads to poorer results, regardless of alignment. Incidence of posttraumatic arthritis reportedly ranges from 0-58%.20  One study reported that up to 25% of patients develop posttraumatic arthritis even after fixation.
    • In 2006, Ly and colleagues reported the results of their study comparing primary 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 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 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 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. Whether this improves long-term results is not yet known.
    • 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 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 true efficacy.
  • 18. References
    • Gaines RJ, Wright G, Stewart J. Injury to the tarsometatarsal joint complex during fixation of Lisfranc fracture dislocations: an anatomic study.  J Trauma . Apr 2009;66(4):1125-8.  [Medline] .
    • Cook KD, Jeffries LC, O'Connor JP, Svach D. Determining the strongest orientation for "Lisfranc's screw" in transverse plane tarsometatarsal injuries: a cadaveric study.  J Foot Ankle Surg . Jul-Aug 2009;48(4):427-31.  [Medline] .
    • Kaar S, Femino J, Morag Y. Lisfranc joint displacement following sequential ligament sectioning.  J Bone Joint Surg Am . Oct 2007;89(10):2225-32.  [Medline] .
    • Hardcastle PH, Reschauer R, Kutscha-Lissberg E, et al. Injuries to the tarsometatarsal joint. Incidence, classification and treatment.  J Bone Joint Surg Br . 1982;64(3):349-56.  [Medline] .  [Full Text] .
    • Desmond EA, Chou LB. Current concepts review: Lisfranc injuries.  Foot Ankle Int . Aug 2006;27(8):653-60.  [Medline] .
    • Lattermann C, Goldstein JL, Wukich DK, et al. Practical management of Lisfranc injuries in athletes.  Clin J Sport Med . Jul 2007;17(4):311-5.  [Medline] .
    • Curtis MJ, Myerson M, Szura B. Tarsometatarsal joint injuries in the athlete.  Am J Sports Med . Jul-Aug 1993;21(4):497-502.  [Medline] .
    • Patillo D, Rudzki JR, Johnson JE, et al. Lisfranc injury in a national hockey league player: a case report.  Int J Sports Med . Nov 2007;28(11):980-4.  [Medline] .
    • Chilvers M, Donahue M, Nassar L, et al. Foot and ankle injuries in elite female gymnasts.  Foot Ankle Int . Feb 2007;28(2):214-8.  [Medline] .
  • 19. Thank You Questions/Comments

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