2. History
Dr. Jacques Lisfranc was a French
gynecologist who was called into the
service of Napoleon’s army where he
served as a trauma surgeon in the
1820’s and 30’s. He also served under
Dr. Dupuytren during this time.
Del Sel first described Lisfranc
dislocations following equine injuries
(JBJS 1955).
3. Anatomy
Tarsometatarsal joint:
• 9 bones,
• ~13 joints,
• 7 weak dorsal ligaments,
• 5 strong plantar ligaments,
• The Lisfranc ligament (+2 other interosseous ligaments)
• Myerson described three functional columns of the
Lisfranc joint. Ouzounian and Shereff described the
sagittal plane motion of each of these columns.
4. Anatomy
• Medial Column: 1st met and medial cuneiform:
4mm of motion in the sagittal plane.
• Central Column: 2nd/3rd mets and central/
lateral cuneiforms. 1mm of motion in sagittal
plane.
• Lateral Column: 4th/5th mets and cuboid. 10mm
of motion in the sagittal plane.
5. Mechanism
of injury
• Accounts for 0.2% of all traumatic injuries. Most
common in MVA and sports injuries.
• Occurs either by direct crushing (i.e. dropping
something on the foot) or indirectly (usually a
plantarflexed and abducted foot).
6. Diagnosis
Clinical
• Midfoot pain and tenderness. Possibly
exacerbated with pronation, abduction or
plantarflexion.
• Plantar ecchymosis
• Be wary of compartment syndrome! Always
check neurovascular status.
7. Pathognomonic “fleck sign” representing an avulsion fx in the 1st IM space.
Look for deviations from normal in the AP, MO and Lat views.
Normal is:
• AP: Medial border of the 2nd met continuous with the medial border of the central
cuneiform. Lateral border of the medial cuneiform continuous with the medial border
of the central cuneiform.
• MO: Medial border of the 4th met continuous with the medial border of the cuboid.
Lateral border of the 3rd met continuous with the lateral border of the lateral
cuneiform.
• Lat: No sagittal displacement. Look for lateral column shortening with a “nutcracker
fracture” of the cuboid.
“Lisfranc variant” is fracture damage extending proximally into the cuboid-
navicular region.
Consider stress radiographs with the foot in plantarflexion or abduction.
CT scan required for full diagnostic work-up and peri-operative planning!
8.
9. Classification
Originally described by Quenu and Kuss,
then modified by Hardcastle,
then modified by Myerson.
The Myerson Classification is listed with the
Quenu and Kuss equivalent in parentheses.
10. Treatment
• Literature strongly favors ORIF with any displacement (>2mm between the 1 st
and 2nd
mets).
Exact anatomic reduction is the key to prognosis.
• Non-operative
Myerson-Hardcastle Quenu and Kuss
Type A Total incongruity in any plane Homolateral
Type B
Partial
incongruity
- B1: 1st
met goes medial
- B2: Lesser mets go lateral
Isolateral
Type C Divergent
- C1: Partial (only 1st
and 2nd
mets involved)
- C2: Total (all mets involved)
Divergent
14. Treatment
Literature strongly favors ORIF with any displacement
(>2mm between the 1st and 2nd mets). Exact anatomic
reduction is the key to prognosis.
Non-operative
• If plain film and stress radiographs show no
displacement, then NWB SLC for 6 weeks with films q2
weeks looking specifically for displacement.
Operative
Goal: Reduction and stabilization of the medial and
central columns. You must reduce the lateral column,
but it is usually left unfixed because of the pronating
mobile adapter mechanism. The medial and central
columns do not have as much sagittal plane motion, but
you still don’t want excess compression with associated
chondrolysis to develop.
15. Incisions
Usually longitudinally over the dorsal-medial
1st
Proximal 2nd interspace (for access to 2,3)
Proximal 4th interspace.• Incisions:
• Usually longitudinally over the dorsal-medial 1 st
• Proximal 2nd
interspace (for access to 2,3)
• Proximal 4th
interspace.
• Fixation:
• Incisions:
• Usually longitudinally over the dorsal-medial 1 st
• Proximal 2nd
interspace (for access to 2,3)
• Proximal 4th
interspace.
16. Fixation
• 1st met to medial cuneiform
• 2nd met to central cuneiform
• 3rd met to lateral cuneiform:
• Crossed 0.062” K-wires
(removed at 8 weeks)
• Cannulated cancellous screws
(removed at ~12 weeks) or
3.5mm corticals.
• Consider putting a notch
1.5cm distal to the joint for
screw to prevent stress risers.
• Drill the hole for the screw in
the superior aspect of the
notch and not the base to
prevent splitting the base.
xation:
• 1st
met to medial cuneiform
• 2nd
met to central cuneiform
• 3rd
met to lateral cuneiform:
• Crossed 0.062” K-wires (removed at 8 weeks)
• cannulated cancellous screws (removed at ~12
weeks) or 3.5mm corticals.
• Consider putting a notch 1.5cm distal to the joint for
screw to prevent stress risers. Drill the hole for the
screw in the superior aspect of the notch and not
the base to prevent splitting the base.
• Consider 4th
met to cuboid and 5th
met to cuboid with a
single 0.062” K-wire
• Lisfranc Screw: Medial cuneiform to 2nd met base, screw in a
17. Fixation
• Consider 4th met to
cuboid and 5th met to
cuboid with a single
0.062” K-wire
• Lisfranc Screw: Medial
cuneiform to 2nd met
base, screw in a lag
fashion
• Length of the lateral
column must be
restored following a
“nutcracker fracture.”
Consider using an H-
plate or external
fixation.
62” K-wire
crew: Medial cuneiform to 2nd
met base, screw in a
n
the lateral column must be restored following a
er fracture.” Consider using an H-plate or external
oned to PWB SLC for 4 weeks transitioned to rehab.
ly be resumed at 6 months.
yone develops post-tr aumatic arthritis to some extent.
18. Post-operative
• NWB SLC for 8 weeks transitioned to PWB SLC for 4 weeks
transitioned to rehab. High impact activity can usually be
resumed at 6 months.
Complications
• ARTHROSIS! Essentially everyone develops post-traumatic
arthritis to some extent.
19. Additional
Reading
[Myerson M. The diagnosis and treatment of
injuries to the Lisfranc joint complex. Orthop
Clin North Am. 1989; 20(4): 655-64.]
[Hardcastle PH, et al. Injuries to the
tarsometatarsal joint. Incidence, classification,
and treatment. JBJS-Br. 1982; 64(3): 349-56.]
[Desmond EA, Chou LB. Current concepts
review: Lisfranc injuries. Foot Ankle Int. 2006;
27(8): 653-60.
21. How do you
assess Lis Franc’s
joint
radiographically?
• AP: Medial border of the 2nd metatarsal
base should be aligned with the medial
border of the middle cuneiform
• 30 degree lateral oblique: Medial border of
the 4th metatarsal base should be aligned
with the medial border of the cuboid
• Lateral: Dorsal border of the 2nd metatarsal
base should be aligned with the middle
cuneiform base
• Desmond, FAI, 2006.
Myerson, Foot & Ankle, 1986.
26. What other
injuries are
accociated
with Lis Franc
Fx/Dislocation
?
►Nutcracker type fracture of the cuboid
►Chopart subluxation/dislocation
►Calcaneal fractures
►Proximal injuries
►Compartment syndrome
►Disrupted neurovascular supply
►Soft tissue envelope compromise
27. What is the
goal of
reduction in
displaced lis
franc
injuries?
Anatomic alignment of the bases of the
metatarsals with their respective tarsal bones.
28. What are
Charnley’s
four steps to
closed
reduction?
• Re-create/exaggerate the deformity
• Distract the deformity
• Reduce the deformity
• Cast the body part
29. What are
principles to
reduction that
are specific to
lis franc’s
complex?
►Key to reduction: 2nd metatarsal
►Step 1: Medial column
►Step 2: Lis Franc ligament complex
►Step 3: Lateral rays
From: Kelkikian. Operative Treatment of the
Foot and Ankle. 1998.
30. If you take a
lis franc
injury to the
OR, what are
your fixation
options?
►Closed reduction, cast immobilization
►PerQ fixation with K-wires only
►PerQ fixation with K-wires 4 – 5; ORIF of 1-3 PRN
►ORIF (no K-wires) with screws
►ORIF with plates
►External fixation
►Partial arthrodesis
►Full arthrodesis
32. What are
some of the
major
complications
associated
with this
injury?
• DJD
• CRPS
• Compartment syndrome
• Cuboid syndrome
• Additional surgery/fusion
