Lisfranc injury foot

1. LISFRANC
INJURY
Presented by:
DR. TARUN GUPTA
DNB ORTHO RESIDENT
UNIQUE HOSPITAL ,INDORE
Moderated By:
DR ANUJ NIGAM
DNB ORTHO RESIDENT

2. LISFRANC INJURY :
(Lisfranc fracture dislocation)
condition characterized by disruption between
the articulation of the medial cuneiform
and base of the 2nd
metatarsal

3. LISFRANC JOINT COMPLEX
a)Combination of :
1.Tarsometatarsal joint articulation
2.Intertarsal articulation
3.Intermetatarsal articulation
b)Lisfranc joint complex has a relatively rigid
Medial column(1st
,2nd
,3rd
tarsometatarsal joints)
and mobile lateral column(4th
,5th
TMT joints)

4. LISFRANC LIGAMENT
It is the most important stabilizer of 2nd
metatarsal
An interossesous ligament that goes from medial cuneiform to base of
2nd
metatarsal
Helps in maintaining the midfoot arch
Ligament is tightened with PRONATION and ABDUCTION of forefoot

5. Other ligaments:
1.Plantar tarsometatarsal ligaments
between medial cuneiform and 2nd
and 3rd
metatarsal
along with Lisfranc ligament give transverse instability
2.Dorsal tarsometatarsal ligaments
between
dorsal ligament are weaker ,therefore bony displacement is often
dorsal
3.Intermetatarsal ligaments
between 2nd
to 5th
metatarsal bases
1st
and 2nd
metatarsal are not connected by ligament

7. MECHANISM OF INJURY
• Most common dislocation of the foot
• Low energy injuries may result in sprain of the ligament
• High energy injuries results in complete ligament disruption or
osseo-ligamentous disruption of the complex
• Causes motor vehicle accident , fall from height , ballet
dancer ,atheletic injuries ,horse riding

8. A) Direct injury :
Direct crush injury leads to disruption of the articulation

9. b) Indirect injury :
• The TMT joint disruption results from
indirect rotational force and axial load
applied to the HYPER PLANTAR FLEXED
forefoot .
• The abduction moment applied to
forefoot displaces 2nd
to 4th
metatarsals
dorsally

11. CLINICAL FEATURE :
• Patient present with swelling(quite significant and nay even mask
bony deformity ) in midfoot
• Severe Pain in the forefoot
• Unable to bear weight
• Tenderness over tarsometatarsal joint
• May forefoot shortening and widening
• Plantar ecchymosis is pathognomic of Lisfranc injury
• Must look for Foot compartment syndrome

14. X RAY FINDINGS
• AP VIEW: malalignment of the medial border of middle cuneiform aligns with
the medial border of the 2nd
metatarsal DIAGNOSTIC of LISFRANC injury
Normal Lisfranc injury

15. Internal Oblique view:
• Malalignment of the medial border of the lateral cuneiform aligns
with the medial edge of the base of the 3rd
metatarsal
• Malalignment of the medial edge of the cuboid aligns with medial
edge of the 4th
metatarsal

16. LATERAL VIEW:
• Non weight bearing x ray shows
• Dorsal displacement of the base of the first or second metatarsal

17. FLECK SIGN :
• Seen in first intermetatarsal space
• Represents avulsion of Lisfranc ligament from base of 2nd
metatarsal

18. CT SCAN:
• CT plays an important role in looking at
the widening of the joint spaces
• CT also can detect associated fractures
• Confirming the diagnosis
• Help to formulate the surgical plan

19. DOPPLER STUDY : if dorsalis pedis artery is not palpable
• Dorsalis pedis artery and Deep peroneal nerve cross the joint
superioly and are at risk during Lisfranc dislocation

20. CLASSIFICATION
• Quenu and kuss classification :
• based on direction of displacement at tarsometatarsal joint

21. Homolateral : All five metatarsal displaced in the same
direction
Isolated : one or two metatarsal displaced from others
Divergent : lateral displacement of 2nd
-5th
metatarsal and
medial displacement of 1st
metatarsal

22. MEYERSON classification :
• Type A: total incongruity (lateral and dorsoplantar )
• Type b : partial incongruity (medial and lateral )
• Type c :divergent (partial and total )

23. Homolateral/total incongruity(type A)
• All 5 metatarsal displace in common direction
• Fracture base of 2nd
metatarsal

24. Isolated /partial congruity (type b)
Type b1 :partial incongruity affecting the first ray in relative isolation
(partial medial incongruity )
Type b2 :partial incongruity in which the displacement affects one or
more of the lateral four metatarsals(lateral incongruity)

25. Divergent :
Total or partial displacement

26. TREATMENT :
AIM: stable anatomic alignment
• 1. nonoperative
• 2.operative

27. NONOPERATIVE:
• Indication:
• Nondisplaced aur minimally displaced
• <2mm displacement of tarsometatarsal joint in any plane
• Patient with surgical contraindication like
• Poor medical status
• Charcot joint
• Vascular disease

28. Foot is placed in below knee splint and when
swelling reduced then Cast applied for 8 weeks

29. Operative :
• Indication : displacementof tarsaometatarsal joint
>2mm

30. Most common approach used two longitudinal
incisions

31. 1.ORIF is the standard of care with screw
fixation of the medial column with 3.5mm cc
screw and temporary fixation of lateral column
with k wire
2.Screw fixation is more stable than k wire
fixation
3.lateral column (4th
and 5th
metatarsal ) can be
reduced and fix to cuboid with k wire

32. 1.Multiple cannulated screw provide best multidirectional stability
2. screw placement :
between medial cuneiform and 2nd
metatarsal
between 1st
metatarsal and medial cuneiform
between 2nd
metatarsal and middle cuneiform
between intercuneiform (medial to middle cuneiform )
3rd
metatarsal to middle cuneiform (if required )

34. Post operative protocol :
• Foot is immobilized in non weight bearing cast for 6 weeks
• Progressive weight bearing is then allowed after 6 weeks
• Cast removal done once pain free weight bearing is achieved
• if lateral column fix with k wire then k wire removal at 6-8 weeks
• Screw removal in 3-6 months

35. Postoperative complication :
• Posttraumatic arthitiritis
• Compartment syndrome if swelling persist
• Nonunion
• malunion

36. THANK YOU