Mid foot lisfranc fracture


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Mid foot lisfranc fracture

  1. 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. 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. 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. 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. 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. 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. 7.  Associated Structures: 1. Dorsalis pedis artery – courses between 1st and 2nd metatarsal bases 2. Deep peroneal nerve: runs alongside the artery
  8. 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. 9.  2nd MT is recessed between the medial and lateral cuneiforms: › “Keystone” mortise that greatly adds stability in transverse plane
  10. 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. 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. 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. 13. Placing the foot into extreme plantar flexion with an axial load.
  14. 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. 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. 16. Direct Injuries: plantar displacement is more common, but dorsal displacement can also occur. Open fracture/compartment syndrome/soft tissue injury greater
  17. 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. 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. 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. 20.  Sprains are the most common injury to the tarso-metatarsal ligament.  graded I, II and III  Burroughs et al 1998
  21. 21.  Grade I - Pain at the joint, minimal swelling and no instability of the joint
  22. 22.  Grade II – Increased pain and swelling of the joint, with mild laxity but no instability
  23. 23.  Grade III – Complete ligamentous disruption and may represent a fracture-dislocation
  24. 24. HOMOLATERAL: most common
  25. 25. ISOLATED
  26. 26. DIVERGENT: least commom
  27. 27. Homolateral or Total Incongruity: • All 5 metatarsals displace in common direction •Fracture base of 2nd common
  28. 28. Isolated Partial Incongruities: • Displacement of 1 or more metatarsals away from the others
  29. 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. 30. Total incongruity – Can be either medially or laterally displaced
  31. 31. Partial incongruity – Either medial (Type B1)or lateral (Type B2), the most common type
  32. 32. Divergent displacement – Either partial (type C1) or total (type C2)
  33. 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. 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. 35.  Ecchymosis may appear late  Local tenderness at tarsometatarsal joints  Gentle stressing plantar/dorsiflexion and rotation will reveal instability
  36. 36. AP, Lateral, and 30 Oblique X-Rays are mandatory
  37. 37.  To look for alignment  AP : The lateral border of the 1st metatarsal is aligned with The Lateral border of the medial uneiform
  38. 38.  AP: the medial border of the 2nd metatarsal is in line with the medial border of the intermediate cuneiform
  39. 39.  Medial and lateral borders of the lateral cuneiform should align with the medial and lateral borders of the 3rd metatarsal
  40. 40.  Medial border of the cuboid should align with the medial border of the 4th metatarsal
  41. 41.  Lateral: The dorsal surface of the 1st and 2nd metatarsals should be level to the corresponding cuneiforms
  42. 42.  Standing views provide “stress” and may demonstrate subtle diastasis  Comparison views are very helpful
  43. 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. 44.  Anteroposterior X-ray presenting a type A (lateral) injury according to Myerson et al. classification
  45. 45.  Anteroposterior X-ray presenting a type B2 (partial lateral) injury according to Myerson et al. classification
  46. 46.  Anteroposterior X-ray presenting a type C2 (total) injury according to Myerson et al. classification
  47. 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. 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. 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. 50.  Surgical emergencies: 1. Open fractures 2. Vascular compromise (dorsalis pedis) 3. Compartment syndrome
  51. 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. 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. 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. 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. 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. 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. 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. 58. Preop AP Postop AP Postop Lateral
  59. 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. 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. 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. 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. 63. Thank you
  64. 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. 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. 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;