Lisfranc Injury

1. Dr. Santosh Batajoo
Orthopedic surgery

2. History
 Named after Jacques Lisfranc de St. Martin,
french surgeon
 He described an amputation
involving the tarsometatarsal
joint due to a severe gangerene
that developed when a soldier
fell from a horse with his foot
caught in a stirrup.

3.  Tarso-metatarsal (TMT) injuries or fracature -
dislocation at the tarsometatarsal joint
 Disruptions that occur at the
midfoot-forefoot junction.
 This part of the foot at the
apex of the arch can be difficult to
heal because of the stress of the weight.

4. Anatomy

5.  Lisfranc joint complex consists of 3
articulations –
1. Tarsometatrsal articulation
2. Intermetatrsal articulation
3. Intertarsal articulations

6.  The five TMT joints are held intact by ligaments
 The second metatarsal base is set into a recess
formed by the medial, intermediate and lateral
cuneiforms.
 No transverse ligament between the first and
second MT base.
 Plantar ligament between second MT base and
medial cuneiform is short and thick (Lisfranc’s
ligament) which provides stability in this area

7.  Secondary stabilizers- plantar fascia, the
intrinsic muscles, tibial and peroneal tendons, so
dispacement is more likely to be dorsally
because of stronger structures on the plantar
aspect.
 The middle 3 MT bases and their cuneiforms
form a transverse or Roman arch.

8.  Medial column- 1st MT, medial cuneiform &
navicular facet
 Middle column- 2nd, 3rd MTs with corresponding
cuneiforms and navicular articulations
 Lateral column- 4th, 5th MTs and cuboid
articulations.

9. Classification
(Mayerson’s)/Quenu and
KussType A (homolateral)
 Displacement of all 5 MTs with or without
fracture of the base of the 2nd MT
 Displacement is lateral or dorsolateral
Type B (isolated)
 One or more articulations remain intact
 B1- medially displaced
 B2- laterally displaced

10. Type C (Divergent)
 Medial displacement of the 1st MT and lateral
displacement of any combination of the lateral
four toes.
 C1- partial
 C2- complete

11. Nunley and Vertullo Athletic
Injuries
 Stage I- tear of dorsal ligaments and sparing of
the lisfranc ligament
 Stage II- injury to the lisfranc ligament with
elongation or rupture ( radiographic diastasis of
1 to 5 mm greater than the contralateral foot)
 Stage III- A progression of the above, with
damage to the planter TMT ligaments joints
along with potential fracture.

12. Mechanism
 Indirect mechanism – longitudinal force to a foot
that is planter-flexed in extreme equinus.
 Twisting and crushing injuries with the foot
buckling or twisting at the midfoot-forefoot
junction.

13. Direct mechanism
 Often high energy injuries as in motor vehicle
accidents, industrial accidents
 Less violent injuries- athletes and elderly
patients, fall from height with the foot in tiptoe

14. Clinical features
 History of road traffic accidents and falls
 Pain and swelling across the dorsum of the foot
 Tenderness at articulations
 Deformity
 Ecchymosis at the planter aspect of the foot

15.  Inability to bear weight on the foot
 Pain on abduction and pronation of forefoot with
the hindfoot fixed.

16. Radiology
X-rays
 The medial edge of the 2nd MT should be in line with
the medial edge of the 2nd cuneiform on the AP view.
 The medial edge of the 4th MT should be in line with
the medial aspect of the cuboid on the oblique view.
 Dorsal displacement of the 2nd MT base.

17.  A ‘fleck sign’ represents an avulsion of lisfranc
ligament.
CT scan
MRI - identifying ligament injuries
Bone scans

18. Treatment
 Depends upon the severity of the injury
 Undisplaced sprains – cast immobilizaton for 4-6
weeks
 Closed nondisplaced (˂2mm) injuries – non-
weight bearing case for 6 weeks followed by
weight bearing cast for an additional 4-6 weeks.
 Subluxation or dislocation- reduction under
anaesthesia, percutaneous K-wires or screws
and cast immobilization for 6-8 weeks.

19. Open reduction –
 if closed reduction fails.
 Displaced fracture, displacement of TMT joint ˃
2mm.
 Common approach- 2 dorsal longitudinal
incisions. One lateral to EHL from navicular to
the 1st MT space and other from the cuboid to
the third web space distally.
 Fixation with guide wires and screws.

21. Post operative
 Immobilized in a non-weight bearing cast for 6
weeks
 Progressive weight bearing after 6 weeks
 Cast removal
 Lateral column stabilization is removed at 2 to 3
months.
 Medial column stabilization is removed after 6
months.

22. Complicaitons
 Early complications
1. Compartment syndrome that could
result in ischaemic contractures.
2. Vascular injury – dorsalis pedis artery
3. Infections
 late complications
1. Post traumatic arthritis
2. Flatfoot deformity
3. Painful hardware
4. CRPS

23. Thank you