4. Injuries of the tarso-
metatarsal articulation
encompass a wide spectrum
ranging from mild sprains or
subtle subluxations to widely
displaced debilitating injuries
This part of the foot at the
apex of the arch can be
difficult to heal, because a
significant amount of stress
passes through this area with
weight bearing
5. Mechanisms of Injury
Lisfranc joint complex injury can
occur as a result of direct or indirect
trauma ,caused by high-energy forces
in motor vehicle crashes, industrial
accidents and falls from high places.
Surgeons 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.
6. ANATOMY
The Lisfranc Joint is
comprised of articular
surfaces between the
base of all 5 metatarsals,
the 3 cuneiforms and the
cuboid.
7. Longitudinal arch – dorso convex spanning
Stabilized by
Planter apeneurosis
Long planter ligament
Peronous longus tendon
Lisfranc ligament bundle
M cuniform to 2 MT
M cuniform to 2 and 3 MT
Provide substantial stability
8. Transverse stability provided by
the wedge-shaped metatarsal
bases and their corresponding
cuneiform-cuboid articulations,
with the second metatarsal
recessed between the medial and
lateral cuneiforms as the keystone.
Stability in this area is provided by
the Lisfranc ligament, which runs
from the medial cuneiform to the
second metatarsal.
9.
10. The midial column consists of the
first metatarsal, medial cuneiform,
and navicular facet;
the middle column refers to the
second and third metatarsals with
their corresponding cuneiforms and
navicular articulations;
the lateral column refers to the
fourth and fifth metatarsals and their
cuboid articulations.
12. Type A injuries: Displacement of all
five metatarsals with or without
fracture of the base of the second
metatarsal.
The usual displacement is lateral or
dorsolateral, and the metatarsals
move as a unit. These injuries are
referred to as homolateral.
Type B injuries: One or more
articulations remain intact.
Type B1 injuries are medially
displaced, sometimes involving the
intercuneiform or naviculocuneiform
joint.
13. Type B2 injuries are laterally
displaced and may involve the
first metatarsal-cuneiform joint.
Type C injuries: Divergent
injuries that can be partial (C1)
or complete (C2) displacement.
14. EVALUATION
Any injury resulting in midfoot
tenderness and swelling merits a
careful physical and radiographic
examination
examining each articulation for
tenderness and swelling, especially
the medial cuneiform–first metatarsal
joint, which often appears
nondisplaced on radiographs.
The inability to bear weight on the
foot is another sign of potential
instability.
15.
16.
17.
18.
19.
20. Key things for evaluation
AIM anatomical
alignment of the
involved joints.
21. 1. The medial shaft of the second
metatarsal should be aligned with
the medial aspect of the middle
cuneiform on the anteroposterior
view.
22. 2. The medial shaft of the fourth
metatarsal should be aligned
with the medial aspect of the
cuboid on the oblique view.
23. 3. The first metatarsal–
cuneiform articulation should
have no incongruency.
24. 4. A “fleck sign” should be sought
in the medial cuneiform– second
metatarsal space. This
represents an avulsion of the
Lisfranc ligament.
28. Closed, non displaced (<2 mm)
injuries can be treated with a
non–weight bearing cast for 6
weeks followed by use of a
weight-bearing cast for an
additional 4 to 6 weeks.
Repeat radiographs should be
obtained to ensure that no
displacement is occurring in the
cast.
29. Displaced fractures should be
treated operatively . Closed
reduction, using finger traps
and countertraction, can be
successful if displacement is
not severe.
30. Fixation should be used to
maintain the reduction.
Steinmann pins can be used,
especially for the lateral two
joints; however, 4-mm
cannulated or 4-mm standard,
partially threaded cancellous
screws provide excellent fixation
and can be inserted under
image control.
31. Using cannulated screws makes
removal easier by employing a
guide pin to find the screw head
and ultimately to seat with the
screwdriver. If the reduction is
inadequate, or significant
comminution is present, open
reduction is preferred, especially
in partial (type B) or divergent
(type C) patterns.
32.
33.
34.
35. ORIF
With the patient under a
regional or general anesthetic,
make a dorsal incision lateral to
the extensor halluces longus
tendon over the interval
between the base of the first
and second metatarsals,
A second incision may be
needed more laterally if open
reduction of the fourth and fifth
tarsometatarsal joints is
necessary
Locate and incise the inferior
extensor retinaculum.
36. Isolate the dorsalis pedis artery
and deep peroneal nerve, and
use a vessel loop for retraction
of these structures medially or
laterally to allow inspection of
different areas of the Lisfranc
joint.
37. Remove any debris from the
Lisfranc region between the
base of the second metatarsal
and the medial cuneiform to
allow the space to be reduced.
Reduce the first tarsometatarsal
joint and hold it with guidewires
for cannulated screws. Place a
screw from the dorsal aspect of
the first metatarsal into the
medial cuneiform A second
screw can be placed from
proximal to distal across the first
38. Under fluoroscopic guidance,
pass a guidewire from the medial
cuneiform into the base of the
second metatarsal while holding
the reduction with a towel clip.
Place the appropriate 4.0-mm
cannulated screw over the
guidewire.
The second and third metatarsal–
cuneiform joints can be reduced
and fixed similarly with one screw
across the joint. Occasionally,
bony comminution may preclude
screw fixation. In this case,
fixation can be accomplished with
dorsal plates.
39. If an intercuneiform screw is needed,
insert it under fluoroscopic guidance from
the medial side of the medial cuneiform
into the middle cuneiform.
Reduce lateral metatarsocuboid
disruptions either closed with smooth
Steinmann pins or open through a parallel
incision centered dorsolaterally over the
articulations.
Close the dorsal skin with interrupted
nylon sutures.
40.
41.
42. POST-OPERATIVE CARE
A bulky dressing and posterior splint are applied postoperatively.
These are converted to a short-leg, non-weight-bearing cast at 7 to
10 days postoperatively . Weight bearing may be allowed at 6 to 8
weeks, toe touch on cruthes
laterally placed Steinmann pins are removed at 6 to 8 weeks.
Medial screws are removed at 4 to 5 months.
43. Outcome
Medial column anatomical alignment has linked as good outcome
flattening of medial longitudinal arch was associated with poor
outcome
Can be corrected by change in level of activity and shoe modification
44. Complications
Early
Compartment syndrome
Wound infection
Healing disturbance
Late
Post traumatic or secondary osteoarthritis
Delayed union
Non union
Chronic pain
Hardware problems
Flat foot
