Lisfranc injuries -surgical management , dr mohamed ashraf ,HOD orthopaedics,...drashraf369
lisfranc injuries are a group of very complex foot injuries.these injury is notorious for missed and mismanaged due to associated more lethal multisystem trauma.dr mohamed ashraf ,dept of orthopaedics,govt medical college,alleppey,kerala,india is doing the presentation with various examples to show how not to miss these injuries.
Lisfranc injuries -surgical management , dr mohamed ashraf ,HOD orthopaedics,...drashraf369
lisfranc injuries are a group of very complex foot injuries.these injury is notorious for missed and mismanaged due to associated more lethal multisystem trauma.dr mohamed ashraf ,dept of orthopaedics,govt medical college,alleppey,kerala,india is doing the presentation with various examples to show how not to miss these injuries.
At the end of this lecture you will be able to:-
Describe the anatomy of the ligaments stabilising the wrist, DRUJ and the MCP joints
Assess confidently the stability of these joints and identify the anatomy of the lesions
Identify and provide a management plan for patients with ligament injuries and their post-op rehabilitation.
In this article, we present how to evaluate syndesmosis injury by a case discussion. We also review the current concepts of syndesmosis injury in ankle fracture especially intraoperative evaluation and how to set syndesmotic screw fixation.
Posterolateral corner injuries of knee joint Samir Dwidmuthe
Missed posterolateral corner injuries of knee joint is a common cause for failure of ACL and PCL reconstruction only next to malpositioned tunnels.
Isolated PLC injuries are uncommon, making up <2% of all acute knee ligamentous injuries. Covey JBJS 2001
Incidence of PLC injuries associated with concomitant ACL and PCL disruptions are much more common (43% to 80%). Ranawat JAAOS 2008
A recent (MRI) analysis of surgical tibialplateau fractures demonstrated an incidence of PLC injuries in 68% of cases. Gardner JOT 2005
Take home message
PLC injuries to be ruled out in every case of ACL& PCL rupture.
Neurovascular integrity to be checked in every case.
Grade I & II can be managed conservatively.
Grade III Acute- Repair.
Grade III Chronic- Anatomic PLC recon.
Beware of varus knee alignment.
Correcting Varus Deformity of the Knee in Total Knee ReplacementVaibhav Bagaria
Varus Deformity is one of the commonest deformity encountered during TKR. An algorithmic approach helps to address the deformity correctly and allows the surgery to be successful.
At the end of this lecture you will be able to:-
Describe the anatomy of the ligaments stabilising the wrist, DRUJ and the MCP joints
Assess confidently the stability of these joints and identify the anatomy of the lesions
Identify and provide a management plan for patients with ligament injuries and their post-op rehabilitation.
In this article, we present how to evaluate syndesmosis injury by a case discussion. We also review the current concepts of syndesmosis injury in ankle fracture especially intraoperative evaluation and how to set syndesmotic screw fixation.
Posterolateral corner injuries of knee joint Samir Dwidmuthe
Missed posterolateral corner injuries of knee joint is a common cause for failure of ACL and PCL reconstruction only next to malpositioned tunnels.
Isolated PLC injuries are uncommon, making up <2% of all acute knee ligamentous injuries. Covey JBJS 2001
Incidence of PLC injuries associated with concomitant ACL and PCL disruptions are much more common (43% to 80%). Ranawat JAAOS 2008
A recent (MRI) analysis of surgical tibialplateau fractures demonstrated an incidence of PLC injuries in 68% of cases. Gardner JOT 2005
Take home message
PLC injuries to be ruled out in every case of ACL& PCL rupture.
Neurovascular integrity to be checked in every case.
Grade I & II can be managed conservatively.
Grade III Acute- Repair.
Grade III Chronic- Anatomic PLC recon.
Beware of varus knee alignment.
Correcting Varus Deformity of the Knee in Total Knee ReplacementVaibhav Bagaria
Varus Deformity is one of the commonest deformity encountered during TKR. An algorithmic approach helps to address the deformity correctly and allows the surgery to be successful.
paediatric injuries around the elbow
supracondylar elbow injuries
pulled elbow in paediatric age r
radiological signs around elbow in supracondylar fracture humerus
1) Subtrochanteric Fracture
Subtrochanteric typically defined as area from lesser trochanter to 5cm distal fractures with an associated intertrochanteric component may be called peritrochanteric fracture.
*Unique Aspect
Blood loss is greater than with femoral neck or trochanteric fractures – covered with anastomosing branches of the medial and lateral circumflex femoral arteries branch of profunda femoris trunk.
2) Femoral Shaft Fracture
Femoral shaft fracture is defined as a fracture of the diaphysis occurring between 5 cm distal to the lesser trochanter and 5 cm proximal to the adductor tubercle
The femoral shaft is padded with large muscles.
- reduction can be difficult as muscle contraction displaces the fracture
- healing potential is improved by having this well-vascularized
*Age
-usually a fracture of young adults and results from a high energy injury
-elderly patients should be considered ‘pathological’ until proved otherwise
-children under 4 years the suspected possibility of physical abuse
*FRACTURES ASSOCIATED WITH VASCULAR INJURY
Warning signs of an associated vascular injury are
(1) excessive bleeding or haematoma formation; and
(2) paraesthesia, pallor or pulselessness in the leg and foot.
~Warm ischemia in 2-3H
~If > 6H – salvage not possible
*‘FLOATING KNEE’
Ipsilateral fractures of the femur and tibia may leave the knee joint ‘floating’
3) Distal Femoral Fracture
Defined as fractures from articular surface to 5cm above metaphyseal flare
*clinical feature
The knee is swollen because of a haemarthrosis – this can be severe enough to cause blistering later
Movement is too painful to be attempted
The tibial pulses should always be checked to ensure the popliteal artery was not injured in the fracture.
Reference: Apley's System of Orthopaedic and Fracture (9th edition)
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
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A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
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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
