1) A Lisfranc fracture is a fracture or dislocation of the tarsal bones where they meet the bases of the metatarsal bones in the midfoot. 2) It is usually caused by high-energy twisting injuries or axial loading with the foot fixed. Common mechanisms are falls from heights or motor vehicle accidents. 3) Diagnosis involves x-rays of the foot, and sometimes CT or MRI to further evaluate bone and ligament injuries. Operative treatment is usually needed for displaced fractures to restore the normal alignment of the bones.

1. Dr. Vicky deepu 05

2.  LISFRANC FRACTURE is basically known as fracture
dislocation of tarsal and metatarsal joint complex, which
includes tarsal bones articulate with cuneiform, cuboid and
lisfranc.
 The metatarsals dislocate from their normal articulation with
the mid-tarsal bones

3. Jacques Lisfranc de St. Martin
(April 2, 1790 – May 13, 1847)
 Lisfranc described an amputation involving the tarsometatarsal
joint due to a severe gangrene that developed when a soldier
fell from a horse with his foot caught in a stirrup.

4. INCIDENCE
 Incidence is 1 in 55,000 people each year.
 Most commonly involves the 1st and 2nd metatarsals and the
medial cuneiform.
 Approximately 4% of professional football players sustain
Lisfranc injuries each year.

5. ANATOMY
 Ap plane, the base of the
second metatarsal is recessed
between the medial and
lateral cunieforms.
 This limits translation of the
metatarsals in the frontal
plane

6.  Coronal plane, middle three metatarsal bases are trapezoidal
that forming a transverse arch that prevents plantar
displacement of metatarsal bases.
 The second metatarsal base is the keystone in the transverse
arch of the foot.
 The bony architecture is composed of 5 MTs and their
respective articulations with the cuneiforms medially and the
cuboid laterally.
 The TMT joint complex represents the dividing line between
the midfoot and the forefoot

7. LIGAMENT:
 Ligamentous support begins with the strong ligamentous
linking at the bases of the 2nd through 5th metatarsals.
 Most important ligament is the lisfranc ligament that attaches
from the medial cuniform to the base of second metatarsal.

8.  Ligamentous, bony and soft tissue support provides intrensic stability
across the plantar aspect of lisfranc joint.
 Dorsal aspect is not reinforced like the plantar aspect.
 There is no ligamentous connection between the 1st and 2nd
metatarsals.
 Dorsalis pedis artery dives between the first and second metatarsals
at lisfranc joint, may be damaged during injury, approach, reduction.
 Motion across tarsometatarsal joints, 10-20 degree of dorsal plantar
motion at the 5th metatarso cuboidal joint
 20 degree of plantar flexion from neutral at the metatarsocuneiform .

9. COLUMN:

10. MECHANISM OF INJURY
3 most common mechanisms :
# Twisting
# Axial loading of a fixed foot
# Crush injury

11. TWISTING:
 Forcefull abduction of the forefoot on the tarsus results in
fracture of the second metatarsal and shear or crush fracture of
the cuboid.
 Commonly seen in horse riders, equestrian accidents when
a rider fell from a horse with the foot engaged in the stirrup.
 Nowadays seen most commonly in motor vehicle accidents.

12. AXIAL LOADING OF A FIXED
FOOT :
 Two different plantar flexion
mechanisms lead to dorsal joint
failure.
 The first occurs in ankle equinus
and metatarsophalangeal joint
plantar flexion, with the Lisfranc
joint engaged along an elongated
lever arm. The joint is “rolled
over” by the body
 Placing the foot into extreme
plantar flexion with an axial load

14. CRUSH INJURY:
 Most common in industrial type of injuries to lisfranc joint,
often with sagital plane displacement, soft tissue compromise
and compartment syndrome.

15. CLASSIFICATION
 Classification schemes for lisfranc injuries guides in defining
the extent and pattern of injury.

16. QUENU AND KUSS
 Commonly observed pattern of injury.
HOMOLATERAL: all five metatarsals displaced in
the same direction.
ISOLATED: one or two metatarsals displaced
from the others.
DIVERGENT: displacement of the metatarsals in
both the sagittal and coronal planes

18. MYERSON
 Based on commonly observed patterns of injury with regard to
treatment.
TOTAL INCONGRUITY: lateral and dorsoplantar
PARTIAL INCONGRUITY: medial and lateral
DIVERGENT: partial and total

20. CLINICAL PRESENTATION
 Midfoot pain with difficulty in weight bearing
 Swelling across the dorsum of the foot
 Deformity variable due to possible spontaneous reduction.
 Plantar Ecchymosis is the pathognomonic for a lisfranc injury.

21.  Careful neurovascular examination to elicit dorsalis pedis
artery injury, compartment syndrome must be ruled out and
monitoring for compartment syndrome is necessary.
 PIANO KEY SIGN:
Stressing the second tarsometatarsal joint by elevating
and depressing the second metatarsal head relative to the first
metatarsal head elicits pain at the Lisfranc joint.
Cant be elicited in acute condition.

22. IMAGING
 First investigation is a plain film x-ray AP and 30 ̊ Oblique

23. AP X-RAY

24. IN AP LOOK FOR
 On the AP, the lateral border of the 1st metatarsal is aligned
with the Lateral border of the medial cuneiform.
 On the AP the medial border of the 2nd metatarsal is in line
with the medial border of the intermediate cuneiform

25. OBLIQUE X-RAY

26. IN OBLIQUE VIEW LOOK FOR
 Medial and lateral borders of the lateral Cuneiform should
align with the medial and lateral borders of the 3rdmetatarsal.
 Medial border of the cuboid should align with the medial
border of the 4th metatarsal

27. STRESS RADIOGRAPHS
 Radiographs must be obtained with the patient bearing weight
in case of subtle injuries.

28. CT
 CT plays an important role in looking at the widening of the
joint spaces
 CT also can detect associated fractures
 Help with confirming the diagnosis
 Help to formulate the surgical
treatment plan

29. 3D CT

30. MRI
 MRI has an advantage in identifying partial ligament injuries
and subtle ligament injuries.
 Especially useful in low velocity injuries and in settings of
Normal radiographs.
 MRI can be useful to evaluate the
soft tissue damage.
 Looks at the Lisfranc ligament
 Not routinely used

32.  Doppler ultrasound may be used to look at the dorsalis pedis
artery if it can not be felt by hand

33. FRACTURES ASSOCIATED WITH LISFRANC
DISLOCATIONS
 Base of 2nd metatarsal
 Cuboid
 Fractures of the shafts of the metatarsals
 Navicular

34. MANAGEMENT
The key to successful outcome in Lisfranc injuries is
anatomical alignment of the involved joints.
Non-operative
Operative

35. NON OPERATIVE:
 Injuries that present with painful weight bearing, pain with
metatarsal motion, tenderness on palpation but fail to exhibit
instability should be considered sprain.
 Patient with nondisplaced ligamentous injury with or without
small plantar avulsion fractures of the
metatarsal or tarsal bones should
be placed in a below knee cast

36.  Injuries can be treated with a non–weight bearing cast for 6
weeks followed by a weight bearing cast for an additional 4 to
6 weeks.
 Repeat x-rays are necessary once swelling decreases, to detect
osseous displacement

37. OPERATIVE:
 Operative management should be considered when
displacement of the tarsometatarsal joint is > 2mm.
 Fixation should be used to maintain the reduction.
 Best results are obtained through anatomic reduction and stable
fixation.

38.  Most common approach is
using two longitudinal
incisions.

40.  A dorsal 5 cm longitudinal incision was made just lateral to the EHL,
extending from the navicular to the first metatarsal space.
 Sharp dissection with minimal soft tissue disruption was carried out.
 The EHL was retracted medially and the dorsalis pedis artery and the deep
peroneal nerve were retracted laterally, use a vessel loop for retraction.

41.  The capsule over the base of second metatarsal was incised and the
articular surface of the middle cuneiform was identi fied.
 The first and second TMT joints were reduced checking for both rotational
and angular alignment.
 Provisional stabilization was performed using the threaded guide wires.

42.  A second incision was made from the cuboid to the third web space distally.
 The superficial peroneal nerve was protected.
 The lateral border of the third metatarsal was reduced to the lateral border of
the lateral cuneiform.
 A guide wire was used to fix the lateral column going from the fourth
metatarsal to the cuboid.
• Reduction was checked

43. PRE OP
POST OP

44. PRE OPERATIVE:

45. POST OPERATIVE:

46. POST-OP MANAGEMENT
 Foot is immobilized in a non-weight bearing cast for 6weeks.
 Progressive weight bearing is then allowed after 6weeks.
 Cast removal is done once pain free full weight bearing is
achieved.
 Lat column stabilization is removed at 8 to 12 weeks.
 Medial column stabilization should not be removed until 6
months, better leaving screws indefinitely unless symptomatic.

47. Complications
The major complications of this fracture complex are incomplete
reduction, loss of reduction or post-traumatic arthropathy
 Post traumatic arthritis:
The x-ray appearance of degeneration of the joint is not
unusual with this injury and does not correlate well with
clinical symptoms.
Anatomic reduction of the joint complex with medial column
arthrodesis is the treatment of choice for symptomatic
arthropathy

48.  Compartment syndrome:
A tense swollen foot may hide a serious compartment
syndrome that may result in ischaemic contrature.
 Neurovascular injury
During trauma, approach.
 Infections:

49. REFERENCE:
 Lisfranc Open Reduction and Internal Fixation
- Robert Frangie
 Campbell's Operative Orthopaedics. 12th edition, pg 4189
 Apley’s system of orthopaedics and fracture 9th edition, pg 932

50. THANK YOU