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Lisfranc and Forefoot fracture in adult.pptx
- 1. Lisfranc Injury in Adults Presenter: Dr. Kaushal Raj Kafle Moderator: Dr. Sharad Adhikari
- 2. Contents • Clinical Anatomy • Stability of TMT joints • Lisfranc Injury • Radiographic evaluation • Classification • Management • Outcome
- 3. Clinical Anatomy Key stone : Lateral column : cuboid between calcaneus and the bases of the fourth and fifth metatarsals Medial column : navicular and the lateral cuneiform in the coronal plane
- 5. Clinical Anatomy • Mobility of the medial column of the TMT complex is not essential for gait, • Rigidity of medial column needed to propel body in terminal stance • Lateral column : cushioning effect during midstance when bearing weight
- 6. • Tarso metatarsal joint forms the mortis with the cuneiform • Roman Arch formed by metatarsals 1–3 and respective cuneiforms • Strong plantar and interosseous ligaments Stability of TMT joint
- 8. • No intermetatarsal ligament between M1 and M2. • The Lisfranc (C1M2) ligament is the strongest midfoot ligament • Dorsal Lisfranc ligaments provide relatively less stability Lisfranc Ligamentous Bundle
- 9. Lisfranc Fracture Dislocations Rare Young male and athletes. Accounts for 0.1 to 0.4 % . Misdiagnosed in 20% of cases rare Intricate anatomy and confusing Xray Failure to suspicion by primary physician Assosciated with polytrauma Frank Fracture dislocation to Subtle ligamentous injury.
- 10. Mechanism of Injury Indirect • Axial loading of plantar flexed foot. • Subtle and higher likelihood of misdiagnosis. • Football, American Football, Horseriding Direct • MVA, Crush • Significant Soft tissue injury • Open injury 12% • Compartment syndrome • Plantar Displacement
- 11. Indirect Mechanism • Plantarflexed forefoot and a longitudinal force applied through the metatarsal bone • Rolling, twisting force over the midtarsal bones in the plantigrade, fixed forefoot
- 12. CLINICAL FEATURES Pain, swelling, inability to weight bear and stand on tip toe. Tender dorsum of mid foot Pathognomic: Plantar ecchymosis Gentle stressing plantar/dorsiflexion and rotation will reveal instability-piano key sign DNVS DPA impingement Compartment syndrome
- 13. • The anterior tibial artery, cross ankle to form dorsalis pedis artery, • It also communicates with the medial plantar artery through the first metatarsal space. • Lisfranc fracture/dislocation can damage both elements of this anastomosis and cause ischemia to the medial side of the distal portion of the foots
- 14. • Abduction pronation maneuver Myerson and Cerrato Comparable to apprehension test • TMT compression test
- 15. RADIOGRAPHIC FEATURES AP View Standard AP IDEAL both feet weight bearing in single cassettee Oblique (30 deg in IR) True lateral
- 17. Others
- 18. Lisfranc Injury Step Fleck Sign
- 20. Positive medial column sign and increased gap in 1st TMT joint. Dynamic radiograph
- 22. MRI Lisfranc ligamentous injury, occult injury after negative stress views. Occult fracture Edema Predicts instability CT scan Intraarticular comminution Fracture pattern
- 23. Classification Quenu and Kuss classification HOMOLATERAL ISOLATED DIVERGENT
- 24. Myerson classification Incorporates osseous injury of medial column
- 25. Athletic Lisfranc Injury Classification • Diastasis between 1st and 2nd MT • Stage I non operative treatment • Stage II and III requires operative treatment
- 26. Goal of Treatment • Ultimate : painless stable plantigrade foot • Restore the stability of Lisfranc joint • Anatomical reduction of Lisfranc Complex • Surgical Goals • Restoration of both columns of foot • Preservation of essential joint of lateral TMT joint complex • Safe environment of adequate soft tissue coverage: ORIF • Features of soft tissue compromise : secondary reconstruction following a temporary external fixation and soft tissue decompression
- 27. Non Operative Indication : 1. Non displaced/pure ligamentous type 1. Malaligment <1mm 2. Articular displacement<2mm 2. Intact medial column of foot 3. No vascular or soft tissue compromise 4. Surgical contraindication
- 28. Non Operative • Below knee cast for 6weeks + Non weight bearing mobilization. • Progress to toe touching weight bearing for 6weeks clinical and x-ray healing • Physiotherapy • Stiff sole foot ware for medial column support.
- 29. Operative management • Soft tissue status • Duration since injury • Generally indicated for ALL Lisfranc Injury • Optimal Treatment remains ambigious
- 30. Operative management Indication: 1. Malalignment ≥ 1 mm. 2. Articular incongruity > 2mm. 3. Soft tissue or bone fragment preventing reduction. 4. Medial column instability or shortening 5. Associated with compartment syndrome
- 31. External Fixation pyramidal fashion spanning from the distal tibia to the forefoot and the calcaneus external fixation on the medial, lateral, or both columns
- 32. • Dorsal Longitudinal incision TMT 1-2 TMT 4-5 • Full thickness fasciocutaneous flap Internal Fixation
- 34. Percutaneous Fixation Home run screw
- 35. Flexible fixation • Tight Rope • Pure ligamentous type • Non Rigid fixation • No requirement of implant removal
- 36. Arthrodesis Indication: 1. Major ligamentous disruption with multidirectional instability. 2. Comminuted intraarticular # at MT base 3. Mid foot crush injury combined with intraarticular # dislocation.
- 37. Arthrodesis • Historically ORIF was the standard • Fusion salvage procedure in failed ORIF with PTOA • primary fusion : definitive when extensive articular cartilage damage that makes PTOA inevitable. • Primary fusion would avert a secondary procedure, additional rehabilitation, and increased financial burden.
- 38. Arthrodesis with plate and multiple screw
- 40. Outcome • One in 3 patient will continue to have pain at site of injury • Anatomic reduction has better results than non anatomical reduction • Poor Outcome • Pure Ligamentous injury • High energy injuries • Type C2 injuries • Non anatomical alignment • Obese • Elderly
- 41. Missed or Delayed Diagnosis • Devastating • Progressive mid foot instability • Arch Collapse • Forefoot Abduction • Post Traumatic OA • after 6 weeks fixed deformity can be expected in missed or insufficiently treated TMT injuries. • If a deformity becomes fixed, secondary repositioning can be impaired necessitating corrective osteotomy and/or arthrodesis
- 42. Complications • Early 1. Compartment syndrome 2. Wound infection 3. Soft tissue complication • Late 1. Secondary osteoarthritis (M/C) 2. Delayed union or non union 3. Chronic pain 4. CRPS 5. Pes planus 6. Stiffness 7. Bunion deformity 8. Gait Disturbances
- 43. Compartment syndrome • Risk in Lisfranc fracture dislocation 34 %
- 44. Forefoot injury
- 45. Metatarsal fracture • Constitute 35% all foot injuries. • Age 20-50 yrs. • Low energy trauma > High Energy trauma • Direct>indirect • Most common : 5th metatarsal # • Proximal metaphyseal and metatarsal base stays relatively well aligned and associated with TMT joint injuries
- 46. 5th Metatarsal Fracture • 2/3rd of MT fracture • Proximal base fracture • Distal spiral fracture
- 47. 5th Metatarsal # Tendons Attachment Blood Supply
- 48. 93% 4% 3%
- 49. Mechanisms of injury based on zones • Zone 1: Avulsion# : Sudden twisting of hindfoot with weight on lateral metatarsal. • Zone 2/ Jones # : Adduction of forefoot. • Zone 3/stress # : Repetitive cyclic load. Mostly in athletes . Dancers Fracture : Rolling over the outerborder of foot
- 50. Clinical Feature • Pain, swelling, and tenderness on the outside of the foot. • Difficulties with walking.
- 52. Management
- 53. First Metatarsal Fracture • Constitute 1.5% of all metatarsal # • Mostly in age < 4yrs • Mechanism of injury can be both direct and indirect. • Susceptible to arterial arch injury and compartment syndrome in soft tissue trauma.
- 54. Management • Non operative treatment indication 1. Isolated # 2. No instability in stress radiograph 3. Minimal displacement
- 56. Central metatarsal # • Commonly associated with injuries to the first ray, and Lisfranc joint injuries. • Second and the third MTs are important as they comprise the keystone of the foot. • Base of each central metatarsal is a series of three ligaments (dorsal, central, and plantar), which stabilize and support each with their neighbor. • Stress # in 2nd and 3rd MTs linked to mechanical pathologies
- 58. Take Home Message • Commonly missed Injuries and high morbidity • Unexplained Mid Foot Swelling always suspect Lisfranc injuries • Investigate to rule out Lisfranc Injury • Anatomical Reduction is necessary • Almost all require fixation •
- 59. References • Rockwood and Green,8th edition • Campbell’s orthopedics,14th edition • Macree orthopedics
Editor's Notes
- Midfoot : TMT joint complex as a three column system: the medial column (first TMT joint), the intermediate column (second/third TMT joints), and the lateral column (fourth/fifth TMT joints) The longitudinal arch is a dorso-convex bow spanning from the head of the metatarsals to the calcaneus stabilized by the plantar aponeurosis, the long plantar ligament, and the peroneus longus tendon
- medial column bears the majority of weight during gait and that motion is restricted, thus, mobility of the medial column of the TMT complex is not essential for gait, restoration of arch height and length is essential and fusion has become an option the function of the joints of the foot into essential, nonessential, and unnecessary. While the fourth and fifth TMT joints are classified as nonessential, their function within the lateral column of the foot is important providing a cushioning effect during midstance when bearing weight
- The midfoot is inherently stable because of its osseous arrangement. The metatarsal bases form a Roman arch structure in the axial section, with M2 acting as a keystone, articulating proximally with C2, and wedged between C1 and C3 with on average 8 and 4 mm of contact, respectively The importance of M2 to the Lisfranc joint complex is demonstrated by an increased rate of Lisfranc injuries with a shallower M2 mortise and with a smaller ratio of M2 length to foot length.
- The osseous tarsal complex is comprised of the navicular, the cuboid, and the three cuneiform bones. Due to its positioning, resulting from a relative short intermedial cuneiform and sandwiched between the adjacent medial and lateral cuneiforms, the second metatarsal has been recognized as the keystone within this osseous scaffold. This architectural characteristic accounts for substantial bony stability.
- At the tarsometatarsal joints, there are longitudinally oriented dorsal ligaments, transversely oriented interosseous ligaments, and obliquely oriented plantar ligaments. The intermetatarsal ligaments, which include dorsal, interosseous, and plantar components, transversely connect the M2 to M5 bases. “Lisfranc ligament bundle,” spanning from the first cuneiform to the second metatarsal M2M3 ligament connecting the plantar aspect of the medial cuneiform to the bases of the second and third metatarsals, provide substantial stability to the TMT joint line. In a biomechanical analysis load to failure and stiffness were more than two times greater for the Lisfranc ligament than for the dorsal ligament connecting the medial cuneiform and base of the second metatarsal. Other contributors to midfoot stability include capsules; plantar muscles; tendons of the peroneus longus, tibialis anterior, and tibialis posterior; and the plantar fascia, which all maintain the arch of the foot.
- Rare 1/55000 people intricate anatomy of the midfoot rendering diagnosis and detection of subtle cases difficult using X-ray alone Uncommon occurrence Failure to suspect by primary physicians Associated with polytrauma
- Indirect injury, most often axial loading, follows the longitudinal column of the foot, and subjects it to rotational, bending and compressive forces. When axially loaded, a plantar flexed foot sustains rupture first of the weaker dorsal ligamentous structures. fracture–dislocation becomes complete if the proximal metatarsals fracture and/or the stronger plantar ligaments rupture.
- plantarflexed forefoot and a longitudinal force applied through the metatarsal bone rolling, twisting force over the midtarsal bones in the plantigrade, fixed forefoot
- The anterior tibial artery, cross ankle to form dorsalis pedis artery, It also communicates with the medial plantar artery through the first metatarsal space. Lisfranc fracture/dislocation can damage both elements of this anastomosis and cause ischemia to the medial side of the distal portion of the foots
- Examination should also include provocative maneuvers to evaluate for instability—squeezing of the midfoot, pronation, supination, abduction, adduction, single limb weightbearing, and passive motion in sagittal and coronal planes of all 3 columns of the midfoot. 39,56 In the clinic setting, provocative maneuvers can be performed under fluoroscopy, as discussed in the following section, to help guide diagnosis and treatment. With regard to diagnostic testing, Myerson and Cerrato described the abduction–pronation maneuver, comparable to an apprehension test, and the transverse TMT-1/2 squeeze test as subtle but useful clinical tools.
- With nonweightbearing films, subtle Lisfranc injuries are missed at a reported rate of 20% to 50%. Weight-bearing Xray distinguish the instability of subtle ligamentous injuries from simple sprains. The first/second-intermetatarsal base distance in healthy adults on weight-bearing radiographs has been shown to average 2.5 mm Fleck sign avulsion fracture of the base of the second metatarsal or medial cuneiform, is pathognomic for a Lisfranc injury.
- Complex anatomy of the midfoot with overlapping projections, lateral border of the medial cuneiform is in line with the lateral border of the base of the first metatarsal. Furthermore, a colinear relation is present between the medial margin of the base of the second metatarsal and the adjacent intermediate cuneiform. Similarly, the medial border of the base of the fourth metatarsal is in line with the medial border of the cuboid, which can only be assessed sufficiently on the oblique radiographic projection. Malalignment of 1 mm or more has been characterized as pathologic.18
- The use of stress films to identify unstable injuries is important. A: Non-weight-bearing radiograph of midfoot pain. B: A weight-bearing stress view of the same foot showing widening between the first and second rays.
- Dynamic imaging under A: Normal. B: Pathologic. 1, medial column line; 2, widening of the first TMT joint space; 3, subluxation by lateral translation of the base of the first metatarsal. The white circle identifies the “positive medial column sign/mills sign” A tangent placed along the medial border of the medial cuneiform should intersect the base of the first metatarsal. In the case of medial TMT instability with forefoot abduction stress this line passes medial to the base (a positive “medial column sign”). When imaging is equivocal, it may be necessary to consider a stress examination under anesthesia. Stress maneuvers performed under fluoroscopy allow dynamic evaluation of the foot, which is advantageous over previously discussed static imaging modalities in identifying instability. 39 Stress maneuvers are similar to those used in the physical examination—squeezing of the midfoot, pronation, supination, abduction, adduction, and shucking of M1 in dorsal and plantar directions (Figure 4). 15,16 In 2 different cadaver studies, abduction stress maneuver was superior to weight-bearing radiographs in diagnosis of Lisfranc instability with diagnostic accuracy reported to be 75-100%. 15,25
- The medial border of M2 is not aligned with the medial border of C2 on the anteroposterior radiograph >2 mm gapping difference is noted between the base of M1 and M2 or between C1 and the base of M2 on the anteroposterior radiograph 18 The medial and lateral borders of M1 are not aligned with the medial and lateral borders of C1 on the oblique radiograph 62 The lateral border of M3 is not aligned with the lateral border of C3 on the oblique radiograph The medial border of M4 is not aligned with the medial border of Cu on the oblique radiograph Step-off of the dorsal cortex from M1 to C1 on the lateral radiograph. The plantar border of C1 dips below the plantar border of M5 on the lateral radiograph 18 “Fleck sign”—any avulsion fragment from the lateral edge of C1 or the medial edge of the base of M2. 40 Be aware of potential mimics, such as a free-standing type os intermetatarseum, which is well corticated and smooth in shape 10 Medial column tangential line—a line tangential to the medial aspect of the navicular and medial cuneiform that does not intersect the base of M1 on the anteroposterior abduction stress view 15 Associated signs suggesting Lisfranc injury—for example, compression fracture of cuboid, metatarsal base or neck fractures, and metatarsophalangeal joint dislocation/subluxation
- The diagnostic accuracy of radiographs, even of weightbearing patients with negative radiographic evaluation for Lisfranc injury, but with continued clinical concern, should obtain further imaging by dynamic stress radiograph, computed tomography (CT), or magnetic resonance imaging (MRI). CT is ideal subtle fracture persistent displacement not evident on plain radiographs complex anatomy of the midfoot with overlapping projections, CT allows for better visualization of fracture patterns and comminution of joint surfaces , CT is nonweightbearing and nondynamic. pure ligamentous injuries. Weightbearing CT is increasing in popularity MRI : ligament integrity, occult fractures, or edema. strongly predicts instability,
- Based on pattern of injury Classification devised by Quenu and Kuss Depicts homolateral disruption where all metatarsals travel in the same direction. Partial disruption involves only the first metatarsal or all the lesser rays. Divergent dislocation occurs when there is complete disruption of the tarsometatarsal joints but the first ray and the lesser rays displace in opposite directions
- modified Hardcastle classification as described by Myerson Incorporates osseous injury of medial column Type A injuries include complete incongruity of the TMT joint line in any plane or direction. A Type B1 injury is determined by partial incongruity involving the first ray (partial–medial incongruity). Dislocation of one or more of the lateral four metatarsal bones characterizes a Type B2 injury pattern, also termed partial-lateral incongruity. A Type C1 (divergent) injury has a diverging injury pattern comprised of medialization of the first ray associated with dislocation and partial incongruity of the lateral metatarsals. A Type C2 injury has a diverging injury pattern with complete incongruity
- The end goal following foot and ankle injury is to achieve a stable and painless plantigrade foot. Specifically, to restore stability following Lisfranc injuries, anatomic reduction of the Lisfranc complex is essential. Because Lisfranc injuries generally involve a component of instability that can lead to deformity, the role of nonoperative management in Lisfranc injuries is limited. In the literature, nonoperative management has been reserved for Lisfranc injuries without evidence of instability, such as those with <2 mm diastasis or extra-articular fractures with stability confirmed by weightbearing and stress views.
- . Because Lisfranc injuries generally involve a component of instability that can lead to deformity, the role of nonoperative management in Lisfranc injuries is limited. In the literature, nonoperative management has been reserved for Lisfranc injuries without evidence of instability, such as those with <2 mm diastasis or extra-articular fractures with stability confirmed by weightbearing and stress views.
- 6 weeks fixed deformity can be expected > secondary repositioning can be impaired necessitating corrective osteotomy and/or arthrodesis. Therefore, operative treatment should be initiated within 4 to 6 weeks after the injury. a significant soft tissue compromise : a closed reduction, to restore medial and lateral column alignment, followed by primary external fixation for temporary stabilization until the soft tissues permit open reduction and internal fixation. Because there is a wide spectrum of severity, instability patterns, and concomitant joint conditions, there has been no concrete evidence supporting any particular treatment modality. Ongoing debates exist in regard to fusion vs fixation, the role of suture buttons, transarticular screws vs extra-articular plates, operative timing, and need for removal of hardware.
- Closed reduction:, axial traction + mild pressure over the displaced metatarsal base : sagittal plane. Coronal : an additional abduction–adduction maneuver As the second metatarsal is the keystone within the osseous scaffold of the Lisfranc complex, it needs to be addressed in the most meticulous fashion. Sometimes a “pop” can be felt during reduction, which then should be assessed using fluoroscopy.
- External fixation can be performed in a pyramidal fashion spanning from the distal tibia to the forefoot and the calcaneus, respectively. Alternatively, spanning external fixation on the medial, lateral, or both columns without inclusion of the ankle joint is an option.
- The tendons of the extensor hallucis longus and brevis are identified and retracted by smooth hooks either laterally or medially depending on the part of the TMT complex to be addressed. A full-thickness fasciocutaneous flap is created to protect the vascular and neural bundle. Subperiosteal dissection is used to visualize and reduce the three medial TMT joints. the capsule is incised and the joint is inspected. joint debridement prevents entrapment of bony and ligamentous residua, : reduction barrier. Leaving a skin bridge of at least 3 cm is mandatory to prevent secondary skin necrosis. The second incision is placed over lateral part of TMT 3, as well as TMT 4/5, and the cuboid. The lateral cutaneous branch of the peroneal nerve should be identified and protected. However, in most cases TMT 3 can be easily accessed via the medial approach.
- Osteosynthesis of Lisfranc injury with comminuted # of base of 2nd MT Lisfranc injury fixed with only k wire for both medial and lateral
- Choice of implant is controversial Home run screw The medial cuneiform is then reduced using a pointed reduction clamp to the intermedial and lateral cuneiforms and fixation is achieved using 2.7-mm cortical screws.
- Tight Rope Pure ligamentous type Non Rigid fixation No requirement of implant removal A reduction clamp operated under a fluoroscopic image intensifier was used to diminish the diastasis between the medial cuneiform and second metatarsal base. (B) The Lisfranc joint was traversed using a guide wire. (C) An oblong button was positioned medial to the center of the medial cuneiform and an endobutton was positioned at the lateral cortex of the second metatarsal base.
- With our modern understanding of the functional anatomy of the foot, knowing that the medial column bears the majority of weight during gait and that motion is restricted, thus, mobility of the medial column of the TMT complex is not essential for gait, restoration of arch height and length is essential and fusion has become an option.134 Hansen132 separated the function of the joints of the foot into essential, nonessential, and unnecessary. While the fourth and fifth TMT joints are classified as nonessential, their function within the lateral column of the foot is important providing a cushioning effect during midstance when bearing weight. Primary arthrodesis has been reported to lead to improved functional outcomes for comminuted Lisfranc fracture– dislocations with destruction of the articular surface.141,191,279 The extent of articular compromise needed to indicate a primary arthrodesis has not been determined, but destruction of more than 50% of the articular surface area has been proposed as an indication for fusion.95 Others have recommended fusion in selected cases when there is (1) major ligamentous disruption combined with multidirectional instability of the TMT joint complex, (2) a comminuted intra-articular fracture at the metatarsal base of the medial complex, or (3) a midfoot crush injury combined with intra-articular fracture– dislocation.65 Arthrodesis of the lateral column of the TMT joint complex should be avoided however.234 The increased mobility of the fourth and fifth TMT rays is important for normal foot function. Therefore, the fourth and fifth TMT joints have been characterized as “essential joints” within the TMT joint complex.14
- , In the long-run, primary arthrodesis has been shown to result in better functional outcomes when compared to open reduction and fixation at both mid-term (24 months)141 and long-term (42 months)191 follow-up.
- AAFOS : Pain 40 Function 50 : Activity limitation, requirement of support, minimum walking distance, walking surface, gait abnormalities, Motion FlexEx VarVal InvEvr Alignment 10
- Overall prognosis is guarded Risk of non union : isolated plate fixation Smoking and non anatomical alignment Other situations where primary fusion has been recommended include patients with delayed presentations and for obese or elderly patients in whom fixation has a higher rate of failure.
- Missed or delayed diagnoses can be devastating; patients may develop progressive midfoot instability, arch collapse, forefoot abduction, or post-traumatic osteoarthritis (PTOA) that results in stiffness, chronic pain, and dysfunction of the foot and ankle complex. after 6 weeks fixed deformity can be expected in missed or insufficiently treated TMT injuries. If a deformity becomes fixed, secondary repositioning can be impaired necessitating corrective osteotomy and/or arthrodesis
- , flattening of the medial longitudinal arch was associated with a poor functional outcome including persistence of pain, a change in the level of activity or return to work status, and shoe modifications. Interestingly, both a delay in treatment and work-related injuries have been correlated with significantly reduced functional outcomes.5
- Motorcycle accidents are all high energy trauma > any metatarsal > soft tissue compromise and compartment Because of soft tissue attachment. Uniqnueness of 1st and 5th mt we will study separately and central mt #
- Adolscent : apophysis Sesamoid : os peroneum on lateral border of cuboid (peroneus longus ) os versalianum : proximal to the base of 5thMT insertion of peroneus brevis
- 3 muscles peroneus brevis, peroneus tertius and Abductor digiti quinti Strong attachemnet to plantar fascia
- I Sudden inversion of hind foot with weight on MT II Adduction of forefoot
- remainder of fifth metatarsal fractures not caused by a direct blow has been termed dancer’s fracture. The usual pattern is a spiral, oblique fracture of the shaft progressing from distal-lateral to proximal-medial. The mechanism of injury is typically a rotational force being applied to the foot while it is axially loaded in a plantarflexed position. The usual method is by rolling over the outer border of the foot
- Preferred ray for laoding during running, walking and turning independent movement due to lack of 1st dorsal ligament TA plantar medial surface peroneus longus : plantar lateral base
- 3 weeks non weight bearing and 3 weeks of weight bearing as tolerated