Lisfranc fracture dislocation

1. LISFRANC
FRACTURE
DISLOCATION
Dr.Ponnilavan

2. ANATOMY
• In the AP plane, the base of the second
metatarsal is recessed between the medial
and lateral cuneiforms. This limits
translation of the metatarsals in the frontal
plane.
• In the coronal plane, the middle three
metatarsal bases are trapezoidal, forming a
transverse arch that prevents plantar
displacement of the metatarsal bases.

3. • The second metatarsal base is the keystone
in the transverse arch of the foot.
• There is only slight motion across the tarso-
metatarsal joints, with 10 to 20 degrees of
dorsoplantar motion at the fifth metatarso-
cuboid joint and 20 degrees plantar flexion
at the first metatarso-cuneiform joint

4. • The ligamentous support begins with the
strong ligaments linking the bases of the
second through fifth metatarsals.
• The most important ligament is Lisfranc
ligament, which attaches the medial
cuneiform to the base of the second
metatarsal.

6. MECHANISM
• Twisting
• Axial loading
• Crushing

7. • Twisting: Forceful abduction of the forefoot
on the tarsus results in fracture of the base
of the second metatarsal and shear or crush
fracture of the cuboid.
• Most common mechanism

8. • Axial loading of a fixed foot may be seen
with extreme ankle equinus with axial
loading of the body weight, such as a missed
step off a curb or landing from a jump during
a dance maneuver.
• Crushing mechanisms are common in
industrial injuries to Lisfranc joint, often
with soft tissue compromise, and
compartment syndrome

9. AXIAL LOADING

10. CLINICAL EVALUATION
• Patients present with variable foot
deformity, pain, swelling, and tenderness on
the dorsum of the foot.
• Diagnosis requires a high degree of clinical
suspicion.
• Often missed or misdisgnosed as a simple
sprain

11. • Careful neurovascular examination is
essential
• Maybe assosiated with laceration of the
dorsalis pedis artery.
• Severe swelling of the foot is common and
compartment syndrome of the foot must be
ruled out

12. RADIOGRAPHIC EVALUATION
• The medial border of the second metatarsal
should be colinear with the medial border of
the middle cuneiform on the AP view
• The medial border of the fourth metatarsal
should be colinear with the medial border of
the cuboid on the oblique view

15. • Dorsal displacement of the metatarsals on
the lateral view is indicative of ligamentous
compromise.
• Fleck fractures around the base of the
second metatarsal are indicative of
disruption of Lisfranc joint.

16. • Weight-bearing radiographs provide a stress
film of the joint complex.
• Stress views can be obtained.
• CT scan to assess intraarticular comminution.

17. CLASSIFICATION

18. OUENU AND KUSS
CLASSIFICATION
• Homolateral: All five metatarsals displaced
in the same direction
• Isolated: One or two metatarsals displaced
from the others
• Divergent: Displacement of the metatarsals
in 2 planes

20. MYERSON CLASSIFICATION
• Total incongruity: Lateral and dorsoplantar
• Partial incongruity: Medial and lateral
• Divergent: Partial and total

22. TREATMENT

23. NON OPERATIVE
• Injuries that present with painful weight
bearing, and tenderness but fail to exhibit
any signs of instability should be considered a
sprain.
• <2mm displacement of tarsometatarsal joint
• Patients with nondisplaced/ ligamentous
injuries should be placed in a short leg cast

24. • Initially, the patient is kept non weight
bearing with crutches and is permitted to
bear weight as comfort allows.
• Repeat x-rays are necessary once swelling
decreases, to detect osseous displacement.

25. OPERATIVE MANAGEMENT
• This should be considered when
displacement of the tarsometatarsal joint is
>2 mm.
• The best results are obtained through
anatomic reduction and stable fixation.
• The most common approach is using two
longitudinal incisions.

27. • The first is centered over the first/second
intermetatarsal space allowing identification
of the neurovascular bundle and access to
the medial two tarsometatarsal joints.
• A second longitudinal incision is made over
the fourth metatarsal

28. • The key to reduction is correction of the
fracture-dislocation of the second metatarsal
base.
• Once reduction is accomplished, fixation is
maintained by kirschner wires or screw
fixation

29. • The lateral metatarsals frequently reduce
with reduction of the medial column
• If intercuneiform instability exists, an
intercuneiform screw / k wire can be used.
• Stiffness from ORIF is not of significant
concern because of the already limited
motion of the tarsometatarsal joints.

34. COMPLICATIONS
• Posttraumatic arthritis
• Compartment syndrome
• Infection
• CRPS/RSD
• Neurovascular injury
• Hardware failure

35. THANK YOU