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.

1. Lisfranc injuries…
Easy to miss….
hard to get over….
Dr Mohamed Ashraf
Professor and head
Govt TD medical college
Alleppey,kerala,india
drashraf369@gmail.com

2. Jacquez Lisfranc de st.martin
Did the amputation !
Never described the injury !!

3. Lisfranc-statistics
• 1 in 55000 in a year
• 0.2 % of all fractures
• 67 % RTA
• 30 % crush,fall,sports
• 30 % low energy trauma vuori and aro
• 20 % missed or misdiagnosed
terry philbin,foot and ankleclinic,2003

4. TMT joints
• Medial column-ray 1
• Middle column-ray 2 & 3
• Lateral column-ray 4 & 5
• TMT2- recessed and stable
• TMT- trapezoidal,hence arch stable
• IM ligament-very strong[except M1-M2]

5. column

6. 2nd TMT joint
“lisfranc joint”
• TMT1-TMT2 weak connection
• CUN 1-TMT2- strong oblique lisfranc ligament
• Lisfranc ligament-8-10mm long,5-6mm thick
• bundles –dorsal,plantar[thick],interosseus
• LISFRANC lig-plantar bundle stronger
• Hence – more dorsal dislocation

7. Midtarsal injuries
Wide spectrum
• Mild sprain
• Subtle subluxation
• Displaced debilitating dislocations

8. Anatomical reason for missed
• TMT is at summit of arch
• More stress through the area
• Hence once missed,deformity progress
• No ligament between M1 and M2
• M1 hypermobile-frequently injured
• M2-C2 recessed like keystone-more injury

9. Myerson modification
[of quenu and kuss]
A-ALL MT AS A BLOCK
lateral or dorsolateral
with or without M2 base #
homolateral complete
B-ONE OR MORE TMT INTACT-MEDIAL/LATERAL
homolateral incomplete
C-DIVERGANT – PARTIAL / COMPLETE

10. Injury mechanism
• Direct or indirect
• External rotation of pronated foot
• Foot planted and twisted
• Isolated trauma
• Polytrauma missed
• Minor trauma missed

11. Clinical points not to miss
• Midfoot swelling
• Localised tenderness-more specific
• Pronation/supination pain-most
reliable[myer,am j of sports med.]
• Adduction/abduction pain
• CURTIS TEST-passive pronation,abduction pain
• Painful weight bearing-tip toeing

12. Whole foot swelling
• Dorsalis pedis between MT1 and MT2
• Must consider compartment syndrome
• Echymosis

13. Missed by
Deceptive presentations
• Spontaneosly reduced dislocations
• Neuropathic foot
• Mentally challenged persons
• Movement disorders-parkinsonism

14. lisfranc in diabetes
• Commonly missed
• Rapidly progress to midfoot break and
charcots arthropathy
• Sensory dysfunction
• Motor imbalance
• Difficult to manage-trophic ulcer,wound
healing
Levitt B A ,clinical podiatric surgery,2013

15. Polytrauma causes to miss
Focus on more serious system injuries
Sedation and analgesia
Ignored due to head injury or spinal cord injury
Patient often bedridden

16. Missed in “X ray”
• Non-weight bearing
• Weight bearing
• Stress
• AP/LAT/30 OBLIQUE

17. How not to miss in xray
• AP MT2-CUN2 Medial line
• AP MT4-CUBOID medial line
• AP M1-C1 congrous joint line
• 20% missed on plain xray
Mantas,clinical sports medicine

18. Radiological signs
• AP Fleck sign chip/avulsion # at CU1-M2base
• AP MT1-MT2 normal 2mm
• AP naviculo-cuneiform subluxation
• AP cuboid ,navicular compression #
• MT base fractures

19. Stress xray
• Flattening of arch
• Widening of space
• NWB WB

20. Lisfranc-stastistics
Xi Y et al 153 cases
• Homolateral incomplete-common
• Divergant-rare
• 15 %- negetive xray,positive MRI
• 70%- M1-M2 > 2mm
• 45%- chip # M1-M2
• 70%- chip # M2 base
• 10%- purely ligamentous

21. CT or NO CT ?
• Subtle malalignment
• Intraarticular fractures

22. MRI
• Cadaveric study
• Divided lisfranc ligament in different pattern
• Analysed by MRI
• Found MRI most sensitive to diagnose
miguel castro,musculoskeletal imaging,2010

23. MRI
• MRI is the best diagnostic tool
Xi Y,Imaging diagnosis of lisfranc injuries,2016 [153 cases]
Rensick D,MRI in tarsal injuries,2000

24. MRI
Can see
1.partial/complete
ligament injury
2.dorsal/interosseus
/plantar bundles
3.Other TMT
ligaments
4.Fluid collection
5.Subtle
malalignments

25. Cost of a miss

26. Missed diagnosis
• Commonly missed [20-30%]
• May lead to significant functional complications
• Make subsequent management difficult
Philbin T ,foot and ankle clinic
Nunley,am j of sports medicine

27. PROBLEMS OF MISSED
• Stiff forefoot
• Painful flatfoot
• Intrinsic contracture
• Planovalgus deformity
• Ankle or malleolar impingement
• Pressure over MT head
• Late OA

28. Delayed diagnosis
• 25 % may need arthrodesis later
TIM 2002
• Upto 40 % may develop sec OA
• Initial xray or severity have no predictive value
• But torn plantar bundle CUN 1-MT2,3 –in MRI
bad outcome
Raikin S M ,JBJS am,2009

29. Poor outcome
• Non-anatomical reduction-50-60 % OA
• Pure ligamentous injuries
• High energy trauma
• Homolateral

30. Timing of surgery
• Within 24 hours
• If present with severe swelling-10-14 dys
• Reconstruction not later than 4 weeks
• Result after 6 weeks- poor
soft tissue contractures
more dissection
cartilage necrosis
poor ligament healing

31. Late cases
• Two stage procedures [3 months injury]
Initial distraction – ring or jess
Followed by reconstruction k wire or screw
Mehraj D,strategies trauma limb reconstr 2017

32. ORIF -LISFRANC
• Longitudinal incision –over 1st space
• 2nd incision- if needed- over 4th space
• Isolate dorsalis pedis and deep peronael br

33. Key to success
• Anatomical reduction
• <2mm -6 weeks-non weight bearing
• 6 weeks partial weight bearing
• serial repeat xrays
• Closed reduction &fixation-k wire,4mm ccs,cs
• ORIF-k wire,screws

34. Late cases-management
• Symtomatic foot
• Sec OA
• arthrodesis-TMT 1,2,3,
• resection- TMT 4,5
Aronow M S ,foot and ankle clinic 2006

35. Lisfranc-Subtle injuries
• Forefoot pronation/abduction-pain
• Midfoot compression-pain
• M1 dorso-plantar movement-pain
• M1-M2 squeezing-pain

36. Subtle injury-classification
[nunley and vertullo]
• Stage 1-can bear weight,but can’t do sports
• weight bearing xray almost normal
• Stage 2-space M1-M2 2-5 mm
• no loss of arch
• Stage3 –arch collapse

37. The best management of neglected
lisfranc is to avoid it by….
clinically
• Tenderness
• Twist the foot
• Tiptoeing
radiologically
Colinear lines
MT1-MT2 Interval
Joint congruity
if doubtful
go for MRI

38. Lisfranc injuries…..
• Are easy to miss even by seasoned
surgeons
• Especially in polytrauma and
neorotrauma
• Consequences are devastating
• The best way to avoid it is to keep a high
index of suspicion

40. Dr mohamed ashraf
MBBS [GMC CALICUT]
D ORTHO [GMC TRIVANDRUM]
MS ORTHO [MMC MADRAS]
DNB ,MNAMS [NEW DELHI]
drashraf369@gmail.com