1) A Lisfranc injury involves damage to the ligaments and bones in the midfoot region where the metatarsals connect to the tarsus. 2) It is important to properly diagnose and treat Lisfranc injuries, as untreated or misdiagnosed injuries can lead to long-term functional limitations. 3) Diagnosis involves clinical exam, weight-bearing x-rays, and sometimes advanced imaging like CT or MRI. Surgical treatment aims to restore proper alignment and stabilize the injured joints through open reduction and internal fixation.

1. LISFRANC INJURY
Dr Praveen Kumar Reddy

2. • Injuries to the foot can have a dramatic impact on the
overall health, activity, and emotional status of patients.
• A recent study looking at the outcomes of multiple trauma
patients with and without foot involvement found a
significant worsening of the outcome in the presence of a
foot injury.

3. • Their conclusion is that more attention and
aggressive management need to be given to
foot injuries to improve the outcome of
multiply injured patients.

4. Jacques Lisfranc de St. Martin
(April 2, 1790 – May 13, 1847)
• Pioneering French surgeon and gynecologist.
Pioneered …………….
• Lithotomy
• Amputation of Cervix Uteri
• Removal of Rectum
The Lisfranc joint and the Lisfranc
fracture are named after him.

5. • 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.

6. Foot Anatomy

7. • Lisfranc joint complex
consists of three
articulations including
– Tarsometatarsal articulation
.
– Intermetatarsal articulation.
– Intertarsal articulations.

8. • The Lisfranc complex is made up of bony and
ligamentous elements
• The bony architecture is composed of
• 5 MTs and their respective articulations with
the cuneiforms medially and the cuboid
laterally.

9. Stability of TMT joint
• The trapezoidal shape of
the middle three MT
bases and their associated
cuneiforms produce a
stable arch referred to as
the “transverse” or
“Roman” arch.

10. • The keystone to the transverse arch is the
second TMT joint, a product of the recessed
middle cuneiform

11. • Peicha et al showed that persons
with Lisfranc injury had a shallower
medial mortise depth compared with
control subjects. They suggested that
adequate mortise depth provides for
greater stability by allowing for a stronger
Lisfranc ligament.
Peicha G, Labovitz J, Seibert FJ, et al.: The anatomy of the joint as a risk factor
for Lisfranc dislocation and fracture-dislocation: An anatomical and radiological case
control study. J Bone Joint Surg Br2002;84(7):981-985

12. Ligaments

13. • Transverse Ligaments
• Oblique Ligaments
Dorsal
Planter
Interosseus

14. 2bands

16. Lisfranc Ligament

17. • In a biomechanical evaluation, Solan et al
assessed the strength of each ligamentous
set—dorsal, interosseous, and plantar—by
stressing it to failure. They concluded that
the Lisfranc ligament was strongest,
followed by the plantar ligaments and the
dorsal ligaments.

18. • Structural stability to the transverse arch is
enhanced by the short plantar muscles as well
as by the muscular and tendinous support of
the peroneus longus and the tibialis anterior
and tibialis posterior.

19. Foot Muscles – Plantar Surface
First layer
– Abductor
Hallucis
– Abductor Digiti
Minimi
– Flexor
Digitorum
Brevis

20. Foot Muscles – Plantar Surface
• Second Layer.
Tendons of FHL, FDL.
Lumbricals.

21. Foot Muscles – Plantar Surface
Third Layer
– Flexor Hallucis Brevis
– Adductor Hallucis
• Transverse and
Oblique Heads

22. Foot Muscles – Plantar Surface
Fourth or
Interosseus Layer
2 muscles-
Plantar Interossei.
Dorsal Interossei.
2 tendons-
- peroneus longus .
- Tibialis posterior.

23. Incidence
• Injuries to the Lisfranc joint occur in 1 per 55,000
individuals each year in the United States and are 2
to 3 times more common in men.
• Approximately 4% of professional football players
sustain Lisfranc injuries each year

25. Mechanism of Injury
• Direct Injury
• Indirect Injury

26. • 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

28. Urgent Braking

29. • Indirect Injury

30. Indirect injury
• Twisting injuries lead
to forceful abduction
of the forefoot, often
resulting in a 2nd
metatarsal base
fracture and/or
compression fracture
of the cuboid (“ nut
cracker”)

31. Classification
• Classification systems are inherently effective
in allowing for the description of both high-
and low-impact injuries.
• Many Classifications developed and updated.
• None of them useful in Deciding the
treatment and overall prognosis and Clinical
Outcome.

32. Quenu and Kuss (1909):
• Homolateral
• Isolated
• Divergent
1. Modified by Hardcastle in 1982
2. Further modified by Myerson in 1986

33. Quenu and Kuss (1909)

34. Homolateral Divergent

35. isolated

36. Hardcastle (1982)
Homolateral or Total
Incongruity:
• All 5 metatarsals
displace in common
direction
•Fracture base of 2nd
common

37. Isolated Partial
Incongruities:
• Displacement of 1 or
more metatarsals away
from the others

38. Divergent:
• Lateral displacement of
lesser metatarsals with
medial displacement of
the 1st metatarsal

39. TOTAL INCONGRUITY
PARTIAL INCONGRUITY
DIVERGENT

40. Chiodo& Myerson(2001)COLUMNAR THEORY

41. • Columns of the midfootmedial column
– includes first tarsometatarsal joint
• middle column
– includes second and third tarsometatarsal joints
• lateral column
– includes fourth and fifth tarsometatarsal
joints (most mobile)

42. Nunley and Vertullo Athletic
Injuries(2002)
3-stage diagnostic classification.
• Stage I - A tear of dorsal ligaments and sparing of
the Lisfranc ligament
• Stage II - Direct injury to the Lisfranc ligament with
elongation or rupture(Radiographic diastasis of 1 to
5 mm greater than the contralateral foot )
• Stage III - A progression of the above, with damage
to the plantar TMT ligaments and joints, along with
potential fracture

44. Clinical Findings
• Midfoot pain with
difficulty in weight
bearing
• Swelling across the
dorsum of the foot
• Deformity variable
due to possible
spontaneous
reduction

45. • Check neurovascular
status for compromise of
dorsalis pedis artery
and/or deep peroneal
nerve injury
• COMPARTMENT
SYNDROME

46. Planter Ecchymosis Sign

47. • The passive pronation-abduction test
described by is performed by eliciting
pain on abduction and pronation of the
forefoot with the hindfoot fixed.

48. • Trevino and Kodros described a “rotation
test,” in which 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.

49. PIANO KEY SIGN

50. DIAGNOSIS
• Requires a high degree of clinical suspicion
20% misdiagnosed
40% no treatment in the 1st week
• ??? MIDFOOT SPRAIN???

51. RADIOGRAPHIC EVALUATION
• Xrays
• Computed tomography (CT) scan.
• MRI
• Bone Scans
• UltraSound scan

52. Radiographic Evaluation
• AP, Lateral, and 30°
Oblique X-Rays are
mandatory
• AP: The medial
margin of the 2nd
metatarsal base and
medial margin of the
medial cuneifrom
should be aligned

53. Radiographic Evaluation
• Oblique: Medial base
of the 4th metatarsal
and medial margin of
the cuboid should be
alligned

54. AP View Xrays

55. Oblique View Xrays
3
4
5

56. Radiographic Evaluation
• Lateral: The dorsal
surface of the 1st and
2nd metatarsals
should be level to the
corresponding
cuneiforms

57. Lisfranc Injury

58. • A “fleck sign” should
be sought in the medial
cuneiform–second
metatarsal space. This
represents an avulsion
of the Lisfranc
ligament.

59. • Lisfranc injuries BIG challenge
• 20% of injuries go unrecognized, likely
secondary to the difficulty encountered with
standard Xray
• Many so-called sprains present with non–
weight-bearing radiographs that are difficult
to interpret.

60. • 50% of athletes with midfoot injuries had
normal non–weight-bearing radiographs

61. Stress Radiographs
• Radiographs must be obtained with the patient
bearing weight in case of subtle injuries.
• If the radiograph reveals no displacement, and the
patient cannot bear weight, a short leg cast should
be used for 2 weeks, and the radiographs should be
repeated with weight bearing

62. AP Full Wt bearing Xray

63. Taking Lateral Views

64. NWB Xray FWB Xray

65. 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.

66. Magnetic Resonance Imaging
• In a recent study evaluating the predictive value
of MRI for midfoot instability, Raikin et al found
that MRI demonstrating a rupture or grade 2
sprain of the plantar ligament between the first
cuneiform and the bases of the second and third
MTs is highly predictive of midfoot instability, and
these patients should be treated with surgical
stabilization

67. MRI

68. 3D CT SCAN

69. Stress Fluroscopy under
Anaesthesia
The foot is stressed in a medial/lateral plane. The forefoot is forced laterally with the hindfoot
brought medially….Pronation Abduction Stress

70. Management
CONSERVATIVE
SURGICAL

71. Check Stability………..
• The definition of instability
presently is defined as a greater
than 2-mm shift in normal joint
position.
• Diastasis between the first and second MT in
the injured midfoot is considered normal
provided that it measures <2.7 mm.

72. Goals of Treatment
• Painless,
• Plantigrade
• Stable foot.
• Maintenance of anatomic alignment seems to
be the critical factor in achieving a satisfactory
result.

73. Non operative Management
• Indications
– <2-mm displacement of the tarsometatarsal joint in
any plane
– No evidence of joint line instability with weight-
bearing or stress radiographs

74. Treatment
– Short leg non-weight-bearing cast
for 6 weeks
– Weight bearing cast for an
additional 4 to 6 weeks
– Recheck stability with stress views
at 10 days from injury

75. Surgical Intervention
• Best results are obtained through anatomic
reduction and stable fixation.
 The timing of surgery is predicted on resolution
of swelling, when the skin begins to wrinkle.
 Lisfranc injuries are best managed within the first
2 weeks following the inciting event.

76. • Closed manipulation under anesthesia with
casting as a definitive treatment has been shown
to be a poor choice because maintenance of the
reduction is too difficult and residual deformity
can lead to significant morbidity.

77. Operative Treatment
• Surgical emergencies:
1. Open fractures
2. Vascular
compromise (dorsalis
pedis)
3. Compartment
syndrome

78. • Dorsal incisions
centered over
the involved
joints are used
to approach the
midfoot.

79. Operative Treatment
Technique
1. incision centered at
TMT joint and along
axis of 2nd ray, lateral
to EHL tendon
2. Identify and protect
NV bundle

80. Operative Treatment
Technique
• Reduce and
provisionally stabilize
2nd TMT joint
• Reduce and
provisionally stabilize
1st TMT joint
• If lateral TMT joints
remain displaced use
additional incision
2nd met. Base
unreduced
reduced

81. Operative Treatment
Technique
• If reductions are
anatomic proceed
with permanent
fixation:
1. Screw fixation is
preferable for the
medial column
2. “Pocket hole” to
prevent dorsal cortex
fracture

82. Operative Treatment
Technique
3. Screws are
positional not lag
4. To aid reduction or
if still unstable use a
screw from medial
cuneiform to base of
2nd metatarsal

83. Operative Treatment
Technique
5. If intercuneiform
instability exists use an
intercuneiform screw
6.The lateral metatarsals
frequently reduce with
the medial column and
pin fixation for mobility
is acceptable

85. Preop AP
Postop AP
Postop Lateral

86. Lisfranc Fracture fixed with screws and
K wires

87. • Dorsal plating for bridging fixation of
comminuted fractures can be used.

88. • Screw fixation remains the traditional
fixation technique, although there is
evidence to suggest that primary
arthrodesis may be superior for the
purely ligamentous midfoot injury.

91. Postoperative Management
• Splint 10 –14 days, nonweight bearing
• Short leg cast, nonweight bearing 4 – 6 weeks
• Short leg weight bearing cast or brace for an
additional 4 – 6 weeks
• Arch support for 3 – 6 months

92. Hardware Removal
• Lateral column stabilization can be removed at
6 to 12 weeks
• Medial fixation should not be removed for 4
to 6 months
• Some advocate leaving screws indefinitely
unless symptomatic

93. COMPLICATIONS
EARLY
LATE

94. EARLY COMPLICATIONS
• Vascular injuries.
• Foot compartment syndrome.
• Infections and wound complications

95. LATE COMPLICATIONS
• Post traumatic arthritis
1. Present in most, but may not be symptomatic
2. Related to initial injury and adequacy of
reduction
3. Treated with arthrodesis for medial column
4. Interpositional arthroplasty may be
considered for lateral column

96. • Good or excellent results have been
accomplished in 50% to 95% of patients
with anatomic alignment, compared with
17% to 30% of patients with nonanatomic
alignment following injury

97. • Neuromas.
• Flatfoot deformity with instability with weight
bearing.
• Painful hardware, hardware failure, or
breakage.
• Complex regional pain syndrome.

98. Prognosis
• Long rehabilitation (> 1 year)
• Incomplete reduction leads to increased
incidence of deformity and chronic foot pain
• Incidence of traumatic arthritis (0 – 58%) and
related to intraarticular surface damage and
comminution.

99. Thank you sir