BONY LISFRANC INJURY MANAGEMENT

1. LISFRANC FRACTURE AND
DISLOCATION—BASIC CONCEPTS
Ayan Goswami
Foot & Ankle Reconstruction
Traumatology Surgery

2. History of Lisfranc
 Jacques Lisfranc de St. Martin
 French gynecologist.
 April 2, 1790 – May 13, 1847

3. History of Lisfranc
 Devised a new amputation technique.
 Saved time by avoiding bones.
 Followed a series of joints called Lisfranc
joint.
 DID NOT describe mechanism of injury

4. Introduction
 Lisfranc’s ligament: Plantar aspect of the
medial cuneiform to the base of the second
metatarsal.
 Three Parts Dorsal, plantar, and interosseous.
 Limits motion of medial cuneiform to base of 2nd
metatarsal.

5. Anatomy
 Wedged shape of bones at Lisfranc joint form
an exquisite Roman arch.
 The Lisfranc joint includes three synovial
cavities.
 Very limited flexion and extension.
Adduction/abduction at fourth and fifth
tarso-metatarsal joints.

6. Mechanism of Injury
 Direct
 Indirect
 Low and high energy injury

7. Direct Injuries
Force directly applied to Lisfranc’s
articulation.
Ie: Heavy object fall on foot.
Plantar displacement more common.
Lisfranc’s injury:
open fracture
compartment syndrome
soft tissue injury.

9. Indirect Injury
Most common.
Axial loading or twisting.
 Hyper-plantar flexion and ligament rupture.
 Metatarsal base dislocates dorsally.
 Associated with vascular compromise.

10. High Energy Injury
 MotorVehicle Accident.
 Foot planted on brake pedal/floor during impact.
 Foot forced:
 Hyper-plantarflexion with valgus or varus component.
 High energy impact disrupts
 Osteo-ligamentous restraints
 Dislocation of Lisfranc joint.

11. Low Energy Injury
 Foot plantarflexed with MPJ maximally
dorsiflexed.
 Force directed onto heel.
 Leads to hyperplantarflexion in the Lisfranc joint.

12. The Normal Foot

15. Case Study #1
 33-year-old male, no PMH, presents ED
 Metal cabinet dropped on left foot
 Swollen left foot
 Unable to ambulate
 Ortho consulted

16.  ALLERGIES: None
MEDICATIONS: None
SOCIAL HISTORY: None.
FAMILY HISTORY: History of CVA.

17. Physical Evaluation
 Doppler – Biphasic wave
 +Edema – Extending from toes to ankle
 +Ecchymosis
 No open lesions
 Foot deformed.

19. X-Ray of The Left Foot
 Displacement first, second, third, fourth and
fifth metatarsal.
 Homolateral divergence on the
radiograph.

20. How do we treat this?
 Overlooked 20% of the time.
 1/55,000 each year. Fewer than 1% of all
fractures.
 Treatment of Choice—ORIF VS. Arthrodesis

21. Complications With ORIF
• Screw breakage
• Posttraumatic OA
• DVT
• Compartment syndrome
• Superficial infection
• Missed associated injury
Complications With Arthrodesis
• Pseudoarthrosis
• Painful hardware
• Nonunion
• Delayed union

22. Treatment Options & Literature Review
Sheibani-Rad, S. et al. Arthrodesis versus ORIF for Lisfranc
fractures.
• A literature review of the 2 most common treatments for Lisfranc
injuries:
• Primary arthrodesis
• ORIF

23. Sheibani-Rad, S. et. al. Arthrodesis versus ORIF
For Lisfranc fractures
Significant Findings:
 35% of patients with anatomic reduction developed OA, whereas 80% of patients with non-
anatomic reduction developed OA
 Closed reduction and casting is usually unsuccessful due to instability of the injury and will not
prevent further displacement nor allow for removal of interposed soft tissue that impede
anatomic reduction
 ORIF most common treatment
 Even with anatomic reduction 40-94% of patients will develop post-traumatic arthritis and
need fusion.
 Reoperation rate in ORIF is 75-79%
 Reoperation rate in arthrodesis is 17-20%
CONCLUSION: Sheibani-Rad et al., overall, ORIF and arthrodesis
have satisfactory and equivalent results; however,
arthrodesis may have an improved clinical outcome.
Arthrodesis should be used in patients with compete ligamentous injuries. Further studies of direct
comparisons needed.

24. Treatment Options & Literature Review
 Rammelt et al., studied ORIF in 22 patients VS. secondary
corrective arthrodesis in 22 patients.
 20 patients available for follow-up at 36 months after operation.
 ORIF GROUPAmerican Orthopaedic Foot and Ankle Society midfoot
score was 81.4.
 ARTHRODESIS midfoot score of 71.8.
 CONCLUSION: Rammelt et al., ORIF leads to improved
functional results, earlier return to work
and greater patient satisfaction.

26. Our Patient
 In the ED- Posterior splint and admission to
the hospital.
 CT of the left foot.
 Booked patient for ORIF of left foot.

27. In The OR
 ORIF left foot four cannulated partially
threaded screws
 Three dorsal incisions
 Medial side first met-cuneiform joint.
 Second incision between second and third
metatarsal.
 Third incision over fourth interspace.

28. In The OR
 First met-cuneiform fixated with 4-0 partially
threaded cannulated screws.
 2nd met base , 4-0 cannulated screw placed
across 2nd met-cuneiform joint.
 3rd incision, cannulated 4-0 screw placed
across third met-cuneiform joint.

29. Post-Op X-ray

31. Conclusion
 AO Fixation Allows better stability and decreased
mobilization.
 After ORIF Immobilize in a cast for 8 to 12 weeks.
 Non-casted, full weight-bearing allowed at 11 to 12
weeks.
 After cast removal, patient to wear protective shoes with
orthotics.

32. References
 Clinical Orthopaedics & Related Research; Lisfranc's Fracture-Dislocations: Etiology, Radiology,
and Results of Treatment GOOSSENS, M. M.D.; STOOP, N. DE M.D.
 Primary open reduction and fixation compared with delayed corrective arthrodesis in the treatment
of tarsometatarsal (Lisfranc) fracture dislocation S. Rammelt, MD, PhD JOURNAL OF BONE
AND JOINT SURGERY.
 Giannestras NJ, Sammarco GJ. Fractures and dislocations in the foot. In: Rockwood CA Jr, Green
DP, eds. Fractures. Philadelphia: Lippincott, 1975:1400-1495
Aitken AP, Poulson D. Dislocation of the tarsometatarsal joint. J Bone Joint Surg [Am]
1963;45:246-260
 Bassett FH III. Dislocation of the tarsometatarsal joints. South MedJ 1964;57:1294-13O2
 Wiley JJ. The mechanism of tarso-metatarsal joint injuries. J Bone Joint Surg [Br] 1971 ;53 :474-
482
 Wilson DW. Injuries of the tarso-metatarsal joints. J Bone Joint Surg [Br] 1972;54 :677-686
 Cassebaum WH. Lisfranc fracture-dislocation. Clin Orthop 1963;3O:116-128
 Del Sel JM. The surgical treatment of tarsal-metatarsal fracture- dislocations. J Bone Joint Surg [Br]
I 955;37 : 203-207
 Granberry WM, Lipscomb PR. Dislocation of the tarsometatarsal joints. Surg Gynecol Obstet
1962;1 1 4 : 467-469
 Lenczner EM, Waddell JP, Graham JD. Tarsal-metatarsal (Lisfranc) dislocation. J Trauma 1974;1
4:1012-1020
 Wilppula E. Tarsometatarsal fracture-dislocation. Acta Orthop Scand 1973;44 : 335-345
 Trotter M, Peterson AR. Osteology and arthrology. In: Anson BJ, ed. Morris’human anatomy. New
York: McGraw-Hill, 1966: 304-307, 415-416