1. The Lisfranc joint, or tarsometatarsal articulation of the foot, is named for Jacques Lisfranc (1790-1847), a field surgeon in Napoleon's army. Lisfranc described an amputation performed through this joint because of gangrene that developed after an injury incurred when a soldier fell off a horse with his foot caught in the stirrup.1,2<br />The area known as Lisfranc's joint represents the transition between the midfoot and forefoot. It consists of the three cuneiform-metatarsal articulations and the two cuboid-metatarsal articulations of the fourth and fifth rays<br />The osseus alignment of this joint complex is important to understand for treatment considerations.The first articulation is a broad surface, usually 3 cm deep, and with a broad plantar base and dorsal apex. <br />The bony architecture of this joint, specifically the quot;
keystonequot;
wedging of the second metatarsal into the cuneiform, forms the focal point that supports the entire tarsometatarsal articulation.2 This anatomy establishes a quot;
weak linkquot;
that, with stress, is prone to injury. The second and third are much smaller and triangular in shape with the apex plantar. The second is recessed from the first by approximately 1 cm and from the third by 0.5 cm. <br />The fourth and fifth are more trapezoidal in shape and lie in a separate plane plantar and lateral to the joints of the medial column. The inherent stability of this region is due in part to the recessed second metatarsal base but even to a greater degree to the numerous strong ligamentous attachments across each tarsometatarsal joint and between each ray.<br />The important characteristics to note are as follows: (a) the plantar ligaments are significantly stronger than the dorsal ligaments; (b) the multiple ligaments overlap among the joints of the lesser four tarsometatarsal joints; and (c) the Lisfranc ligament, which is the largest and strongest ligament of this joint complex, represents the only ligamentous support between the medial leg and the middle and lateral legs in the forefoot.<br />The Lisfranc ligament is a large band of plantar collagenous tissue that spans the articulation of the medial cuneiform and the second metatarsal base .The Lisfranc ligament originates from the plantar lateral aspect of the medial cuneiform just below the plantar extent of the second tarsometatarsal joint and inserts on the plantar and medial aspect of the second metatarsal base. At best it is an indirect link between the first and second metatarsals. There is no ligamentous connection between the first and second metatarsals.<br />Mechanisms of Injury----Lisfranc joint complex injury can occur as a result of direct or indirect trauma.3,11 Direct trauma occurs when an external force strikes the foot. With indirect trauma, force is transmitted to the stationary foot so that the weight of the body becomes a deforming force by torque, rotation or compression<br />The diagnosis is based on careful physical examination of the foot in question. In the case of isolated injury, pain anywhere over the tarsometatarsal joint complex is significant for a possible injury. Passive dorsiflexion and plantarflexion of individual metatarsal heads will elicit pain at the proximal articulations. Pain at the midfoot with attempted single limb heel lift also points to a potential Lisfranc injury. The presence of plantar ecchymosis is also suggestive of ligamentous injury.<br />X-ray evaluation is crucial in the diagnosis and treatment of this injury. It is used to assess the stability of the joint and to catalog the presence of collateral injuries. If possible at the time of presentation, weight-bearing films of the foot in an anteroposterior, lateral, and 30-degree medial oblique position should be obtained<br />On each of the three views, the observer is looking for a disruption of the normal in line arrangement between the metatarsal base and the opposing tarsal bone. The AP view allows assessment of the alignment of the lateral border of the first cuneiform with the first metatarsal base and the medial border of the second metatarsal base with the second cuneiform. The 30-degree oblique view shows the alignment of the medial border of the third metatarsal with the lateral cuneiform and the medial border of the fourth metatarsal base with the medial border of the cuboid. The lateral view allows a rough assessment of the alignment of the dorsum of the second metatarsal with the middle cuneiform. The position of the second metatarsal on the AP view and the position of the fourth metatarsal on the oblique are the most consistent indicators for unstable injuries.<br />TABLE 56-5 Closed Management of Tarsometatarsal InjuriesIndications <2 mm displacement of the tarsometatarsal joint in any plane No evidence of joint line instability with weight-bearing or stress x-rays Treatment Short leg non-weight-bearing cast for up to 6 weeks Recheck stability with stress views at 10 days from injury Progressive weight-bearing in protective brace as symptoms abate <br />The definition of instability presently is defined as a greater than 2-mm shift in normal joint position. The presence of instability in this region requires anatomic reduction. It is generally agreed that the best results are obtained through anatomic reduction and stable fixation<br />Classification<br />Type A Injuries <br />Type A injuries involve displacement of all five metatarsals with or without fracture of the base of the second metatarsal. The usual displacement is lateral or dorsolateral, and the metatarsals move as a unit. These injuries are referred to as homolateral. <br />Type B Injuries <br />In type B injuries, one or more articulations remain intact. Type B1 injuries are medially displaced, sometimes involving the intercuneiform or naviculocuneiform joint. Type B2 injuries are laterally displaced and may involve the first metatarsal–cuneiform joint.<br />Type C Injuries <br />Type C injuries are divergent injuries and can be partial (C1) or complete (C2). These generally are high-energy injuries, associated with significant swelling, and prone to complications, especially compartment syndrome.<br />