Mid foot lisfranc fracture

Mid-foot: Lisfranc Fracture/Dislocation

Dr Abhishek Sachdev

Any bony or ligamentous injury

involving the tarsometatarsal joint complex.

Where the metatarsals dislocate from their normal articulation with the mid-tarsal bones

Most commonly involves the 1st and 2nd

Metatarsals and the medial cuneiform

Incidence is 1 in 55,000 people each year

Easily missed on initial x-rays Can be difficult to diagnose

Named after the Napoleonic-era surgeon who described amputations at this level without ever defining a specific injury› Dr. Lisfranc› Injury was common in cavalry

troops› Due to design of the stirrup› Severe vascular complications › Amputation was performed

Anatomy

Lisfranc’s joint: articulation between the 3 cuneifoms and cuboid (tarsus) and the bases of the 5 metatarsals

Osseous stability is provided by the Roman arch of the metatarsals and the recessed keystone of the second metatarsal base

Anatomy

Lisfranc’s ligament: large oblique ligament that extends from the plantar aspect of the medial cuneiform to the base of the second metatarsal (there is no transverse metatarsal ligament from 1 to 2)

Anatomy

Interosseous ligaments: connect the 2nd to 5th metatarsal bases both dorsal and plantar (stronger and larger)

Secondary stabilizers: plantar fascia, peroneus longus, and intrinsincs

Anatomy Four Major Units

* 1st MT – Medial Cuneiform : 6 degrees of Mobility

* 2nd MT – Middle Cuneiform : Firmly Fixed

* 3rd MT – Lateral Cuneiform : Firmly Fixed

* 4th – 5th MT – Cuboid : Mobile

Anatomy

Associated Structures:1. Dorsalis pedis artery – courses between 1st and 2nd metatarsal bases2. Deep peroneal nerve: runs alongside the artery

Lisfranc’s joint: › Key to the transverse arch of the foot

Lisfranc’s ligament attaches the medial cuneiform to the base of the 2nd metatarsal

Continued ligamentous support linking the bases of the 2nd-5th metatarsals

No ligamentous connection between the 1st and 2nd metatarsals› Allows for frequently seen divergent injury

Dorsalis pedis dives between bases of 1st & 2nd

Anatomy

2nd MT is recessed between the medial and lateral cuneiforms:› “Keystone”

mortise that greatly adds stability in transverse plane

Anatomy

Cuneiform, tarsal bones, and medial 3 MT bases:› Have a trapezoidal

configuration that is wider on the dorsal aspect

› Effect of a Roman arch; resisting collapse

Mechanism of Injury :

Hyper-extending the forefoot Catching the forefoot in a hole

in the ground Horseback rider falling and

hanging the forefoot in the stirrup Commonly seen as a Charcot’s Joint

in diabetic patients RTA – especially when foot is trapped

in dorsi-flexion under the foot pedal Crush injuries

Trauma: motor vehicle accidents account for one third to two thirds of all cases (incidence of lower extremity foot trauma has increased with the use of air bags)

Crush injuries Sports-related injuries are also

occurring with increasing frequency

Placing the foot intoextreme plantar flexion with an axial load.

Mechanism of Injury - Indirect

Typical of athletic injury

Axial loading to plantar flexed foot results in hyper-plantar flexion and ligament rupture

Rarely associated with open injury or vascular compromise

Mechanisms of Injury - Direct

Direct Injuries: force is applied directly to the Lisfranc’s articulation. The applied force is to the dorsum of the foot.

Plantar displacement more common

Mechanisms of Injury - Direct

Direct Injuries: plantar displacement is more common, but dorsal displacement can also occur.

Open fracture/compartment syndrome/soft tissue injury greater

Mechanisms of Injury - Indirect

Indirect injuries: more common than direct and result from axial loading or twisting. Metatarsal bases dislocate dorsally more often than plantarly.

Dorsal displacement more common

Mechanism of Injury - Indirect

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”)

Associated Fractures Base of 2nd metatarsal Avulsion of navicular Isolated medial

cuneiform Cuboid Fractures of the

shafts of the metatarsals

Dislocations of the 1st(medial) and 2nd (middle) and cuneonavicular joints

Classification

Sprains are the most common injury to the tarso-metatarsal ligament.

graded I, II and III

Burroughs et al 1998

Grade I - Pain at the joint, minimal swelling and no instability of the joint

Grade II – Increased pain and swelling of the joint, with mild laxity but no instability

Grade III – Complete ligamentous disruption and may represent a fracture-dislocation

ClassificationQuenu and Kuss (1909)

HOMOLATERAL: most common

ClassificationQuenu and Kuss (1909)

ISOLATED

ClassificationQuenu and Kuss (1909)

DIVERGENT: least commom

ClassificationHardcastle (1982)

Homolateral or Total Incongruity:

• All 5 metatarsals displace in common direction

•Fracture base of 2nd common

ClassificationHardcastle (1982)

Isolated Partial Incongruities:

• Displacement of 1 or more metatarsals away from the others

ClassificationHardcastle (1982)

Divergent:

• Lateral displacement of lesser metatarsals with medial displacement of the 1st metatarsal

• May have extension of injury into cuneiforms or talonavicular joint

Myerson (1986) : 3 Types

ClassificationMyerson (1986) : 3 Types

Total incongruity – Can be either medially or laterally displaced

ClassificationMyerson (1986)

Partial incongruity – Either medial (Type B1)or lateral (Type B2), the most common type

ClassificationMyerson (1986)

Divergent displacement – Either partial (type C1) or total (type C2)

Physical Exam

Diagnosis requires high index of suspicion› Midfoot swelling & tenderness

Often in patients with polytrauma Vascular status Assess soft tissues

› Open fx› Degloving injuries› Monitor for compartment syndrome

Swelling and large lump in the midfoot

Unable to weight bear

Tenderness along the tarso-metatarsal joints

Tenderness with passive abduction and pronation of the forefoot with the hindfoot held flexed

Ecchymosis may appear late

Local tenderness at tarsometatarsal joints

Gentle stressing plantar/dorsiflexion and rotation will reveal instability

X-Rays : AP, Lateral & 30° Oblique

AP, Lateral, and 30° Oblique X-Rays are mandatory

Radiographic Evaluation

To look for alignment

AP :

The lateral border of the 1st metatarsal is aligned with

The Lateral border of the medial uneiform

Radiographic Evaluation

AP: the medial border

of the 2nd metatarsal is in line with

the medial border of the intermediate cuneiform

Radiographic Evaluation

Medial and lateral borders of

the lateral cuneiform

should align with

the medial and lateral borders of the 3rd metatarsal

Medial border of the cuboid should

align with

the medial border of the 4th metatarsal

Radiographic Evaluation

Lateral: The dorsal surface of

the 1st and 2nd metatarsals should be level to

the corresponding cuneiforms

Radiographic Evaluation

Standing views provide “stress” and may demonstrate subtle diastasis

Comparison views are very helpful

Radiographic Evaluation

Additional imaging:1. True stress views or fluroscopy2. CT Scans3. Bone scan – for persistent pain with no radiographic findings4. If suspicious: repeat x-rays and keep looking

Anteroposterior X-ray presenting a type A (lateral) injury according to Myerson et al. classification

Anteroposterior X-ray presenting a type B2 (partial lateral) injury according to Myerson et al. classification

Anteroposterior X-ray presenting a type C2 (total) injury according to Myerson et al. classification

Five critical radiographic signs :

 that indicate presence of midfoot instability disruption of the continuity of a line drawn from the medial base

of the second metatarsal to the medial side of the middle cuneiform

widening of the interval between the first and second ray

medial side of the base of the fourth metatarsal does not line up with medial side of cuboid on oblique view

metatarsal base dorsal subluxation on lateral view

disruption of the medial column line (line tangential to the medial aspect of the navicular and the medial cuneiform)

Treatment Operative treatment is indicated for

displacement > 2mm of the TMT joint Some argue for ORIF regardless of displacement Key to successful outcome is anatomic alignment ORIF can be attempted as late as 8 weeks after

injury for pts < 160 lbs; >160lbs arthrodesis of medial three joints

< 2mm of displacement:› NWB SLC for 6 weeks› WB SLC for an additional 4 to 6 weeks› Follow closely with repeat radiographs to ensure no

displacement has occurred

Closed Reduction Spinal or general anesthesia Modified finger traps to great toe and one or

two adjacent toes Longitudinal traction with 5 to 10 lbs Manipulate foot within 5 minute period in

either inversion or eversion Rarely palpable or audible reduction Verify reduction on fluoroscopy Maintain reduction with Steinmann

pins/cannulated screws Final routine radiographs PRIOR to leaving OR

Operative Treatment

Surgical emergencies:1. Open fractures2. Vascular compromise (dorsalis pedis)3. Compartment syndrome

Treatment

Reduction is easiest if performed within 4 –6 hours

Restoration of circulation is critical for soft tissue healing

Compartment syndrome:› Four fascial compartments

Long medial incision to decompress abductor hallucis & deep compartments

Two dorsal incisions betw 2nd & 3rd and betw 4th & 5th to decompress dorsal intrinsic compartments

Extensive vascular compromise› Midfoot level amputation

Fascial Decompression

ORIF

Dorsal incision lateral to EHL in the interval between the 1st & 2nd MT

Isolate dorsalis pedis & deep peroneal nerve Inspect Lisfranc ligament Reduce cuneiforms if needed

› Steinmann pin followed by cannulated screw Guide wire/drill medial cuneiform to base 2nd MT

› Continue fixation as needed to restore anatomic alignment

› Multiple constructs 1st MT to medial cuneiform Cuboid to base of 5th MT

Operative TreatmentTechnique

1 – 3 dorsal incisions:1. 1st incision centered at TMT joint and along axis of 2nd ray, lateral to EHL tendon2. Identify and protect NV bundle

Surgical Exposure

Operative TreatmentTechnique

Reduce and provisionally stabilize 2nd TMT joint

Reduce and provisionally stabilize 1st TMT joint

If lateral TMT joints remain displaced use 2nd or 3rd incision(s)

2nd met. Base unreduced

reduced

Operative TreatmentTechnique

If reductions are anatomic proceed with permanent fixation:1. Screw fixation is preferable for the medial column2. “Pocket hole” to prevent dorsal cortex fracture

Operative TreatmentTechnique

3. Screws are positional not lag4. To aid reduction or if still unstable use a screw from medial cuneiform to base of 2nd metatarsal

Operative Treatment Technique

5. If intercuneiform instability exists use an intercuneiform screw6.The lateral metatarsals frequently reduce with the medial column and pin fixation for mobility is acceptable

Fixation

Case ExamplePreop AP

Postop AP

Postop Lateral

Post Operative Care

Bulky dressing with posterior splint postoperatively

NWB SLC at 7-10 days postop PWB at 6-8 weeks Laterally placed steinmann pins

removed at 8 weeks Medial screws removed at 4 months

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

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

Conclusions

Commonly missed injury Lisfranc joint disruption should be

suspected with flake fxs at base of 2nd MT Anatomic reduction is essential Nearly all require fixation ORIF can be carried out with pins, screws

or both Terrible injuries, especially if missed

› Debilitating foot pain

Thank you

Compartments of Foot :

Anatomy:    - the 9 compartments of the foot can be placed into 4 groups;    - Intrinsic Compartment:           - 4 intrinsic muscles between the 1st and 5th metatarsals;    - Medial Compartment:           - abductor hallucis;           - flexor hallucis brevis;    - Central Compartment: (Calcaneal Compartment)           - flexor digitorum brevis;           - quadratus plantae;           - adductor hallucis;    - Lateral Compartment:           - flexor digiti minimi brevis;           - abductor digiti minimi;

Appropriate treatment for a suspected compartment syndrome of the foot is  immediate and complete fasciotomy;   

abductor hallucis longus, central, lateral, and interosseous compartments must be released;   

Effective decompression of all 4 compartments can be accomplished thru medial longitudinal Henry approach, or through 2 parallel dorsal incision along the lengths of the second and fourth metatarsals;