Lecture 15 parekh lisfranc

Lisfranc Injuries

Selene G. Parekh, MD, MBAAssociate Professor

North Carolina Orthopaedic ClinicDepartment of Orthopaedic Surgery

Adjunct Faculty Fuqua Business SchoolDuke University

Durham, NC919.471.9622

www.seleneparekhmd.com@seleneparekhmd

Overview• Anatomy

• Radiographic Findings

• Surgical Technique

Anatomy

• 3 Column Model• Medial Column

• Medial Cuneiform• 1st Metatarsal

• Middle Column• Middle and Lateral

Cuneiforms• 2nd and 3rd Metatarsals

• Lateral Column• Cuboid• 4th and 5th Metatarsals

Ligamentous Anatomy

• Medial cuneiform – 2nd metatarsal ligament complex • Dorsal ligament• Interosseous

• Lisfranc ligament• Plantar ligament

• Inserts into 2nd and 3rd metatarsal bases

( Solan et al. Foot Ankle Int 2001: 22(8) and de Palma et al. Foot Ankle Int 1997: 18(6) )

Ligamentous Anatomy

• Biomechanical evaluation ( Solan et al. Foot Ankle Int 2001: 22(8) )

Stiffness(N/mm) Strength(N)• Dorsal 40 ± 9 170 ± 33• Lisfranc 90 ± 3 449 ±58• Plantar 62 ± 3 305 ± 38

Lisfranc ligament is stiffest and strongest overall

Diagnosis

• Mechanism of Injury• Indirect

• Loading of plantarflexed foot

• Failure of weak dorsal ligaments

• Most common mechanism

• MVA• Sports injuries• Falls from heights

Diagnosis

• Mechanism of Injury• Direct

• Loading or crushing of dorsum of foot

• Significant soft tissue injury

• Compartment syndrome

• Open injuries

Diagnosis

• Clinical Evaluation• Plantar midfoot ecchymosis

• Gap between 1st and 2nd phalanges

• Tarsometatarsal tenderness

• Pain at TMT joint 2°• PROM metatarsal heads• Weightbearing• Single limb rise

Radiographic Evaluation

• AP view – 15o cephalad tilt (Stein RE. Foot Ankle, 1983)

• Middle Column• Medial border 2nd

metatarsal • Medial border middle

cuneiform• IM space between 1st and

2nd metatarsals is equal to space between the medial and middle cuneiforms

Radiographic Evaluation

• 30o oblique view (Stein RE. Foot Ankle 1983)• Lateral border 3rd

metatarsal continuous with lateral border lateral cuneiform

• Medial border 4th metatarsal continuous with medial border cuboid

• IM space b/w 2nd and 3rd metatarsals equal to space b/w middle and lateral cuneiforms

Radiographic Evaluation

• Lateral View• Superior border of

second metatarsal is continuous with superior border second cuneiform

• No dorsal nor plantar displacement of metatarsal bases

• Subtle

Radiographic Findings

• Fleck Sign

Radiographic Findings

• Intercuneiform Variant

Radiographic Findings

• Fracture/Dislocation

Radiographic Findings

• Cuboid Fracture

Radiographic Findings

• Complete Dislocation

Radiographic Findings

Surgical Management

• Approach• Dorsum of 1st IM space

• Access 1st, 2nd, and 3rd MTC joints

• Avoid• Medial SPN, DPN,

DP artery• Full thickness flaps

Surgical Management

• Approach• Dorsum 4th metatarsal

• Access to 4th and 5th MTC joints

• Avoid Intermediate SPN

Surgical Management

• Direct Visualization of the TMT joints

• Metatarsal fractures addressed first

• Fixation proceeds from medial to lateral

Case Presentation - Subtle

Case Presentation - HWR

Postop Protocol

• Week 0-2 NWB splint

• Week 2-6 in SLNWBC

• Week 6-12 CAM - NWB

• Week 12 – WBAT Shoe

• Week 16-20 – Hardware Removal

Case Presentation – Fracture/Dislocation

Case Presentation – Fracture/Dislocation

Case Presentation – 3 column injury

Case Presentation – 3 column injury

Surgical Approach – Lateral Column Fixation

• Buried K-wire utilized for 4th and 5th TMT• Lateral Column is mobile• Prevents Stiffness• Remove at 6 weeks.

Case Presentation – Cuboid Fracture

Case Presentation – Cuboid Fracture

Surgical Approach – ORIF Cuboid

• Fracture is comminuted• Fixation difficult to achieve

• Locking plate

• Bone graft to support articular surface• Autogenous calcaneus is good source

Case Presentation – Intercuneiform Variant

Case Presentation

Case Presentation

Summary

• Maintain High Level of Suspicion• Weight bearing radiograph critical

• Single Limb WB xray• Stress radiography with sedation

• Multiple presentation types• Surgical Technique

• ORIF metatarsal fracture• Medial to Lateral Fixation• Intraop Stress radiography to ensure joints stable and

reduced.

RE ECT

the ankle

the foot