Mid-foot: Lisfranc Fracture/Dislocation Dr Abhishek Sachdev
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;