LISFRANC

INJURY

Dr.Subodh Pathak

Moderator: Dr.AJOY S.M.

Surgery is bright when operating
but it is still brighter when there is
no blood and mutilation and yet
leads to the patient's recovery
Jacques Lisfranc de Saint-Martin
(1787-1847)
Injuries to the foot can have a dramatic impact
on the overall health, activity, and emotional
status of patients.
A recent study looking at the outcomes of
multiple trauma patients with and without foot
involvement found a significant worsening of
the outcome in the presence of a foot injury.
Their conclusion is that more attention and
aggressive management need to be given to
foot injuries to improve the outcome of
multiply injured patients.
Jacques Lisfranc de St. Martin
(April 2, 1790 May 13, 1847)

Pioneering
Frenchsurgeonandgynecologist.

Pioneered .
Lithotomy
Amputation of Cervix Uteri
Removal of Rectum
TheLisfranc jointand
theLisfranc fractureare
Lisfranc described an amputation
involving the tarsometatarsal joint
due to a severe gangrene that
developed when a soldier fell from a
horse with his foot caught in a
stirrup.
Foot Anatomy
Lisfranc joint
complex consists of
three articulations
including
Tarsometatarsalarticul
ation.
Intermetatarsalarticula
tion.
Intertarsalarticulations
.
TheLisfranccomplex is made up of
bony and ligamentous elements that
combine to add structural support to the
transverse arch.
The bony architecture is composed of
5 MTs and their respective articulations
with the cuneiforms medially and the
cuboid laterally.
The TMT joint complex represents the
dividing line between the midfoot and
the forefoot
Stability of TMT joint

The trapezoidal shape of

the middle three MT bases
and their associated
cuneiforms produce a
stable arch referred to as
the transverse or
Roman arch.
The keystone to the
transverse arch is the
second TMT joint, a
product of the recessed
middle cuneiform
 Peicha et al showed that persons
withLisfrancinjuryhad a
shallower medial mortise depth
compared with control subjects.
They suggested that adequate
mortise depth provides for
greater stability by allowing for a
stronger Lisfrancligament.

PeichaG,LabovitzJ,SeibertFJ,etal.:Theanatomyofthejointasariskfactor
forLisfrancdislocationandfracture-dislocation:Ananatomicalandradiologicalcase
controlstudy.JBoneJointSurgBr2002;84(7):981-985
Ligaments
Transverse Ligame
Oblique Ligaments
Dorsal
Interosse
us Planter
Lisfranc Ligament
2bands
In a biomechanical evaluation,
Solan et al assessed the strength
of each ligamentous setdorsal,
interosseous, and plantarby
stressing it to failure. They
concluded that the Lisfranc
ligament was strongest, followed
by the plantar ligaments and the
dorsal ligaments.
Structural stability to the
transverse arch is enhanced by
the short plantar muscles as well
as by the muscular and tendinous
support of the peroneus longus
and the tibialis anterior and
tibialis posterior.
Foot Muscles Plantar Surface

First layer
Abductor
Hallucis
Abductor
Digiti Minimi
Flexor
Digitorum
Brevis
Foot Muscles Plantar
Surface

Second
Layer.
Tendons of
FHL, FDL.
Lumbricals.
 Foot Muscles Plantar Surface

Third Layer
Flexor Hallucis
Brevis
Adductor Hallucis
Transverse and
Oblique Heads
Flexor Digiti
Minimi brevis.
Foot Muscles Plantar Surface

Fourth or
Interosseus Layer
2 muscles-
Plantar Interossei.
Dorsal Interossei.
2 tendons-
- peroneus longus .
- Tibialis posterior.
 Incidence
Injuries to the Lisfranc joint occur in 1
per 55,000 individuals each year in
the United States and are 2 to 3 times
more common in men.
Approximately 4% of professional
football players sustain Lisfranc
injuries each year
As index of suspicion increases, so
does incidence
Approximately 20% of Lisfrancs
injuries may be overlooked.
Mantas JP, Burks RT. Lisfranc injuries in the athlete.Clin Sports Med. 1994;
13(4):719730.
Thompson MC, Mormino MA. Injury to the tarsometatarsal joint complex.J Am
 Mechanism of Injury

Direct Injury

Indirect Injury
Arthrodesis Versus ORIF for Lisfranc Fractures
Shahin Sheibani-Rad, MD, MS; J. Christiaan Coetzee, MD; M.
Russell Giveans, PhD; Christopher DiGiovanni, MD
Orthopedics
June 2012 - Volume 35 Issue 6: e868-e873
DOI: 10.3928/01477447-20120525-26
Two different plantar
flexion mechanisms lead
to dorsal joint failure.
The first occurs in ankle
equinus and
metatarsophalangeal joint
plantar flexion, with the
Lisfranc joint engaged
along an elongated lever
arm.The joint is rolled
over by the body
Urgent Braking
Indirect Injury
Indirect injury

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)
 Fracture-dislocations
are often associated
with significant soft-
tissue trauma,
vascular compromise,
and compartment
syndrome.
Classification
Classification systems are
inherently effective in allowing
for the description of both high-
and low-impact injuries.
Many Classifications developed
and updated.
None of them useful in Deciding
the treatment and overall
prognosis and Clinical Outcome.
Quenu and Kuss (1909):
Homolateral
Isolated
Divergent

1. Modified by Hardcastle in 1982

2. Further modified by Myerson in
1986
Quenu and Kuss (1909)
Homolater
Divergent
al
 Hardcastle (1982)

Homolateral or Total
Incongruity:
All 5 metatarsals
displace in common
direction
Fracture base of 2nd
common
Isolated Partial
Incongruities:
Displacement of 1
or more
metatarsals away
from the others
Divergent:
Lateral
displacement of
lesser metatarsals
with medial
displacement of the
1st metatarsal
May have
extension of injury
into cuneiforms or
 A B1

TOTAL INCONGRUITY
B2
PARTIAL INCONGRUITY

C1

DIVERGENT
C2
Chiodo& Myerson(2001)COLUMNAR
THEORY
 Nunley and Vertullo Athletic
Injuries(2002)
3-stage diagnostic classification.
Stage I - A tear of dorsal ligaments and
sparing of the Lisfranc ligament
Stage II - Direct injury to the Lisfranc
ligament with elongation or
rupture(Radiographic diastasis of 1 to 5
mm greater than the contralateral foot)
Stage III - A progression of the above,
with damage to the plantar TMT ligaments
 Clinical Findings

Midfoot pain with

difficulty in
weight bearing
Swelling across
the dorsum of the
foot
Deformity
variable due to
possible
spontaneous
Clinical Findings
Check
neurovascular
status for
compromise of
dorsalis pedis artery
and/or deep
peroneal nerve
injury
COMPARTMENT
SYNDROME
Planter Ecchymosis Sign
 The passive pronation-abduction
test described by is performed by
eliciting pain on abduction and
pronation of the forefoot with the
hindfoot fixed.

CurtisMJ,MyersonM,SzuraB:Tarsometatarsal joint injuries in the

athlete.Am J Sports Med1993;21(4):497-502.
Trevino and Kodros described a
rotation test, in which stressing
the second tarsometatarsal joint
by elevating and depressing the
second metatarsal head relative
to the first metatarsal head elicits
pain at the Lisfranc joint.

PIANO KEY SIGN

DIAGNOSIS
Requires a high degree of clinical
suspicion

20% misdiagnosed
40% no treatment in the 1st week

??? MIDFOOT
SPRAIN???
RADIOGRAPHIC EVALUATION

Xrays
Computed tomography (CT) scan.
MRI
Bone Scans
UltraSound scan
Radiographic Evaluation

AP, Lateral, and

30 Oblique X-
Rays are
mandatory
AP: The medial
margin of the 2nd
metatarsal base
and medial
margin of the
medial cuneifrom
should be alligned
Radiographic Evaluation

Oblique: Medial
base of the 4th
metatarsal and
medial margin of
the cuboid should
be alligned
AP View Xrays
Oblique View Xrays

3
4
5
Oblique View Xrays
Radiographic Evaluation

Lateral: The
dorsal surface of
the 1st and 2nd
metatarsals
should be level to
the corresponding
cuneiforms
Lisfranc
Injury
A fleck sign should
be sought in the
medial cuneiform
second metatarsal
space. This
represents an
avulsion of the
Lisfranc ligament.

Myerson et al 1986
Lisfranc injuries BIG challenge

20% of injuries go unrecognized,

likely secondary to the difficulty
encountered with standard Xray

Many so-called sprains present with

nonweight-bearing radiographs
that are difficult to interpret.
50% of athletes with midfoot
injuries had normal nonweight-
bearing radiographs

NunleyJA,VertulloCJ:Classification, investigation, and

management of midfoot sprains: Lisfranc injuries in the athlete. Am J
Sports Med2002;30(6):871-878.
Stress Radiographs
Radiographs must be obtained
with the patient bearing weight in
case of subtle injuries.
If the radiograph reveals no
displacement, and the patient
cannot bear weight, a short leg
cast should be used for 2 weeks,
and the radiographs should be
repeated with weight bearing
AP Full Wt bearing Xray
Taking Lateral Views
NWB Xray FWB Xray
 MRI

MRI has an advantage in identifying

partial ligament injuries and subtle
ligament injuries.

Especially useful in low velocity

injuries and in settings of Normal
radiographs.
 Magnetic Resonance
Imaging

In a recent study evaluating the predictive

value of MRI for midfoot instability, Raikin et
al found that MRI demonstrating a rupture
or grade 2 sprain of the plantar ligament
between the first cuneiform and the bases of
the second and third MTs is highly predictive
of midfoot instability, and these patients
should be treated with surgical stabilization
MRI
3D CT SCAN
 Stress Fluroscopy under
Anaesthesia

The foot is stressed in a medial/lateral plane. The forefoot is forced laterally

with the hindfoot brought medially.Pronation Abduction Stress
Management
CONSERVATIVE

SURGICA
L
Check Stability..
The definition of instability
presently is defined as a greater
than 2-mm shift in normal joint
position.

Diastasis between the first and

second MT in the injured midfoot
is considered normal provided
that it measures <2.7 mm.
Goals of Treatment
Painless,
Plantigrade
Stable foot.

Maintenance of anatomic
alignment seems to be the critical
factor in achieving a satisfactory
result.
Non operative
Management

Indications
<2-mm displacement of the
tarsometatarsal joint in any plane

No evidence of joint line instability

with weight-bearing or stress
radiographs
 Treatmen
t
Short leg non-weight-
bearing cast for 6 weeks

Weight bearing cast for an

additional 4 to 6 weeks

Recheck stability with stress

views at 10 days from injury
Surgical Intervention
Best results are obtained through
anatomic reduction and stable
fixation.
The timing of surgery is
predicated on resolution of
swelling, when the skin begins to
wrinkle.

Lisfranc injuries are best

managed within the first 2 weeks
following the inciting event.
Closed manipulation under
anesthesia with casting as a
definitive treatment has been
shown to be a poor choice
because maintenance of the
reduction is too difficult and
residual deformity can lead to
significant morbidity.
Operative Treatment

Surgical
emergencies:
1. Open fractures
2. Vascular
compromise
(dorsalis pedis)
3. Compartment
syndrome
Dorsal
incisions
centered over
the involved
joints are used
to approach
the midfoot.
Operative Treatment
Technique

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

Reduce and 2nd met. Base

unreduced
provisionally
stabilize 2nd TMT
joint
Reduce and
provisionally
stabilize 1st TMT
reduced
joint
If lateral TMT joints
remain displaced
nd rd
Operative Treatment
Technique

If reductions are
anatomic proceed
with permanent
fixation:
1. Screw fixation is
preferable for the
medial column
2. Pocket hole to
prevent dorsal
cortex fracture
Operative Treatment
Technique

3. Screws are
positional not lag
4. 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
screw
6.The lateral
metatarsals
frequently reduce
with the medial
column and pin
fixation for
Preop AP

Postop AP

Postop Lateral
Lisfranc Fracture fixed with
screws and K wires
 Dorsal plating for bridging
fixation of comminuted fractures
can be used.

Painful hardware has not been a concern, and

removal is not common with properly placed low-
profile plating systems. Weight bearing is
advanced rapidly.
Screw fixation remains the
traditional fixation technique,
although there is evidence to
suggest that primary arthrodesis
may be superior for the purely
ligamentous midfoot injury.
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
 COMPLICATIONS

EARL
Y
LAT
E
EARLY COMPLICATIONS

Vascular injuries.
Foot compartment syndrome.
Infections and wound
complications
LATE COMPLICATIONS
Post traumatic arthritis
1. Present in most, but may not be
symptomatic
2. Related to initial injury and
adequacy of reduction
3. Treated with arthrodesis for
medial column
4. Interpositional arthroplasty may
be considered for lateral column
Good or excellent results have
been accomplished in 50% to 95%
of patients with anatomic
alignment, compared with 17% to
30% of patients with nonanatomic
alignment following injury

Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations
of the tarsometatarsal joints: end results correlated with pathology
and treatment.Foot Ankle. 1986; 6(5):225242.
Neuromas.
Flatfoot deformity with instability
with weight bearing.
Painful hardware, hardware
failure, or breakage.
Complex regional pain syndrome.
Prognosis
Long rehabilitation (> 1 year)
Incomplete reduction leads to
increased incidence of deformity
and chronic foot pain
Incidence of traumatic arthritis (0
58%) and related to
intraarticular surface damage
and comminution.
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