Updated: 10/17/2020

Lisfranc Injury

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https://upload.orthobullets.com/topic/7030/images/lisfranc dorsal dislocation.jpg
Introduction
  • Overview
    • a Lisfranc injury is a tarsometatarsal fracture dislocation characterized by traumatic disruption between the articulation of the medial cuneiform and base of the second metatarsal
      • treatment is generally operative with ORIF, or primary arthrodesis 
  • Epidemiology
    • incidence
      • account for 0.2% of all fractures
    • demographics
      • more common in the third decade
      • males > females
  • Pathophysiology
    • mechanism of injury
      • MVAs, falls from height, and athletic injuries
      • mechanism is usually caused by indirect rotational forces and axial load through hyperplantar flexed forefoot 
        • hyperflexion/compression/abduction moment exerted on forefoot and transmitted to the TMT articulation
        • metatarsals displaced in dorsal/lateral direction
    • pathoanatomy
      • unifying factor is disruption of the TMT joint complex
      • injuries can range from mild sprains to severe dislocations
      • may take form of purely ligamentous injuries or fracture-dislocations
      • ligamentous vs. bony injury pattern has treatment implications
  • Associated conditions
    • proximal metatarsal fractures or tarsal fractures
      • Lisfranc equivalent injuries can present in the form of contiguous proximal metatarsal fractures or tarsal fractures
      • can involve multiple TMT joints
  • Prognosis
    • significant variability regarding return to full activity given heterogenous group of patients in nearly all studies
      • in the military population, at ~3 year follow-up, ~70% patients undergoing ORIF or primary arthrodesis were able to resume occupationally required daily running. 
    • missed injuries can result in progressive foot planovalgus deformity, chronic pain and dysfunction
      • tarsometatarsal fracture-dislocations are easily missed and diagnosis is critical
Anatomy
  • Osteology 
    • Lisfranc joint complex consists of three articulations including
      • tarsometatarsal articulation
      • intermetatarsal articulation
      • intertarsal or intercuneiform articulations
    • columns of the midfoot
      • medial column
        • includes first tarsometatarsal joint
      • middle column
        • includes second and third tarsometatarsal joints
      • lateral column
        • includes fourth and fifth tarsometatarsal joints (most mobile)
  • Ligaments
    • Lisfranc ligament  
      • an interosseous ligament that goes from medial cuneiform to base of 2nd metatarsal on plantar surface   
      • critical to stabilizing the 1st and 2nd tarsometatarsal joints and maintenance of the midfoot arch
      • Lisfranc ligament tightens with pronation and abduction of forefoot
    • plantar tarsometatarsal ligaments
      • injury of the plantar ligament between the medial cuneiform and the second and third metatarsals along with the Lisfranc ligament is necessary to give transverse instability. 
    • dorsal tarsometatarsal ligaments
      • dorsal ligaments are weaker and therefore bony displacement with injury is often dorsal
    • intermetatarsal ligaments
      • between second-fifth metatarsal bases
      • no direct ligamentous attachment between first and second metatarsal
  • Biomechanics
    • Lisfranc joint complex is inherently stable with little motion due to
      • stable osseous architecture
        • second metatarsal fits in mortise created by medial cuneiform and recessed middle cuneiform, "keystone configuration"
      • ligamentous restraints
        • see individual ligaments above
Classification


Hardcastle & Myerson classification 

Type A  • Complete homolateral dislocation
 
Type B1  • Partial injury, medial column dislocation
Type B2  • Partial injury, lateral column dislocation
Type C1

 • Partial injury, divergent dislocation

Type C2
 • Complete injury, divergent dislocation
 


Physical Exam
  • Symptoms
    • severe midfoot pain
    • inability to bear weight
  • Physical exam
    • inspection & palpation
      • medial plantar ecchymosis 
      • swelling throughout midfoot
      • tenderness over tarsometatarsal joint
    • motion
      • instability test
        • grasp metatarsal heads and apply dorsal force to forefoot while other hand palpates the TMT joints
          • dorsal subluxation suggests instability
          • if first and second metatarsals can be displaced medially and laterally, global instability is present and surgery is required
        • when plantar ligaments are intact, dorsal subluxation does not occur with stress exam and injury may be treated nonoperatively
    • provocative tests
      • may reproduce pain with pronation and abduction of forefoot
Imaging
  • Radiographs
    • recommended views
      • AP
      • lateral
      • oblique
      • weight-bearing with comparison view  
        • may be necessary to confirm diagnosis
    • findings
      • five critical radiographic signs that indicate presence of midfoot instability
        • discontinuity of a line drawn from the medial base of the 2nd metatarsal to the medial side of the middle cuneiform
          • seen on AP view
          • diagnostic of Lisfranc injury
        • widening of the interval between the 1st and 2nd ray
          • seen on AP view
          • may see bony fragment (fleck sign) in 1st intermetatarsal space 
            • represents avulsion of Lisfranc ligament from base of 2nd metatarsal
            • diagnostic of Lisfranc injury
        • dorsal displacement of the proximal base of the 1st or 2nd metatarsal  
          • seen on lateral view
        • medial side of the base of the 4th metatarsal does not line up with medial side of cuboid
          • seen on oblique view
        • disruption of the medial column line (line tangential to the medial aspect of the navicular and the medial cuneiform)
          • seen on oblique view
  • CT scan
    • indications
      • useful for preoperative planning in the setting of comminuted bony injuries
      • can help identify subtle injuries
  • MRI
    • indications
      • can be used to confirm presence of purely ligamentous injury
Treatment
  • Nonoperative
    • cast immobilization for 8 weeks 
      • indications
        • certain non-displaced injuries that are stable with weight bearing
        • nonoperative candidates
          • nonambulatory patients
          • presence of serious vascular disease
          • severe peripheral neuropathy
      • outcomes
        • significantly lower functional and radiographic outcomes noted with non-operative management of displaced or transverse unstable injuries
  • Operative
    • temporary pinning and delayed open reduction and internal fixation/arthrodesis 
      • indications
        • displaced lisfranc fracture dislocation injury with significant soft tissue swelling
      • outcomes
        • temporizing reduction and pinning and delayed definitive management with ORIF/arthrodesis has been shown to have decreased risk of wound infection in some low level studies. 
    • open reduction and rigid internal fixation 
      • indications
        • any evidence of instability (> 2mm shift)       
        • favored in bony fracture dislocations as opposed to purely ligamentous injuries
      • outcomes
        • anatomic reduction required for a good result
        • excluding hardware removal, no difference in complications or functional outcomes between ORIF and arthrodesis
    • primary arthrodesis of the first, second and third tarsometatarsal joints
      • indications (controversial)
        • purely ligamentous arch injuries    
        • delayed treatment 
        • chronic deformity
        • complete lisfranc fracture dislocations (Type A or C2)
      • outcomes
        • level 1 evidence demonstrates equivalent functional outcomes compared to primary ORIF     
        • medial column tarsometatarsal fusion shown to be superior to combined medial and lateral column tarsometatarsal arthrodesis  
        • excluding hardware removal, no difference in complications between ORIF and arthrodesis
        • some studies have shown that primary arthrodesis for complete lisfranc fracture dislocations (Type A or C2) results in improved functional outcomes and quality of reduction compared to ORIF
    • midfoot arthrodesis
      • indications
        • destabilization of the midfoot's architecture with progressive arch collapse and forefoot abduction
        • chronic Lisfranc injuries that have led to advanced midfoot arthrosis and have failed conservative therapy  
Technique
  • Cast immobilization
    • close followup with repeat radiographs should be performed to ensure no displacement with weightbearing with non-operative management
  • Temporary pinning and delayed open reduction and internal fixation/arthrodesis
    • technique
      • reduce medial and lateral columns and stabilize with k-wires 
      • K-wires left in place until soft tissue swelling subsides
      • can proceed with K-wire removal and ORIF/arthrodesis when soft tissues allow
    • timing to definitive surgery
      • can delay up to 2-3 weeks for soft tissue swelling to improve
  • Open reduction and rigid internal fixation
    • timing
      • within 24 hours or delay operative treatment until soft tissue swelling subsides (up to 2-3 weeks)
    • approach
      • single or dual longitudinal incisions can be used based on injury pattern and surgeon preference
      • longitudinal incision made in the web space between first and second rays
      • first TMT joint is exposed between the long and short hallux-extensor tendons
    • reduction & fixation
      • reduce intercuneiform instability first
      • fix first through third TMT joints with transarticular screws
        • screw fixation is more stable than K-wire fixation 
        • can also span TMT joints with plates if MT base comminution is present
    • postoperative care
      • early midfoot ROM, protected weight bearing, and hardware removal (k-wires in 6-8 weeks, screws in 3-6 months
      • gradually advance to full weight bearing at 8-10 weeks
      • if patient is asymptomatic and screws transfix only first through third TMT joints, they may be left in place
      • preclude return to vigorous athletic activities for 9 to 12 months
  • Primary arthrodesis of the first, second and third tarsometatarsal joints
    • arthrodesis & fixation
      • expose TMT joints and denude all joint surfaces of cartilage
      • use cortical screws or square plate to fuse joints 
      • in the presence of both medial and lateral column dislocation, temporary lateral column pinning is recommended over lateral column arthrodesis 
    • postoperative care
      • apply cast or splint for 6 weeks
      • progress weight bearing between 6 and 12 weeks in removable boot
      • full weight bearing in standard shoes by 12 weeks post-op
  • Midfoot arthrodesis
    • arthrodesis & fixation
      • expose TMT joints and midfoot  and remove cartilage from first, second, and third TMT joints
      • add bone graft
      • reduce the deformity using windlass mechanism
      • variety of definitive fixation constructs exist
    • postoperative care
      • apply cast or splint for 6 weeks
      • progress weight bearing between 6 and 12 weeks in removable boot
      • begin weight bearing as tolerated at 12 weeks if evidence of healing is noted on radiographs
Complications
  • Posttraumatic arthritis
    • incidence
      • most common complication (~25%)
    • risk factors
      • delayed treatment
      • ORIF
        • up to 80% risk with non-anatomic ORIF
    • treatment
      • treat advanced midfoot arthrosis with midfoot arthrodesis
  • Malunion
    • risk factors
      • non-anatomic ORIF of lisfranc injury
    • treatment
      • shoe modifications (cushioned heel with rocker sole) 
        • indications
          • nonsurgical candidate
      • malunion correction with primary arthrodesis
        • indications
          • surgical candidate that has failed non-operative treatment
  • Nonunion
    • risk factors
      • smoking
    • treatment
      • revision arthrodesis with bone grafting
        •  indicated unless patient is elderly and low demand
  • Hardware removal
    • incidence
      • ~75% of patients who undergo ORIF
        • often a planned secondary procedure, required to allow the TMT joints to return to motion
      • ~20% of patients following arthrodesis
  • Deep infection
    • incidence
      • 3-4%
    • risk factors
      • significant soft tissue swelling at time of definitive surgery
    • treatment
      • irrigation and debridement, possible hardware removal.
  • Planovalgus foot deformity
    • risk factors
      • non-operative management
      • non-anatomic reduction following ORIF
 
 

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Technique Guides (1)
Questions (28)
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(OBQ13.32) A 35-year-old motorcyclist is involved in a motor vehicle accident. He complains of pain and swelling in his right foot. Examination demonstrates dorso-medial midfoot tenderness. A clinical photograph is seen in Figure A. Supine and standing radiographs are seen in Figures B and C respectively. What is the most appropriate definitive treatment step? Tested Concept

QID: 4667
FIGURES:
1

Non-weightbearing in a CAM walker boot for 6-10 weeks

1%

(40/4054)

2

Weightbearing as tolerated in a CAM walker boot for 6-10 weeks

1%

(22/4054)

3

Closed reduction and K-wire fixation of the first and second tarsometatarsal joints

3%

(106/4054)

4

Open reduction and rigid internal fixation of the first and second tarsometatarsal joints

76%

(3091/4054)

5

Open reduction and rigid internal fixation of the first to third tarsometatarsal joints and K-wire fixation of the fourth and fifth tarsometatarsal joints

19%

(765/4054)

L 3 A

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(OBQ13.167) A 22-year-old soccer player complains of foot pain after sustaining a twisting injury. A clinical photo is shown in Figure A. On the physical examination, he is focally tender in the midfoot region. Weight bearing radiographs are shown in Figure B. What is the optimal definitive treatment for this patient? Tested Concept

QID: 4802
FIGURES:
1

Observation alone

0%

(7/2961)

2

Weight bearing in a walking boot

1%

(19/2961)

3

Immobilization in a cast for 8 weeks

1%

(31/2961)

4

Open reduction and internal fixation of the injury

87%

(2564/2961)

5

Open reduction and internal fixation of the injury along with lateral column stabilization

11%

(320/2961)

L 1 A

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(OBQ12.13) A 25-year-old male sustains a left foot injury while playing soccer. His radiographs are shown in figures A and B. Which of the following techniques would lead to the best outcome when addressing his injury? Tested Concept

QID: 4373
FIGURES:
1

Rigid cast immobilization

3%

(122/4745)

2

Spanning medial column external fixation

0%

(22/4745)

3

Percutaneous screw fixation of medial column of foot

6%

(289/4745)

4

K-wire fixation of medial column of foot

2%

(90/4745)

5

Open reduction and internal fixation of medial column of foot

88%

(4185/4745)

L 1 B

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(OBQ11.185) A 40-year-old male sustains a right foot injury after a head-on motor vehicle collision. He is unable to place weight on the foot to ambulate due to pain along the medial aspect of the foot. The pain is exacerbated with abduction of the midfoot. The patient denies pain along the lateral border of the midfoot. He is neurovascularly intact in the foot. An injury radiograph is shown in Figure A, while a clinical image of the foot is shown in Figure B. What is the most appropriate next step in management? Tested Concept

QID: 3608
FIGURES:
1

Open reduction and arthrodesis of the medial two tarsometatarsal joints

56%

(1614/2875)

2

External fixation of the foot followed with staged open reduction and screw fixation across the medial two tarsometatarsal joints

2%

(61/2875)

3

Open reduction and screw fixation across the medial three tarsometatarsal joints and percutaneous pinning of the 4th and 5th tarsometatarsal joints

24%

(677/2875)

4

Debridement of Morel-Lavallee lesion and external fixation of the foot followed with staged open reduction and screw fixation across the medial two tarsometatarsal joints

1%

(20/2875)

5

Open reduction and screw fixation across the medial two tarsometatarsal joints with anatomic ligamentous reconstruction

17%

(488/2875)

L 4 A

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(OBQ09.244) A 24-year-old man sustains an injury to his left foot. Stress radiographs are seen in Figure A. Injury to which ligament or ligaments are needed to produce the transverse instability seen here? Tested Concept

QID: 3057
FIGURES:
1

Spring ligament and bifurcate ligament

2%

(37/2308)

2

Interosseous first cuneiform-second metatarsal ligament

32%

(745/2308)

3

Interosseous first cuneiform-second metatarsal ligament and plantar ligament between the first cuneiform and the second and third metatarsals

58%

(1350/2308)

4

Bifurcate ligament and Interosseous first cuneiform-second metatarsal ligament

4%

(91/2308)

5

Long plantar ligament and plantar ligament between the first cuneiform and the second and third metatarsals

3%

(72/2308)

L 3 C

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(OBQ08.139) As an alternative to open reduction and internal fixation for the injury pattern seen in Figure A, what alternative treatment has been shown to be more effective? Tested Concept

QID: 525
FIGURES:
1

open reduction and arthrodesis of the medial and middle column, reduction and stabilization of the lateral column

81%

(2132/2629)

2

open reduction and primary arthrodesis of the medial, middle, and lateral columns

11%

(279/2629)

3

closed percutanous pinning of the medial, middle, and lateral columns

6%

(166/2629)

4

closed reduction of the midfoot and casting

1%

(36/2629)

5

partial weight bearing in removable boot

0%

(6/2629)

L 1 A

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(OBQ08.222) Which ligament connects the medial cuneiform to the base of the second metatarsal? Tested Concept

QID: 608
1

Spring ligament

1%

(30/2069)

2

Chopart ligament

1%

(16/2069)

3

Lisfranc ligament

97%

(2004/2069)

4

Intermetatarsal ligament

0%

(9/2069)

5

Calcaneofibular ligament

0%

(4/2069)

L 1 C

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(OBQ07.103) A 37-year-old man was involved in a high velocity motor vehicle accident 6 months ago. He spent 4 months in the ICU recovering from a severe head injury. He has now transitioned to a rehabilitation hospital and complains of left foot pain that becomes severe with weightbearing and attempted ambulation. Radiographs are provided in figures A-C. Which of the following is the best management? Tested Concept

QID: 764
FIGURES:
1

Custom orthotics and physical therapy

1%

(9/1674)

2

Closed reduction and percutaneous screw fixation of 1st through 3rd tarsometatarsal joints

2%

(35/1674)

3

Open reduction internal fixation of 1st through 3rd tarsometatarsal joints

19%

(326/1674)

4

Arthrodesis of 1st through 3rd tarsometatarsal joints

73%

(1226/1674)

5

Tarsometatarsal arthrodesis and triple arthrodesis

4%

(62/1674)

L 2 C

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(OBQ06.100) A 30-year-old equestrian caught her foot in a stirrup 1 week ago and now complains of midfoot pain with difficulty bearing weight. Radiographs are shown in figure A. What treatment is most appropriate? Tested Concept

QID: 211
FIGURES:
1

Non-weight bearing in an aircast

4%

(75/2140)

2

Weight bearing as tolerated in a walking cast

3%

(66/2140)

3

Modified-Brostrom procedure

3%

(54/2140)

4

Delayed corrective osteotomy and arthrodesis of the medial column

1%

(27/2140)

5

Arthrodesis of the medial tarsometatarsal joints

89%

(1906/2140)

L 1 A

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(OBQ06.132) A 54-year-old male sustained a right foot injury two years ago in a motor vehicle collision. The patient reports he was treated for a ligament injury in his foot with a non-weightbearing short leg cast for 2 months. Physical examination reveals no signs of infection and full sensation and motor strength in the foot. During gait examination he has pain during push-off of the right foot and loss of medial longitudinal arch height in the stance phase. A radiograph obtained at the time of initial injury is shown in Figure A. What is the most appropriate next step in management? Tested Concept

QID: 318
FIGURES:
1

Lateral column lengthening procedure (Evans)

4%

(42/1018)

2

Tarsometatarsal joint arthrodesis

87%

(883/1018)

3

Talonavicular joint arthrodesis

3%

(29/1018)

4

Lateral wedge closing calcaneal osteotomy (Dwyer)

1%

(13/1018)

5

Subtalar, talonavicular, and calcaneocuboid joint arthrodesis (Triple)

5%

(46/1018)

L 1 C

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(OBQ04.1) A 54-year-old woman sustains a twisting injury to her foot. A radiograph is provided in Figure A. Which of the following is the most appropriate treatment? Tested Concept

QID: 112
FIGURES:
1

closed reduction and pinning

4%

(84/2275)

2

closed reduction and casting

1%

(27/2275)

3

open reduction and internal fixation

93%

(2120/2275)

4

CAM walker and weight bearing as tolerated

1%

(29/2275)

5

weight bearing as tolerated

0%

(7/2275)

L 1 B

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