Please confirm topic selection

Are you sure you want to trigger topic in your Anconeus AI algorithm?

Images
https://upload.orthobullets.com/topic/7030/images/AP_moved.jpg
https://upload.orthobullets.com/topic/7030/images/lateral_moved.jpg
https://upload.orthobullets.com/topic/7030/images/lisfranc dorsal dislocation.jpg
  • Summary
    • 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.
    • Diagnosis is confirmed by radiographs which may show widening of the interval between the 1st and 2nd ray.
    • Treatment is generally operative with either ORIF or arthrodesis.
  • Epidemiology
    • Incidence
      • account for 0.2% of all fractures
    • Demographics
      • males > females
      • more common in the third decade
  • ETIOLOGY
    • Pathophysiology
      • mechanism of injury
        • MVAs, falls from height, and athletic injuries
        • injury cascade
          • mechanism is usually caused by indirect rotational forces and axial load through hyper-plantarflexed 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
      • tarsal fractures
      • proximal metatarsal fractures
        • Lisfranc equivalent injuries can present in the form of contiguous proximal metatarsal fractures or tarsal fractures
        • can involve multiple TMT joints
  • 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
  • Presentation
    • History
      • history of high energy trauma or sporting accident
    • 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
      • 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
  • Differential
    • Key Differential
      • metatarsal base fracture
      • metatarsal stress fracture
      • tarsal fracture
  • 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 percutaneous pinning and delayed ORIF or 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
          • 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
          • chronic deformity
          • complete Lisfranc fracture dislocations (Type A or C2)
        • outcomes
          • function 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
            • 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
          • complications
            • excluding hardware removal, no difference in complications between ORIF and arthrodesis
      • 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 percutaneous pinning
      • 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 
      • risk factors
        • delayed treatment
        • ORIF
          • up to 80% risk with non-anatomic ORIF
            • 54% of patients have symptomatic OA at ~10 years followed 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
  • Prognosis
    • Overall Impact on Life Quality
      • 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.
    • Poor prognostic variables
      • missed diagnosis
        • easily missed and diagnosis is critical
        • missed injuries can result in progressive foot planovalgus deformity
          • result in chronic pain and ambulatory dysfunction
Card
1 of 75
Question
1 of 35
Private Note

Attach Treatment Poll
Treatment poll is required to gain more useful feedback from members.
Please enter Question Text
Please enter at least 2 unique options
Please enter at least 2 unique options
Please enter at least 2 unique options