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 may be cast immobilization, ORIF, or arthrodesis depending on whether it is a ligamentous or bony injury Epidemiology incidence account for 0.2% of all fractures demographics more common in the third decade more common in males Pathophysiology 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 mechanism causes include 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 Associated conditions proximal metatarsal fractures or tarsal fractures Lisfranc equivalent injuries can present in the form of contiguous proximal metatarsal fractures or tarsal fractures Prognosis 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 articulations Ligaments Lisfranc ligament critical to stabilizing the second metatarsal and maintenance of the midfoot arch An interosseous ligament that goes from medial cuneiform to base of 2nd metatarsal on plantar surface 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 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) Classification Multiple classification schemes described none proven useful for determining treatment and prognosis Physical Exam Symptoms severe pain inability to bear weight Physical exam inspection & palpation medial plantar bruising swelling throughout midfoot tenderness over tarsometatarsal joint motion & stability 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 compartment syndrome always check for compartment syndrome and take compartment pressures if high suspicion Imaging Radiographs recommended views AP lateral oblique stress may be helpful to show instability when non-weight bearing radiographs are normal and there is high suspicion 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 useful for diagnosis and preoperative planning MRI can be used to confirm presence of purely ligamentous injury Tested Differential Bone contusion Ankle sprain navicular fracture Treatment Nonoperative cast immobilization for 8 weeks indications no displacement on weight-bearing and stress radiographs and no evidence of bony injury on CT (usually dorsal sprains) certain nonoperative candidates nonambulatory patients presence of serious vascular disease severe peripheral neuropathy instability in only the transverse plane Operative 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 primary arthrodesis of the first, second and third tarsometatarsal joints indications purely ligamentous arch injuries delayed treatment chronic deformity outcomes level 1 evidence demonstrates equivalent functional outcomes and decreased rate of hardware removal or revision surgery compared to primary ORIF primary arthodesis is an alternative to ORIF in patients with any evidence of instability with possible benefits medial column tarsometatarsal fusion shown to be superior to combined medial and lateral column tarsometatarsal 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 General Surgical Considerations equipment fluoroscopy and radiolucent table small fragment and mini fragment sets (2.0mm-4.0mm screws) reduction clamps, k-wires, dental pick, Homan retractors small battery powered drill timing of surgery emergently only if the presence of compartment syndrome open injury irreducible dislocations delay operative treatment until soft tissue swelling subsides (up to 2-3 weeks) if grossly unstable and in presence of significant soft tissue swelling consider early external fixation Open reduction and rigid internal fixation 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 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 to fuse joints 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 touch down weight bearing in a cast for 6 weeks begin weight bearing at 10 weeks if evidence of healing is noted on radiographs Complications Posttraumatic arthritis most common complication may cause altered gait and long term disability treat advanced midfoot arthrosis with midfoot arthrodesis Nonunion uncommon revision surgery indicated unless patient is elderly and low demand
Technique Guide CPT Codes: 28306 Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Lisfranc Open Reduction and Internal fixation Orthobullets Team Foot & Ankle - Lisfranc Injury
QUESTIONS 1 of 26 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Review Topic | Tested Concept QID: 4667 FIGURES: A B C Type & Select Correct Answer 1 Non-weightbearing in a CAM walker boot for 6-10 weeks 1% (39/3960) 2 Weightbearing as tolerated in a CAM walker boot for 6-10 weeks 1% (22/3960) 3 Closed reduction and K-wire fixation of the first and second tarsometatarsal joints 3% (103/3960) 4 Open reduction and rigid internal fixation of the first and second tarsometatarsal joints 76% (3021/3960) 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% (747/3960) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Review Topic | Tested Concept QID: 4373 FIGURES: A B Type & Select Correct Answer 1 Rigid cast immobilization 3% (122/4691) 2 Spanning medial column external fixation 0% (22/4691) 3 Percutaneous screw fixation of medial column of foot 6% (286/4691) 4 K-wire fixation of medial column of foot 2% (90/4691) 5 Open reduction and internal fixation of medial column of foot 88% (4136/4691) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Review Topic | Tested Concept QID: 3608 FIGURES: A B Type & Select Correct Answer 1 Open reduction and arthrodesis of the medial two tarsometatarsal joints 56% (1598/2850) 2 External fixation of the foot followed with staged open reduction and screw fixation across the medial two tarsometatarsal joints 2% (60/2850) 3 Open reduction and screw fixation across the medial three tarsometatarsal joints and percutaneous pinning of the 4th and 5th tarsometatarsal joints 24% (673/2850) 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% (20/2850) 5 Open reduction and screw fixation across the medial two tarsometatarsal joints with anatomic ligamentous reconstruction 17% (485/2850) L 4 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Review Topic | Tested Concept QID: 3057 FIGURES: A Type & Select Correct Answer 1 Spring ligament and bifurcate ligament 2% (37/2247) 2 Interosseous first cuneiform-second metatarsal ligament 32% (726/2247) 3 Interosseous first cuneiform-second metatarsal ligament and plantar ligament between the first cuneiform and the second and third metatarsals 58% (1310/2247) 4 Bifurcate ligament and Interosseous first cuneiform-second metatarsal ligament 4% (91/2247) 5 Long plantar ligament and plantar ligament between the first cuneiform and the second and third metatarsals 3% (71/2247) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Review Topic | Tested Concept QID: 525 FIGURES: A B Type & Select Correct Answer 1 open reduction and arthrodesis of the medial and middle column, reduction and stabilization of the lateral column 81% (2095/2586) 2 open reduction and primary arthrodesis of the medial, middle, and lateral columns 11% (278/2586) 3 closed percutanous pinning of the medial, middle, and lateral columns 6% (163/2586) 4 closed reduction of the midfoot and casting 1% (35/2586) 5 partial weight bearing in removable boot 0% (6/2586) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept (OBQ08.222) Which ligament connects the medial cuneiform to the base of the second metatarsal? Review Topic | Tested Concept QID: 608 Type & Select Correct Answer 1 Spring ligament 2% (30/1953) 2 Chopart ligament 1% (14/1953) 3 Lisfranc ligament 97% (1890/1953) 4 Intermetatarsal ligament 0% (9/1953) 5 Calcaneofibular ligament 0% (4/1953) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept (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? Review Topic | Tested Concept QID: 764 FIGURES: A B C Type & Select Correct Answer 1 Custom orthotics and physical therapy 1% (9/1611) 2 Closed reduction and percutaneous screw fixation of 1st through 3rd tarsometatarsal joints 2% (35/1611) 3 Open reduction internal fixation of 1st through 3rd tarsometatarsal joints 19% (314/1611) 4 Arthrodesis of 1st through 3rd tarsometatarsal joints 73% (1177/1611) 5 Tarsometatarsal arthrodesis and triple arthrodesis 4% (61/1611) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (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? Review Topic | Tested Concept QID: 211 FIGURES: A Type & Select Correct Answer 1 Non-weight bearing in an aircast 4% (73/2043) 2 Weight bearing as tolerated in a walking cast 3% (64/2043) 3 Modified-Brostrom procedure 2% (48/2043) 4 Delayed corrective osteotomy and arthrodesis of the medial column 1% (26/2043) 5 Arthrodesis of the medial tarsometatarsal joints 89% (1820/2043) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (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? Review Topic | Tested Concept QID: 318 FIGURES: A Type & Select Correct Answer 1 Lateral column lengthening procedure (Evans) 4% (40/974) 2 Tarsometatarsal joint arthrodesis 86% (841/974) 3 Talonavicular joint arthrodesis 3% (29/974) 4 Lateral wedge closing calcaneal osteotomy (Dwyer) 1% (13/974) 5 Subtalar, talonavicular, and calcaneocuboid joint arthrodesis (Triple) 5% (46/974) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (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? Review Topic | Tested Concept QID: 112 FIGURES: A Type & Select Correct Answer 1 closed reduction and pinning 4% (77/2152) 2 closed reduction and casting 1% (26/2152) 3 open reduction and internal fixation 93% (2006/2152) 4 CAM walker and weight bearing as tolerated 1% (28/2152) 5 weight bearing as tolerated 0% (7/2152) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept
All Videos (6) Podcasts (2) Login to View Community Videos Login to View Community Videos 2019 California Orthopaedic Association Annual Meeting Are We Being Screwed by Plates? - Tom Harris, MD (COA 2019) Thomas Harris Foot & Ankle - Lisfranc Injury 7/17/2019 335 views (2) Login to View Community Videos Login to View Community Videos 2019 California Orthopaedic Association Annual Meeting Are We Being Screwed by Plates? - Glenn Pfeffer, MD (COA 2019) Glenn Pfeffer Foot & Ankle - Lisfranc Injury 7/16/2019 380 views (2) Login to View Community Videos Login to View Community Videos California Orthopaedic Association Annual Meeting - 2017 The Lisfranc Articulation/Ligament - Sonya Ahmed, M.D.(COA 2017, 7.1) Sonya Ahmed Foot & Ankle - Lisfranc Injury 4/12/2018 978 views (5) Question Session⎜TKA Periprosthetic Fracture & Lisfranc Injury Orthobullets Team Foot & Ankle - Lisfranc Injury Listen Now 17:18 min 11/11/2019 36 plays (1) Foot & Ankle | Lisfranc Injury (Tarsometatarsal fracture-dislocation) Team Orthobullets 4 Foot & Ankle - Lisfranc Injury Listen Now 11:47 min 10/18/2019 334 plays (11) See More See Less
Right Lisfranc Injury with Comminuted Navicular Fracture in 39M (C101234) Jerrod Steimle Foot & Ankle - Lisfranc Injury B 8/9/2019 7 0 0 Right midfoot pain in a 20M Athlete (C2719) Steven Steinlauf Foot & Ankle - Lisfranc Injury E 10/30/2016 770 3 2 Purely ligamentous injuries of Lisfranc in 17M (C2455) Yves Willemin Foot & Ankle - Lisfranc Injury E 12/1/2015 1393 10 13 See More See Less