Dr. Ebraheim's animated educational video describing Lisfranc injury.
Lisfranc injury is an important topic. Lisfranc injury indicates disruption between the base of the 2nd metatarsal and the medial cuneiform. Lisfranc injuries are a spectrum of injuries of the tarsometatarsal joints. It could be due to apparent sprain, obvious injury or severe dislocation.
Diagnosis is missed in about 25-30% of cases especially in multiple trauma patients. A high index of suspicion is needed to prevent progression of the foot deformity, chronic pain and dysfunction. May need weight bearing films for diagnosis of Lisfranc injury.
Lisfranc injury may be associated with compartment syndrome.
Lisfranc injury could be purely ligamentous or can be associated with fractures. ORIF is better in cases of fractures. Arthrodesis is better in cases of purely ligamentous injury. In general, ligamentous injury does worse than fractures.
The Lisfranc ligament is a large oblique ligament that extends from the plantar aspect of the medial cuneiform to the base of the second metatarsal. The Lisfranc ligament stabilizes the 2nd metatarsal and maintains the midfoot arch. Osseous stability is provided by the roman atch of the metatarsal and the recessed keystone of the 2nd metatarsal base.
Tarsometatarsal joint complex is divided into three units:
•Medial: 1st tarsometatarsal joints- first metatarsal joint- 6 degrees mobility.
•Middle: 2nd & 3rd tarsometatarsal joints-rigid
•Lateral: 4th &5th tarsometatarsal joints – mobile (this is why you do not fuse the 4th & 5th tarsometatarsal joints).
The dorsalis pedis artery and the deep peroneal nerve both run between the first and second metatarsal bases.
Mechanism of injury:
•Direct injuries: plantar displacement is more common.
•Indirect injuries: more common than direct injuries. Results from axial loading or twisting on a plantar flexed midfoot. Dorsal displacement of the 2nd metatarsal is more common. Check the aligment of the dorsum of the 2nd metatarsal with the middle cuneiform.
Tarsal fracture, especially a cuboid fracture.
•Results from twisting injury causing forceful abduction of the forefoot.
•Fracture of base of the 2nd metatarsal and compression fracture of the cuboid.
Classification of Lisfranc injuries
Lisfranc classifications are not useful in deciding the treatment or the prognosis of injury. Severe injuries are obvious, easily diagnosed and may develop compartment syndrome of the foot. Injuries with minimal displacement could be missed and they will need surgery regardless of the classification. Arthritis may develop even with minimal displacement.
In general there is three patterns of injury based on commonly observed patterns:
1.Total incongruity: all five metatarsals are displaced in the same direction. Total incongruity occurs lateral or medial, with lateral being more common.
2.Partial incongruity: one or two metatarsal displaced from the others.
3.Divergent: lateral displacement of the lesser metatarsals with medial displacement of the first metatarsal.
The one thing all these injuries have in common is disruption of the tarsometatarsal joint complex.
•Patient has severe pain in the midfoot and is unable to bear weight
•There may be some swelling in the midfoot dorsally.
•Plantar bruising may be present especially medially. Plantar ecchymosis is a classic clinical sign of potential lisfranc injury.
•Tenderness over the tarsometatarsal joint.
•Check the skin condition and rule out compartment syndrome.
•Check the neurovascular status of the foot.
•Weight-bearing standing x-rays with comparison views if x-rays are normal and if the physician clinically suspects a lisfranc injury,
•Another alternative is to get physician assisted midfoot stress radiograph.
Cast: dorsal sprain and no instability: patient can be treated with non-weight bearing cast for 6 weeks an return to activity gradually.
Surgery: for instability: ORIF with cortical screws if there is bony fractures. When you do ORIF- need anatomic reduction. Hardware removal between 5-6 months.
Arthrodesis if the injury is purely ligamentous. Healing of the ligaments is less reliable than bony healing. Arthrodesis is also done in old injuries if there is delay in treatment for if there is failure of open reduction and internal fixation of Lisfranc injury. Midfoot arthrodesis is also used for chronic lisfranc injury that leads to severe midfoot arthritis with progressive arch collapse and midfoot abduction.
Fusion of the medial and middle column: 1st , 2nd and 3rd tarsometatarsal joints. Do not fuse the lateral column. Lateral column- do reduction and stabilization by k-wire fixation.
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