Lisfranc Injury,Trauma

1. LISFRANC
INJURY
Dr.Subodh Pathak

2. “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)

3. 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.

4. Jacques Lisfranc de St. Martin
(April 2, 1790 – May 13, 1847)
Pioneering French surgeon and gynecolo
gist.
Pioneered …………….
Lithotomy
Amputation of Cervix Uteri
Removal of Rectum
The Lisfranc joint and the Lisfranc
fracture are named after him.

5. 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.

6. Foot Anatomy

7. Lisfranc joint complex
consists of three
articulations including
◦ Tarsometatarsal articulatio
n.
◦ Intermetatarsal articulation
.
◦ Intertarsal articulations.

8. The Lisfranc complex 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

9. 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

10. Peicha et al showed that persons
with Lisfranc injury had a shallower
medial mortise depth compared with
control subjects. They suggested that
adequate mortise depth provides for
greater stability by allowing for a
stronger Lisfranc ligament.
Peicha G, Labovitz J, Seibert FJ, et al.: The anatomy of the joint as a risk factor
for Lisfranc dislocation and fracture-dislocation: An anatomical and radiological case
control study. J Bone Joint Surg Br2002;84(7):981-985

11. Ligaments

12. Transverse Ligament
Oblique Ligaments
Dorsal
Planter
Interosseu
s

14. Lisfranc Ligament

15. 2bands

16. In a biomechanical evaluation, Solan
et al assessed the strength of each
ligamentous set—dorsal,
interosseous, and plantar—by
stressing it to failure. They concluded
that the Lisfranc ligament was
strongest, followed by the plantar
ligaments and the dorsal ligaments.

17. 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.

18. Foot Muscles – Plantar Surface
First layer
◦ Abductor
Hallucis
◦ Abductor Digiti
Minimi
◦ Flexor
Digitorum
Brevis

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

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

21. Foot Muscles – Plantar Surface
Fourth or
Interosseus
Layer
2 muscles-
Plantar Interossei.
Dorsal Interossei.
2 tendons-
- peroneus
longus .
- Tibialis
posterior.

22. 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 Lisfranc’s injuries
may be overlooked.
Mantas JP, Burks RT. Lisfranc injuries in the athlete. Clin Sports Med. 1994; 13(4):719–730.
Thompson MC, Mormino MA. Injury to the tarsometatarsal joint complex. J Am Acad Orthop
Surg. 2003; 11(4):260–267.

23. Mechanism of Injury
Direct Injury
Indirect Injury

24. Orthopedics
June 2012 - Volume 35 · Issue 6: e868-e873
DOI: 10.3928/01477447-20120525-26
Arthrodesis Versus ORIF for Lisfranc Fractures
Shahin Sheibani-Rad, MD, MS; J. Christiaan Coetzee, MD; M. Russell
Giveans, PhD; Christopher DiGiovanni, MD

25. 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

27. Urgent Braking

28. Indirect Injury

29. 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”)

30. Fracture-dislocations
are often associated
with significant soft-
tissue trauma, vascular
compromise, and
compartment syndrome.

31. 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.

32. Quenu and Kuss (1909):
Homolateral
Isolated
Divergent
1. Modified by Hardcastle in 1982
2. Further modified by Myerson in 1986

33. Quenu and Kuss (1909)

34. Homolateral Divergent

35. Hardcastle (1982)
Homolateral or Total
Incongruity:
• All 5 metatarsals
displace in common
direction
•Fracture base of 2nd
common

36. Isolated Partial
Incongruities:
• Displacement of 1 or
more metatarsals
away from the others

37. Divergent:
• Lateral displacement
of lesser metatarsals
with medial
displacement of the 1st
metatarsal
• May have extension
of injury into
cuneiforms or

38. TOTAL INCONGRUITY
PARTIAL INCONGRUITY
DIVERGENT

39. Chiodo& Myerson(2001)COLUMNAR
THEORY

40. 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 and

42. Clinical Findings
Midfoot pain with
difficulty in weight
bearing
Swelling across the
dorsum of the foot
Deformity variable
due to possible
spontaneous
reduction

43. Clinical Findings
Check neurovascular
status for compromise
of dorsalis pedis artery
and/or deep peroneal
nerve injury
COMPARTMENT
SYNDROME

44. Planter Ecchymosis Sign

45. The passive pronation-abduction test
described by is performed by eliciting
pain on abduction and pronation of the
forefoot with the hindfoot fixed.
Curtis MJ, Myerson M, Szura B: Tarsometatarsal joint injuries in the athlete. Am J Sports
Med 1993;21(4):497-502.

46. 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

47. DIAGNOSIS
Requires a high degree of clinical
suspicion
20% misdiagnosed
40% no treatment in the 1st week
??? MIDFOOT SPRAIN???

48. RADIOGRAPHIC
EVALUATION
Xrays
Computed tomography (CT) scan.
MRI
Bone Scans
UltraSound scan

49. 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

50. Radiographic Evaluation
Oblique: Medial
base of the 4th
metatarsal and
medial margin of the
cuboid should be
alligned

51. AP View Xrays

52. Oblique View Xrays
3
4
5

53. Oblique View Xrays

54. Radiographic Evaluation
Lateral: The dorsal
surface of the 1st
and 2nd metatarsals
should be level to
the corresponding
cuneiforms

55. Lisfranc
Injury

56. 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

57. Lisfranc injuries BIG challenge
20% of injuries go unrecognized, likely
secondary to the difficulty encountered
with standard Xray
Many so-called sprains present with
non–weight-bearing radiographs that
are difficult to interpret.

58. 50% of athletes with midfoot injuries
had normal non–weight-bearing
radiographs
Nunley JA, Vertullo CJ: Classification, investigation, and management
of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports
Med2002;30(6):871-878.

59. 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

60. AP Full Wt bearing Xray

61. Taking Lateral Views

63. NWB Xray FWB Xray

64. 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.

65. 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

66. MRI

67. 3D CT SCAN

68. 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

69. Management
CONSERVATIVE
SURGICA
L

70. 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.

71. Goals of Treatment
Painless,
Plantigrade
Stable foot.
Maintenance of anatomic alignment
seems to be the critical factor in
achieving a satisfactory result.

72. 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

73. Treatment
◦ 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

74. 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.

75. 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.

76. Operative Treatment
Surgical
emergencies:
1. Open fractures
2. Vascular
compromise
(dorsalis pedis)
3. Compartment
syndrome

79. Dorsal incisions
centered over
the involved
joints are used
to approach the
midfoot.

80. 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

81. Operative Treatment
Technique
Reduce and
provisionally stabilize
2nd TMT joint
Reduce and
provisionally stabilize
1st TMT joint
If lateral TMT joints
remain displaced use
2nd or 3rd incision
2nd met. Base
unreduced
reduced

82. 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

83. 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

84. 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 mobility
is acceptable

85. Preop AP
Postop AP
Postop Lateral

86. Lisfranc Fracture fixed with
screws and K wires

87. 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.

88. 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.

91. 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

92. 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

93. COMPLICATIONS
EARL
Y
LAT
E

94. EARLY COMPLICATIONS
Vascular injuries.
Foot compartment syndrome.
Infections and wound
complications

95. 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

96. 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):225–242.

97. Neuromas.
Flatfoot deformity with instability with
weight bearing.
Painful hardware, hardware failure, or
breakage.
Complex regional pain syndrome.

98. 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.