You are in: eMedicine Specialties > Orthopedic Surgery > FOOT AND ANKLE Lisfranc Fracture DislocationArticle Last Updated: Jun 16, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Saul G Trevino, MD, Professor of Clinical Orthopedic Surgery, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine Saul G Trevino is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Clinical Orthopaedic Society, Mid-America Orthopaedic Association, Phi Beta Kappa, and Texas Medical Association Coauthor(s): Allison M Wade, MD, Staff Physician, Department of Orthopedic Surgery, University of Missouri, Columbia; John S Early, MD, Foot/Ankle Specialist, Texas Orthopaedic Associates, LLP; Co-Director, North Texas Foot and Ankle Fellowship Baylor University Medical Center; Santaram Vallurupalli, MD, Research Resident, Department of Orthopedic Surgery, University of Missouri at Columbia Editors: James K DeOrio, MD, Director of Foot and Ankle Fellowship Program, Assistant Professor of Orthopedic Surgery, Orthopedic Surgery, St. Luke's Hospital, Jacksonville, Florida; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Shepard R Hurwitz, MD, Executive Director, American Board of Orthopaedic Surgery; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Jason H Calhoun, MD, FAAOS, Chairman, J Vernon Luck Distinguished Professor, Department of Orthopedic Surgery, University of Missouri Author and Editor Disclosure Synonyms and related keywords: tarsometatarsal injuries, TMT injuries, Lisfranc dislocation, Lisfranc injury, midfoot injury, Lisfranc ligament, open reduction and internal fixation, ORIF INTRODUCTIONSection 2 of 12
  The Lisfranc joint, which represents the articulation between the midfoot and forefoot, is composed of the 5 tarsometatarsal (TMT) joints. The Lisfranc ligament is attached to the lateral margin of the medial cuneiform and medial and plantar surface of second metatarsal (MT) base. This is the only ligamentous support between first and second ray at midfoot level. Lisfranc joint injuries are rare, complex, and often misdiagnosed or inadequately treated. Lisfranc injuries can vary from simple ligament sprains to complete disruption of the TMT joint. Lisfranc fracture dislocations and sprains carry a high risk of chronic secondary disability. Best outcomes for these injuries require prompt recognition and then anatomic reduction and stabilization. History of the ProcedureJacques Lisfranc de Saint-Martin (1790-1847), a field surgeon in Napoleon's army serving on the Russian front, described a new amputation technique across the 5 TMT joints—one that did not require any bony osteotomy—as a swift solution to forefoot gangrene secondary to frostbite. This anatomical landmark became known as the Lisfranc joint, a term that is used today in the description of a wide spectrum of traumatic injuries to the TMT area of the foot. However, Lisfranc did not actually describe the injury pattern well known by this eponym. A Lisfranc injury encompasses everything from a sprain to a complete disruption of normal anatomy through the TMT joints. This type of injury was later described in equestrian riders who got their foot caught in a stirrup when they fell from a horse. ProblemThe Lisfranc ligament is a solitary ligament that connects the first ray (first metatarsal-medial cuneiform articulation) to the middle and lateral columns of the foot. Injury to this ligament, even in isolation, will result in functional instability with loss of longitudinal and transverse arch.1 Lisfranc injuries are commonly undiagnosed and carry a high risk of chronic secondary disability. Early recognition and treatment of this injury are important to preserve normal foot biomechanics and function. Injuries to the Lisfranc articulations frequently lead not only to arthritis but also to severe pain. FrequencyLisfranc injuries account for 0.2% of all fractures.2 Incidence of this uncommon injury is reported as approximately 1 per 55,000 persons per year. It can occur in all ages but is more common in the third decade and is more common in males.3 Subtle Lisfranc sprain and diastasis have become more commonly diagnosed in athletes.4, 5 EtiologyThe 2 major causes of Lisfranc injuries are low-energy, sports-related injuries and high-energy motor vehicle and industrial accidents. In low-energy settings, TMT injuries are caused by a direct blow to the joint or by axial loading along the MT, either with medially or laterally directed rotational forces. In high-energy injuries, the method of loading is not significantly different, but the energy absorbed by the articulations results in significantly more collateral damage to bony and soft-tissue structures, creating such injuries as MT fractures, cuneiform instabilities, and cuboid fractures. The damage to the tight, ligamentous structures of this joint complex creates an unstable foot for weight bearing. The sense of instability and pain can occur whether or not overt evidence of instability is present. Chronic sprains resulting from relatively minor trauma can be the most debilitating sprains due to pain with weight bearing. PathophysiologyIn diabetic patients with neuropathy or those with idiopathic insensate feet, subacute diastasis can occur over time without notable pain. Due to the absence of pain, this gradual process occurs, so that a minor injury can lead to a Lisfranc injury. In the authors’ opinion, the hallmark of an impending Lisfranc injury is the loss of the recess of the second MT base with the cuneiform, also known as the keystone. Radiographs are considered abnormal when weight-bearing anteroposterior (AP) views of the foot show the first TMT joint to be at the same level as the second TMT joint, indicating proximal migration of the first ray (Image 1). ClinicalPatients with Lisfranc injuries can present with obvious anatomic deformities or with variable amounts of pain with weight bearing. Lisfranc injury should be excluded in any patient with midfoot pain on either the dorsal or the plantar aspect of the foot during weight bearing. Clinical signs of Lisfranc injury are the following:
All suspected injuries require a careful workup. Even significant injuries can reduce spontaneously, thereby hiding the initial deformity. The exaggerated swelling is the key in the differential diagnosis of subtle injuries. Special attention should be paid to patients with decreased sensation in the feet, such as diabetics, because they may be more at risk for progressive neuropathic changes. Athletes Lisfranc injuries are seen more commonly in football players, gymnasts, ballet dancers, and track-and-field athletes. Lisfranc injury in a professional hockey player has also been reported.6 The Lisfranc injury can potentially be a career-ending injury, particularly in elite gymnasts, as noted by Chilvers and colleagues.7 The mechanism of injury for most athletes is axial loading on a hyperplantarflexed midfoot. For ballet dancers, the pointe shoe design has been shown to stabilize the Lisfranc joint while in the en pointe position.8 INDICATIONSSection 3 of 12
Patients with undisplaced injuries are treated conservatively. Patients with displaced Lisfranc injuries should undergo closed or open reduction. All Lisfranc injuries that cannot be reduced and be made to remain stable by closed means should undergo internal fixation. An absolute indication for open reduction is vascular compromise that does not improve with closed reduction.2 RELEVANT ANATOMYSection 4 of 12
The Lisfranc joint is composed of 5 TMT joints in which the first through third MTs articulate with their corresponding medial, middle, and lateral cuneiforms. The fourth and fifth MTs articulate with the cuboid. The Lisfranc joint can be functionally divided longitudinally into the first ray, or medial column; the middle column, consisting of the second and third TMT joints; and the lateral column, consisting of the fourth and fifth TMT joints. A transverse line through these joints is not straight but highlights a recess, termed the keystone (similar to a Roman arch), formed by the second TMT joint. This joint lies approximately 1 cm proximal to the first TMT joint line and 0.5 cm proximal to the third TMT joint line. The joints are bound by thick plantar ligaments that form an interlocking pattern between the tarsal and lesser MT bones 2-5. These are reinforced by attachments of the posterior tibialis tendon. The first TMT joint also has strong plantar ligaments across the joint; these are reinforced by the attachment of the peroneus longus and anterior tibialis tendons. Also present between the lesser MTs is a series of intermetatarsal ligaments, which force the group to function more as a unit. No intermetatarsal ligaments exist between the first and second MTs, which is why they often exhibit divergent behavior. The weaker dorsal ligaments explain the majority of dorsal dislocations. The Lisfranc ligament originates from the plantar lateral aspect of the medial cuneiform and attaches to the plantar medial aspect of the second MT base. It is the thickest of the ligaments in this region, measuring up to 1 cm wide. This ligament provides the only soft-tissue link between the medial ray and the lesser MT and is responsible for this area's stability. Motion at the TMT joints is variable. The second and third joints are the stiffest, with minimal motion in the dorsal/plantar plane and none in the medial or lateral plane. The third and first TMTs exhibit progressively more motion in both planes but still are relatively stiff and mainly function as areas of adjustment to allow the MT heads to share weight equally. The lateral 2 TMT joints demonstrate roughly 3 times more motion in the dorsal or plantar plane than does the first TMT joint. That motion is significant in the function of the foot and must be preserved to maintain normal function, especially if stiffness occurs in the medial and middle columns. In the column theory, the middle column is more important for rigidity, and the medial and lateral columns are more important for shock absorption during gait. The lateral joints are more important for their mobile contributions to the balancing of forefoot weight bearing. This principle is important in treating these injuries. CONTRAINDICATIONSSection 5 of 12
Anatomic alignment is important for stable function, but the risk of infection and soft-tissue compromise may preclude surgery until the tissues stabilize. Patients with open injuries or vascular compromise should be approached carefully. A delayed fusion of the medial 3 TMT joints can be performed if pain persists with weight bearing. WORKUPSection 6 of 12
Lab StudiesAlthough there are no specific lab studies for Lisfranc injuries, the clinician should be acutely aware of those patients who may be at high risk for subtle injuries, such as undiagnosed diabetics who have decreased sensation in their feet. Imaging StudiesLisfranc injuries, especially subtle injuries, can often be missed.9 Up to 20% of Lisfranc injuries are missed on initial presentation to the emergency department (ED).10 Often, the initial radiograph is normal, particularly in athletes with only a first- or second-degree sprain. In a study by Sherief and colleagues, 8 of the 9 clinicians who participated in the study missed a subtle Lisfranc injury in a diabetic neuropathic foot, and only 61% of the Lisfranc injuries in the study were accurately diagnosed by all of the clinicians.11
Other TestsMagnetic resonance imaging (MRI)
Bone scan
Diagnostic ProceduresWith an ankle block or intravenous sedation, stress the foot under fluoroscopic examination with pressure on the medial forefoot, pushing laterally while the hindfoot is pushed medially. An AP view of the TMT joints reveals any significant instability (see Images 7-8). Histologic FindingsIntra-operative findings that suggest a possible pathologic process should be sent to pathology for accurate diagnosis. StagingIn athletic injuries, Nunley and Vertullo suggested a 3-stage diagnostic classification, as follows12:
TREATMENTSection 7 of 12
Medical TherapyMedical treatment is reserved for injuries that are anatomically stable and nondisplaced. This type of injury is best labeled as a sprain, although associated fractures in the surrounding bone may be present (eg, MT fracture). An athlete with a stable Lisfranc injury usually cannot compete for the remainder of the season. Early return to high-level activity can lead to chronic pain and progressive arthropathy. Therefore, athletes should be given special consideration. Initial treatment should consist of a well-molded, non–weight-bearing, short leg cast worn for a minimum of 6 weeks. Advancement of ambulation depends on resolution of symptoms. Because many of these injuries initially present with midfoot edema that may help to stabilize damaged tissues, all stable injuries should be re-examined approximately 2 weeks following injury. Obtain weight-bearing radiographs at 4-6 weeks to ensure continued anatomic alignment. After 6 weeks, progressive weight bearing can be allowed in a well-molded cast, advancing as comfort allows. When full weight bearing in a cast is comfortable, the patient can be advanced to a supportive shoe and reconditioning. The patient can be advanced to an accommodative orthotic with a contoured carbon shank so as to minimize midfoot stress. Combined closed reduction and casting has no role in the treatment of unstable injuries. Constantly maintaining reduction with casting alone has proven to be too difficult. In addition, interposing soft tissues can impede closed reduction. For example, the anterior tibial tendon can block reduction of a lateral Lisfranc dislocation; similarly, the peroneus brevis tendon can block a medial dislocation reduction. Surgical TherapyAll injuries that are displaced and unstable require surgery. Complete assessment of the intercuneiform and cuboid integrity is important when determining stability. Clinical outcome is highly dependent on restoration of normal anatomic alignment. Present recommendations for treatment consist of open reduction of the unstable area, as well as rigid fixation, with an option in terms of the screws employed, such as 3.5-mm cortical screws or 4.0-4.5 cannulated screws (depending on the size of the bone). Multiple Kirschner wires (K-wires) also have been advocated, but maintaining reduction with them is more difficult (see Image 9). In fact, screw fixation has been shown to have significantly greater biomechanical stability than does K-wire fixation.13 Presentation variations
Preoperative DetailsOften, surgery should be delayed until excessive swelling has resolved, because swelling places the soft tissues at risk. Supine position with a thigh or ankle tourniquet is recommended. Be aware of and ready to address all injuries present before beginning surgery. Intraoperative DetailsA 2-incision approach works best for complete visualization. The medial incision is in line with the first webspace. The branches of the superficial peroneal nerve are identified and protected. The muscle belly of the extensor hallucis brevis covers the neurovascular bundle. Identify and protect the deep peroneal nerve, dorsalis pedis artery, and extensor tendons. Once the area of the second TMT joint is reached, perform subperiosteal dissection across the Lisfranc joint to minimize damage to soft-tissue structures. If needed, a second incision is based over the lateral border of the third MT and is carried distally. The extensor digitorum brevis is divided bluntly, and the TMTs are entered subperiosteally. In this region, the third, fourth, and fifth TMT joints literally are one on top of the other and are easily visualized. With the tarsus stabilized and the joints inspected, reduction usually is easy. The author finds it easiest to reduce the medial column first, by placing a provisional wire across the first TMT joint and, if necessary, a provisional wire between the first and second cuneiform. If acceptable, appropriate cannulated screws are then placed. The second part of the procedure is connecting the medial and middle columns. A cannulated screw is placed across the medial cuneiform to the base of the second MT so as to reduce the Lisfranc diastasis. Other authors suggest starting with the second MT to medial cuneiform fixation. A large, pointed bone-reduction clamp can be used to hold the reduction while screws are placed. The position of the fixation screws is depicted in Image 15. Because no real tissue layers are present at this level of the foot, wound closure can be accomplished with an absorbable suture to close joint capsules and a nonabsorbable suture in using a vertical or horizontal mattress technique to close the skin. Postoperative detailsImmediately postoperatively, the authors recommend a well-padded posterior splint until swelling subsides in 1-2 weeks. At that time, the splint can be converted to a non–weight-bearing, short leg cast if swelling permits. Immobilization in a cast is up to 3 months. The period of time that screws should remain is controversial, as is the question of whether weight bearing should be permitted before screws are removed. Physicians agree that screws across viable joints should be left in no longer than 6 months from the time of surgery. Some advocate that no weight bearing be allowed until the screws are removed, at 3 months after surgery. Follow-up
COMPLICATIONSSection 8 of 12
The following factors can be considered complications of this injury:
Along this joint line, continued chronic pain with weight bearing is best treated with fusion of the first, second, and third TMT joints in an anatomically correct position. With realignment and stabilization of the medial joints, laterally based pain usually subsides. Treat persistent lateral pain following realignment of the medial joints with interposition arthroplasty rather than fusion. This is best performed using a segment of extensor digitorum brevis tendon rolled up and interposed into the debrided joint. This allows continued motion and prevents the compressive bony contact that generates the pain (see Images 19-22). OUTCOME AND PROGNOSISSection 9 of 12
Stable anatomic alignment is the best predictor of outcome. The presence of fractures and/or articular destruction leads to poorer results, regardless of alignment. Incidence of posttraumatic arthritis reportedly ranges from 0-58%.14 One study reported that up to 25% of patients develop posttraumatic arthritis even after fixation. This same study showed that there was no difference between acute and delayed (>6 weeks) surgical fixation. Purely ligamentous injuries seemed to have poorer outcomes. Good results are achieved with open reduction and internal fixation (ORIF) at up to 6 weeks, but poor outcomes are seen after this time due to articular destruction, malalignment, and poor soft-tissue envelope. FUTURE AND CONTROVERSIESSection 10 of 12
Role of acute fusion Stability at this joint level of the foot is the primary concern, and instability appears to be the primary pain generator. Primary fusion of the medial 3 TMT joints has been advocated due to the unpredictability of adequate ligamentous healing to support the foot. Length of time before screw removal Suggestions of length of time that screws should remain in place range from 6 weeks to 3 months after weight bearing begins (up to 6 months from the time of surgery). Results demonstrate that if fixation screws remain in place indefinitely, they have a high tendency to break with time, thereby causing pain. If the joint is not fused purposely during surgery, then some motion is expected; this constant motion causes hardware failure. The timing of screw removal remains a question. Advocates of early removal stress the fear of early screw failure as the main reason for removal. Others believe that the screws should remain in place even during early weight bearing to slowly help condition the damaged ligaments to resume supporting the foot. Long-term follow-up is needed before this issue can be resolved. Use of different bio-absorbable materials The advantage of using different bio-absorbable materials to provide short-term stability following surgical reduction is that no screws need to be removed. Issues are 2-fold:
MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Lisfranc Fracture Dislocation excerpt Article Last Updated: Jun 16, 2008 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
