LISFRANC INJURIES

1
LISFRANC INJURIES

• James M. Steinberg, D.O.
• Garden City Hospital

2
Historical Perspective

• Tarsometatarsal joints
• Fracture-Dislocations
• Named for Napoleons surgeon
• Dr. Lisfranc
• Injury was common in cavalry troops
• Due to design of the stirrup
• Severe vascular complications
• Amputation was performed

3
Etiology

• Injuries to tarsometatarsal joints of the midfoot
  constitute 0.2 of all skeletal fxs
• As many as 20 of these injuries have been
  reported to have been missed initially
• Myerson et al. reported a 4 incidence per year
  in collegiate football players
• Five tarsometatarsal joints are very stable
  immobile
• Usually sustain acute injuries from high-energy
  forces

4
Mechanism of Injury

• MVA
• Industrial accidents
• Sports injuries
• Football direct axial loading onto the heel of
  a foot fixed in equinus
• Equestrian rider gets foot caught in stirrups
  while falling from horse
• Wind surfing straps to allow for pivoting cross
  midfoot, similar to stirrups
• Running/Walking foot caught in hole or mis-step
  off a curb, excessive ankle equinus

5
Mechanism of Injury
6
Anatomy

• Lisfrancs joint
• Key to the transverse arch of the foot
• Lisfrancs ligament attaches the medial cuneiform
  to the base of the 2nd metatarsal
• Continued ligamentous support linking the bases
  of the 2nd-5th metatarsals
• No ligamentous connection between the 1st and 2nd
  metatarsals
• Allows for frequently seen divergent injury
• Dorsalis pedis dives between bases of 1st 2nd

7
Anatomy

• 2nd MT is recessed between the medial and lateral
  cuneiforms
• Keystone mortise that greatly adds stability in
  transverse plane

8
Anatomy

• Cuneiform, tarsal bones, and medial 3 MT bases
• Have a trapezoidal configuration that is wider on
  the dorsal aspect
• Effect of a Roman arch resisting collapse

9
Physical Exam

• Diagnosis requires high index of suspicion
• Midfoot swelling tenderness
• Often in patients with polytrauma
• Vascular status
• Assess soft tissues
• Open fx
• Degloving injuries
• Monitor for compartment syndrome

10
Radiographic Evaluation

• AP, lateral, and oblique films
• Medial border of the 2nd MT should line up with
  the medial border of the middle cuneiform on the
  AP
• Medial border of the 4th MT should line up with
  the medial border of the cuboid on the oblique
• No displacement on the lateral, piano key
• Flake fxs of the base of the 2nd, no matter how
  innocent, are pathonemonic for Lisfranc disruption

11
Radiographic Evaluation

• Stress views in less obvious but suspected cases
• Performed under anesthesia
• Forefoot is held in abduction on AP in plantar
  flexion on the lateral
• CT scans
• Useful in evaluating comminution of
  tarsometatarsal joints and subtle malalignments
• MRI
• Can identify ligamentous damage
• Does NOT offer any significant advantage to
  determine treatment

12
Classification

• Quenu Kuss
• Homolateral all five metatarsals displaced in
  same direction
• Isolated one or two metatarsals displaced in
  same direction
• Divergent metatarsals displaced in both the
  sagittal and coronal planes

13
Classification

• Myerson
• Total incongruity lateral dorsoplantar
• Partial incongruity medial lateral
• Divergent partial and total

14
Treatment

• Operative treatment is indicated for displacement
  gt 2mm of the TMT joint
• Some argue for ORIF regardless of displacement
• Key to successful outcome is anatomic alignment
• ORIF can be attempted as late as 8 weeks after
  injury for pts lt 160 lbs gt160lbs arthrodesis of
  medial three joints
• lt 2mm of displacement
• NWB SLC for 6 weeks
• WB SLC for an additional 4 to 6 weeks
• Follow closely with repeat radiographs to ensure
  no displacement has occurred

15
Treatment

• Reduction is easiest if performed within 4 6
  hours
• Restoration of circulation is critical for soft
  tissue healing
• Compartment syndrome
• Four fascial compartments
• Long medial incision to decompress abductor
  hallucis deep compartments
• Two dorsal incisions betw 2nd 3rd and betw 4th
  5th to decompress dorsal intrinsic compartments
  
• Extensive vascular compromise
• Midfoot level amputation

16
Fascial Decompression
17
Closed Reduction

• Spinal or general anesthesia
• Modified finger traps to great toe and one or two
  adjacent toes
• Longitudinal traction with 5 to 10 lbs
• Manipulate foot within 5 minute period in either
  inversion or eversion
• Rarely palpable or audible reduction
• Verify reduction on fluoroscopy
• Maintain reduction with Steinmann pins/cannulated
  screws
• Final routine radiographs PRIOR to leaving OR

18
ORIF

• Dorsal incision lateral to EHL in the interval
  between the 1st 2nd MT
• Isolate dorsalis pedis deep peroneal nerve
• Inspect Lisfranc ligament
• Reduce cuneiforms if needed
• Steinmann pin followed by cannulated screw
• Guide wire/drill medial cuneiform to base 2nd MT
• Continue fixation as needed to restore anatomic
  alignment
• Multiple constructs
• 1st MT to medial cuneiform
• Cuboid to base of 5th MT

19
Surgical Exposure
20
Fixation
21
Post Operative Care

• Bulky dressing with posterior splint
  postoperatively
• NWB SLC at 7-10 days postop
• PWB at 6-8 weeks
• Laterally placed steinmann pins removed at 8
  weeks
• Medial screws removed at 4 months

22
Conclusions

• Commonly missed injury
• Lisfranc joint disruption should be suspected
  with flake fxs at base of 2nd MT
• Anatomic reduction is essential
• Nearly all require fixation
• ORIF can be carried out with pins, screws or both
• Terrible injuries, especially if missed
• Debilitating foot pain