- 1 Other Names
- 2 Background
- 3 Pathophysiology
- 4 Risk Factors
- 5 Differential Diagnosis
- 6 Clinical Features
- 7 Evaluation
- 8 Classification
- 9 Management
- 10 Rehab and Return to Play
- 11 Complications and Prognosis
- 12 See Also
- 13 References
- Lisfranc Sprain
- Lisfranc Fracture
- Lisfranc Fracture-Dislocation
- Tarsometatarsal dislocation
- This page refers to injuries to the Lisfranc Joint
- The injury is named after Jaques Lisfranc de Saint-Martin, a French army field surgeon
- He described a traumatic amputation through the midfoot in 1815
- They affect approximately 1 in every 55,000 people in the United States (need citation)
- Men are 4 fold more likely than women
- Most common in 3rd decade of life
- Lisfranc Injury Definition
- refer to bony or ligamentous compromise of the tarsometatarsal and intercuneiform joint complex
- Encompasses a broad spectrum of injuries with varying severity from ligamentous sprains to high energy comminuted fracture pattern
- High energy mechanism
- Most commonly occur from direct trauma, high energy forces
- Most commonly, falls from height and road traffic accidents
- Direct crush or significant impact to the midfoot leading to fractures and dislocations of the tarsometatarsal joints
- Not associated with any specific fracture pattern
- Greater risk risk for complications such as open injury, compartment syndrome, wound dehiscence, and vascular disruptions
- Low energy mechanism
- Less commonly due to indirect trauma and low energy forces
- One mechanism occurs from plantarward bending of the metatarsal or a plantarflexed foot associated with a rotational or axial load
- The axial force results in hyperplantarflexion of the foot, causing a tension failure of the weak dorsal ligaments
- Subsequently, a fracture of the plantar metatarsal base or rupture of the plantar capsule allows the metatarsal bases to dorsally displace
- Another mechanism involves abduction injuries where the forefoot is suddenly adducted relative to a fixed hindfoot, such as when falling off a horse with foot in stirrup
- Can lead to a transverse pattern of injury in which the second metatarsal base may fracture and the lesser metatarsals displace laterally
- Lievers et al review of 2000 cases found:
- Motor vehicle accidents (43%)
- Falls from heights (24%)
- Crush injuries (13%)
- Sports injuries (9.7%)
- Lisfranc Joint
- Joint that articulates the midfoot and forefoot creating the tarsometatarsal joints
- Formed by the three cuneiform bones, cuboid proximally with the five metatarsal bases distally
- Ligament complex anchors the joint
- Lisfranc ligament disruption alters stability within the medial and middle columns of the foot
- Reported in Sports
- Fractures & Osseous Disease
- Traumatic/ Acute
- Stress Fractures
- Other Osseous
- Dislocations & Subluxations
- Muscle and Tendon Injuries
- Ligament Injuries
- Clinical presentation can vary wildly
- It is important to characterize the details of the mechanism
- Most patients have swelling and pain in the midfoot
- Mild injuries may present with painful weightbearing, midfoot swelling
- Weight bearing is difficult
- Physical Exam
- In acute setting, pain and swelling may limit exam
- Plantar ecchymosis, swelling can be seen and should raise suspicion (even with normal radiographs)
- The midfoot is typically tender
- Sensation may be altered in the back of the first inter-metatarsal space
- Positive Gap: Increase in distance between the first and second toes due to intercuneiform instability
- Passive range of motion is painful
- Passive abduction of the midfoot while stabilizing the transverse tarsal joint may elicit symptoms
- Special Tests
- Piano Key Test Foot: move the head of the affected metatarsal while holding the midfoot firm
- Standard Radiographs Foot
- Potential findings
- Loss of alignment between the medial edge of the second metatarsal and the medial edge of the second cuneiform bone
- Loss of alignment between the medial border of the cuboid bone and the medial border of the fourth metatarsal
- ‘Fleck sign’ a small bony fragment in the first inter-metatarsal space, signifies the avulsion of the Lisfranc ligament.
- Diastasis of >2 mm between the base of the first and second metatarsals on the AP view
- Dorsal/plantar displacement of metatarsal on lateral view
- Loss of alignment with the dorsal and plantar cortices of the metatarsals and the cortices of the articulating cuneiforms and cuboid
- Weight bearing radiographs
- Indicated if <2 mm displacement on non weight bearing imaging (>2 mm is considered unstable)
- Compare to contralateral, unaffected foot
- If further displacement on these films, the injury is classified as unstable
- If no further displacement, classified as stable
- Can be difficult to obtain in the acute setting, consider under anesthesia
- Gravity stress radiograph
- Nonweightbearing lateral image may at times reveal dorsal gapping at the first metatarso-cuneiform joint
- If suspicious with inconclusive radiographs
- May be help for surgical planning
- Useful to identify non displaced fractures, minimal osseous subluxation
- Advantages over radiographs
- Reveal 60% more metatarsal fractures, twice as many tarsal fractures and joint malalignments
- Particularly useful in subtle lisfranc injuries
- Best at evaluating soft tissue injuries
- Diagnostic value
- 90% sensitive when compared to intra-operative findings
Nunley and Vertillo Classification
- System for low energy, subtle lisfranc injuries
- Stage 1
- Unable to participate in sport
- Pain at the region of the Lisfranc ligament complex
- Injury was undisplaced on weight-bearing radiographs
- Stage 2
- First to second metatarsal bone diastasis of 1–5 mm on an AP weightbearing radiograph
- No evidence of a loss of midfoot arch on a lateral weightbearing radiograph.
- Stage 3
- First to second metatarsal diastasis of greater than 5 mm on an AP weightbearing radiograph
- Loss of midfoot arch height, as evidenced by a decreased distance between the fifth metatarsal and medial cuneiform bones
Hardcastle & Myerson Classification
- Type A: Complete homolateral dislocation
- Type B1: Partial injury, medial column dislocation
- Type B2: Partial injury, lateral column dislocation
- Type C1: Partial injury, divergent dislocation
- Type C2: Complete injury, divergent dislocation
- Non-displaced, stable injuries
- Nunley and Vertillo stage 1
- Weight bearing status
- Non weight bearing for 6-8 weeks
- If still having pain, consider a Walking Boot for further 4-6 weeks
- In most cases, can transition to regular shoe after about 6 weeks
- Can consider soft orthotic, compression stocking for comfort where needed
- Physician should perform serial radiographs every 2 weeks
- This is important to ensure there is no delayed displacement or diastasis
- Isolated ligamentous injury
- Missed diagnosis or inadequately treated
- Open reduction, internal fixation
Rehab and Return to Play
- 6-8 weeks: the foot is typically immobilized in a cast or boot , after which point weightbearing can begin
- 12 weeks: back to a normal shoe, arch support, initiate formal physical therapy
Return to Play/ Work
- Needs to be updated
Complications and Prognosis
- Overall outcomes
- Nonoperative management
- Patients can generally expect full recovery and return to activity with minimal long-term implications
- Missed diagnosis/ Inadequately treated
- Return to sport/ play following surgery
- McMahon followed 38 athletes and found compared to pre-injury, 75% of patient had the same or improved levels of participation, 66% returned to the same level of difficulty
- Deol et al found 16/17 professional soccer and rugby players returned to sport between 20 and 25 weeks
- Soccer players returned faster than rugby players; those with ligamentous injuries returned significantly faster than those with bony injuries.
- McHale followed 28 soccer players and found 93% were able to return to play at 11 months
- Although athletic performance declined among these players, it was not statistically different from the control group
- Dubois-Ferriere et al. retrospectively reviewed 61 patients with Lisfranc injuries treated surgically over a 21-year period
- Most patients were able to return to their previous level of function and employment
- 72% had radiographic evidence of post-traumatic arthritis; 54% were symptomatic
- Predictors of poor outcome (need citation)
- Delays in treatment
- Open injuries
- Articular comminution
- Worker’s compensation injuries
- Purely ligamentous injuries
- Acute Compartment Syndrome
- Foot Osteoarthritis
- Inability to return to sport
- Midfoot sag
- Sports Medicine Review Foot Pain: https://www.sportsmedreview.com/by-joint/foot/
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