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Lisfranc Injury

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Other Names

  • Lisfranc Sprain
  • Lisfranc Fracture
  • Lisfranc Fracture-Dislocation
  • Tarsometatarsal dislocation

Background

History

  • The injury is named after Jaques Lisfranc de Saint-Martin, a French army field surgeon[1]
    • He described a traumatic amputation through the midfoot in 1815

Epidemiology

  • Incidence
    • They affect approximately 1 in every 55,000 people in the United States (need citation)
  • Prevalence
    • Comprise 0.2% of all fractures (need citation)
    • Up to 20% are missed initially, particularly in low-energy or polytrauma situations[2]
    • 87.5% are closed injuries[3]
  • Demographics
    • Men are 4 fold more likely than women[4]
    • Most common in 3rd decade of life

Pathophysiology

Lisfranc joint cross section with the dorsal, interosseous, and plantar oblique ligaments[5]
  • 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

Etiology

  • High energy mechanism
    • Most commonly occur from direct trauma, high energy forces
    • Most commonly, falls from height and road traffic accidents[6]
    • 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[7]
      • 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:[8]
    • Motor vehicle accidents (43%)
    • Falls from heights (24%)
    • Crush injuries (13%)
    • Sports injuries (9.7%)

Associated Conditions

Pathoanatomy


Risk Factors

  • Reported in Sports
    • Basketball
    • Football
    • Rugby
    • Soccer
    • Gymnastics[9]
    • Horseback riding[10]
    • Windsurfing
    • Baseball
    • Ballet
    • Running

Differential Diagnosis


Clinical Features

Plantar ecchymosis is highly suggestive of a lisfranc injury[4]
  • History
    • 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[11]
    • 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)[12]
    • 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

Evaluation

Proposed treatment protocol injuries of the Lisfranc joint[4]

Radiographs

  • Standard Radiographs Foot
    • First line imaging is 3 views (AP, oblique, lateral)
    • AP radiographs with the beam 15° off the vertical plane gives an on-profile view of the TMT joints
    • Sensitivity of standard views is 84.4%[13]
    • Up to 20% of unstable Lisfranc injuries are misdiagnosed on initial plain radiographs[14]
  • 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[15]
Anteroposterior weight-bearing radiograph of the midfoot shows a small chip fracture (arrow) from the medial margin of the M2 base, a finding called the fleck sign[16]

CT

  • Indications
    • If suspicious with inconclusive radiographs
    • May be help for surgical planning
    • Useful to identify non displaced fractures, minimal osseous subluxation[17]
  • Advantages over radiographs
    • Reveal 60% more metatarsal fractures, twice as many tarsal fractures and joint malalignments[18]

MRI

  • Indications
    • Particularly useful in subtle lisfranc injuries
  • Best at evaluating soft tissue injuries
  • Diagnostic value
    • 90% sensitive when compared to intra-operative findings[19]

Classification

Nunley and Vertillo Classification

  • System for low energy, subtle lisfranc injuries[20]
  • 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

Management

Nonoperative

  • Indications
    • Non-displaced, stable injuries
    • Nunley and Vertillo stage 1
  • Immobilization
  • 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

Operative

  • Indications
    • Isolated ligamentous injury
    • Fractures
    • Dislocations
    • Missed diagnosis or inadequately treated
  • Technique
    • Arthrodesis
    • Open reduction, internal fixation

Rehab and Return to Play

Rehabilitation

  • Post-operative
    • 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

Prognosis

  • Overall outcomes
    • If a high-quality reduction is obtained, 85% to 93% of patients report good to excellent outcomes[21][22]
  • Nonoperative management
    • Patients can generally expect full recovery and return to activity with minimal long-term implications[23]
  • Missed diagnosis/ Inadequately treated
    • Poor result with persistent pain, activity limitations, and progressive post-traumatic arthritis in the involved joints[24]
    • Generally require arthrodesis as salvage[25]
  • 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[26]
    • Deol et al found 16/17 professional soccer and rugby players returned to sport between 20 and 25 weeks[27]
      • 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[28]
      • 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[29]
      • 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

Complications


See Also


References

  1. Cassebaum, WH. Lisfranc fracture-dislocations. Clin Orthop Relat Res. 1963;30:116-129.
  2. Perron, AD, Brady, WJ, Keats, TE. Orthopedic pitfalls in the ED: Lisfranc fracture-dislocation. Am J Emerg Med. 2001;19:71-75.
  3. Benirschke SK, Meinberg E, Anderson SA, Jones CB, Cole PA. Fractures and dislocations of the midfoot: Lisfranc and Chopart injuries. J Bone Joint Surg [Am] 2012;94(14):1325–1337.
  4. 4.0 4.1 4.2 Moracia-Ochagavia, I, Rodriguez-Merchan, EC. Lisfranc fracture-dislocations: current management. EFORT Open Rev. 2019;4:430-444.
  5. Chen, Jie, Navraj Sagoo, and Vinod Kumar Panchbhavi. "The Lisfranc Injury: A Literature Review of Anatomy, Etiology, Evaluation, and Management." Foot & Ankle Specialist (2020): 1938640020950133.
  6. Haapamaki, Ville, Martti Kiuru, and Seppo Koskinen. "Lisfranc fracture-dislocation in patients with multiple trauma: diagnosis with multidetector computed tomography." Foot & ankle international 25.9 (2004): 614-619.
  7. Jeffreys, T. E. "Lisfranc's fracture-dislocation." The Journal of bone and joint surgery. British volume 45.3 (1963): 546-551.
  8. Lievers, WB, Frimenko, RE, Crandall, JR, Kent, RW, Park, JS. Age, sex, causal and injury patterns in tarsometatarsal dislocations: a literature review of over 2000 cases. Foot (Edinb). 2012;22:117-124.
  9. Chilvers M, Donahue M, Nassar L, et al. Foot and ankle injuries in elite female gymnasts. Foot Ankle Int 2007;28:214.
  10. Ceroni D, De Rosa V, De Coulon G, et al. The importance of proper shoe gear and safety stirrups in the prevention of equestrian foot injuries. J Foot Ankle Surg 2007;46:32.
  11. Shapiro, Matthew S., Daniel C. Wascher, and Gerald AM Finerman. "Rupture of Lisfranc's ligament in athletes." The American journal of sports medicine 22.5 (1994): 687-691.
  12. Ross, Glen, et al. "Plantar ecchymosis sign: a clinical aid to diagnosis of occult Lisfranc tarsometatarsal injuries." Journal of orthopaedic trauma 10.2 (1996): 119-122.
  13. Rankine, James J., et al. "The diagnostic accuracy of radiographs in Lisfranc injury and the potential value of a craniocaudal projection." American Journal of Roentgenology 198.4 (2012): W365-W369.
  14. Goossens M, DeStoop N. Lisfranc’s fracture-dislocations: etiology, radiology, and results of treatment. Clin Orthop Relat Res. 1983;176:154–162.
  15. Safavi, PS, Weiss, W, Panchbhavi, V. Gravity stress radiograph revealing instability at the first metatarso-cuneiform joint in Lisfranc injury. Cureus. 2017;9:e1015.
  16. Siddiqui, Nasir A., et al. "Evaluation of the tarsometatarsal joint using conventional radiography, CT, and MR imaging." Radiographics 34.2 (2014): 514-531.
  17. Sripanich, Yantarat, et al. "Imaging in Lisfranc injury: a systematic literature review." Skeletal radiology 49.1 (2020): 31-53.
  18. Preidler, KW, Peicha, G, Lajtai, G, et al. Conventional radiography, CT, and MR imaging in patients with hyperflexion injuries of the foot: diagnostic accuracy in the detection of bony and ligamentous changes. AJR Am J Roentgenol. 1999;173:1673-1677.
  19. Raikin, Steven M., et al. "Prediction of midfoot instability in the subtle Lisfranc injury: comparison of magnetic resonance imaging with intraoperative findings." JBJS 91.4 (2009): 892-899.
  20. Nunley, James A., and Christopher J. Vertullo. "Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete." The American journal of sports medicine 30.6 (2002): 871-878.
  21. Kuo, RS, Tejwani, NC, Digiovanni, CW, et al. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am. 2000;82:1609-1618.
  22. Arntz, CT, Veith, RG, Hansen, ST Fractures and fracture-dislocations of the tarsometatarsal joint. J Bone Joint Surg Am. 1988;70:173-181.
  23. Meyer SA, Callaghan JJ, Albright JP, et al. Midfoot sprains in collegiate football players. Am J Sports Med. 1994;22:392–401. doi: 10.1177/036354659402200316.
  24. Curtis M, Myerson M, Szura B. Tarsometatarsal injuries in the athlete. Am J Sports Med. 1994;21:497–502. doi: 10.1177/036354659302100403.
  25. Sangeorzan BJ, Veith RG, Hansen ST. Salvage of Lisfanc’s tarsometatarsal joints by arthrodesis. Foot Ankle Int. 1990;4:193–200. doi: 10.1177/107110079001000401.
  26. MacMahon A, Kim P, Levine DS, Burket J, Roberts MM, Drakos MC, Deland JT, Elliott AJ, Ellis SJ. Return to sports and physical activities after primary partial arthrodesis for Lisfranc injuries in young patients. Foot Ankle Int. 2016;37:355–362.
  27. Deol RS, Roche A, Calder JD. Return to training and playing after acute Lisfranc injuries in elite professional soccer and rugby players. Am J Sports Med. 2016;44:166–170.
  28. McHale KJ, Rozell JC, Milby AH, Carey JL, Sennett BJ. Outcomes of Lisfranc injuries in the National Football League. Am J Sports Med. 2016;44:1810–1817.
  29. Dubois-Ferriere V, Lübbeke A, Chowdhary A, Stern R, Dominguez D, Assal M. Clinical outcomes and development of symptomatic osteoarthritis 2 to 24 years after surgical treatment of tarsometatarsal joint complex injuries. J Bone Joint Surg Am. 2016;98:713–720.
Created by:
John Kiel on 7 July 2019 08:11:28
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Last edited:
4 October 2022 12:38:00
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