Tarsometatarsal Joint Injection

Other Names

• Tarsometatarsal Joint Injection
• Lisfranc Joint Injection

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Background

Joints of the foot

Key Points

• Needle: 25 gauge, 1.5 inch
• Transudcer: high frequency, linear
• Need to identify and avoid dorsalis pedis artery

Anatomy of the Lisfranc Joint

• Characterized by the transition from the midfoot to the forefoot
• Proximal articulation: 3 [[cuneiforms, cuboid
• Distal articulation: 1 - 5 metatarsals
• Second metatarsal acts as the keystone between the medial and lateral cuneiforms
• Connected by Lisfranc Ligamentous Complex, which includes the notorious Lisfranc Ligament
• Dorsalis pedis artery crosses the joint, dives between the first and second metatarsals

Palpation Guidance vs Ultrasound Guidance

• The tarsometatarsal joint can not be reliably injected blindly
• Plapation guided injections have a success rate of 21 to 29%
• Khosla found ultrasound guided injections were succesful 64% of the time, fluoroscopic 89%

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Indications

• Lisfranc Injury
• Charcot Joint
• Tarsometatarsal Joint Pain

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Contraindications

• Absolute
  • Anaphylaxis to injectates
  • Overlying cellulitis, skin lesion or systemic infection
• Relative
  • Can be treated with less invasive means
  • Hyperglycemia or poorly controlled diabetes
  • Lack of symptom improvement with previous injection

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Procedure

Approximate transducer position for long axis, out of plane approach on the medial side

Ultrasound view of the tarsometatarsal joint in long axis

Out of plane approach with needle trajectory marked

Equipment

• Sterile prep (i.e. chloraprep, chlorhexidine, iodine, etc)
• Gloves
• Needle: typically 21-25 gauge, 1.5 inch
• Syringe: 5-10 mL
• Gauze
• Ethyl Chloride
• Bandage
• Injectate
  • Local anesthetic
  • Corticosteroid
• Sterile probe cover

Ultrasound Findings

• Use the high frequency linear transducer, typically depth less than 3 cm
• Common ultrasound findings include:
  • Fracture or dislocation
  • Cortical irregularities
  • Joint effusion
  • Ligamentous laxity or disruption

Ultrasound Guided Technique: Long Axis, Out of Plane

• Patient Position
  • The patient is supine
  • Foot flat on table with knee flexed
• Transducer Position
  • Long axis to the foot
• Needle Approach/ Orientation
  • Out of plane
  • Medial to Lateral
• Target
  • Mid portion of tarsometatarsal Joint
• Pearls and Pitfalls
  • Critical to identify and avoid the dorsalis pedis artery pre procedurally
  • The safest place to do this is between the first cuneiform and first metatarsal

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Aftercare

• Motor exam should be intact
• No major restrictions in most cases
• Can augment with ice, NSAIDS
• Consider Ankle Compression Sleeve

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Complications

• Infection
• Damage to surrounding tissue

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See Also

• Procedures Main
• Ultrasound Main
• Ankle Pain Main

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