Lisfranc Injury

LISFRANC INJURY

TARSOMETATARSAL FRACTURE DISLOCATION

Anatomy of Lisfranc complex

• base of II metatarsal acts as key stone
• medial and lateral cuneiforms provide support on either side of base of II MT, locking it in place
• other 4 MT have little bony support
• plantar ligaments are stronger than weak dorsal tarsometatarsal ligaments and joint capsule
• Lisfranc ligament : strong ligament from base of lateral aspect of medial cuneiform to base of II MT
• any injury to Lisfranc complex – results in long term morbidity

Etiology

• rare injury – more in RTA and sports
• 20% missed initially

Mechanism

• direct
  • trauma to joint complex along dorsal surface
  • crush injury/ weight falling on foot
• indirect
  • more common
  • disruption of whole complex
  • longitudinal loading of a plantar flexed foot

Classification

Myerson's modification of Quenu and Kuss of Lisfranc injury not prognostic – useful for communication
Type A : homo lateral displacement of all 5 MT as a single unit with or without # of base of II MT lateral or dorsoplanar displacement
Type B	One or more articulations remain intact
	B1	Medially displaced – involve intercuneiform or naviculocuneiform joint
	B2	Laterally displaced – involve I metatarsocuneiform joint
Type C	Divergent injuries high energy injuries prone to compartment syndrome and other complications
	C1	Partial
	C2	Complete

Clinical features

• inability to bear weight
• mid foot tenderness and edema – each tarsometatarsal joint should be palpated for tenderness
• Rotation test
  • II tarsometatarsal joint is stressed by elevating and depressing II MT head – pain at Lisfranc joint
• ecchymosis in foot
• associated # - MC is II Metatarsal# - also cuboid #, cuneiform#, other metatarsal#

Radiology

• weight bearing view should be taken
• normal alignment of metatarsal base with tarsal bone should be observed

• I metatarsal : medial cuneiform
• II metatarsal : intermediate cuneiform
• III metatarsal : lateral cuneiform
• IV and V metatarsal : cuboid

• evaluation
  1. medial border of II metatarsal in line with medial border of intermediate cuneiform – AP view
  2. medial border of IV metatarsal in line with medial border of cuboid – oblique view
  3. I metatarsal medial cuneiform articulation should be congruent
  4. avulsion of Lisfranc ligament - fleck sign in medial cuneiform II metatarsal space
  5. naveculo cuneiform articulation evaluated for subluxation
  6. compression # of cuboid

• CT scan not routinely indicated

Treatment

• anatomical alignment of involved joints
• closed, undisplaced (<2mm) injuries
  • non weight bearing cast x6 wks
  • weight bearing cast x next 6 wks
  • repeat radiographs to check displacement
• displaced #
  • closed reduction and fixation with cancellous screws under image control
  • if closed reduction inadequate – open reduction – esp. in Type B partial injuries and Type C (divergent) injuries
• missed or delayed diagnosis
  • attempt anatomical reduction and stabilization x 6 wks
  • if fails / reduction difficult : medial column fusion in symptomatic cases

Complications

• Compartment syndrome
  • rare
  • seen in high energy injuries
  • long medial incision to decompress deep compartments of foot
  • double dorsal incision : to decompress all four compartments – fixation also through same incision
• Degenerative post traumatic arthrosis

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