Lisfranc Injury - DNB Orthopaedics MS Orthopedics MRCS Exam GUIDE -

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Tuesday 6 February 2018

Lisfranc Injury


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

Image result for lisfranc
  • rare injury – more in RTA and sports
  • 20% missed initially
  • 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
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
Medially displaced – involve intercuneiform or naviculocuneiform joint
Laterally displaced – involve I metatarsocuneiform joint
Type C
Divergent injuries
  • high energy injuries
  • prone to compartment syndrome and other complications

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#
  • 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
  • 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

  • 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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