- See: Midfoot/Forefoot Fractures:
- Discussion:
-
anatomy of the midfoot:
-
mechanism:
- because 2nd metatarsal is the longest metatarsal proximally, it will often be frxed at its base,
with the other metatarsals dislocated;
- dorsal capsule of Lisfranc's joint, lacking sufficienct reenforcement, will to support the load and will
collapse, resulting in dorsal frx dislocation of the metatarsal bases;
- references:
-
Lisfranc joint injuries: trauma mechanisms and associated injuries.
-
Pediatric Lisfranc injury: "bunk bed" fracture.
-
Lisfranc Joint Injuries: Trauma Mechanisms and Associated Injuries.
-
classification:
- homo-lateral:
- all 5 metatarsals are displaced in the same direction;
- w/ lateral displacement look for
cuboid frx;
- isolated: one or two metatarsals are displaced from the others;
- divergent:
- metatarsals are displaced in saggital and coronal planes;
- look for extension into the intercuneiform area and
navicular frx;
-
diff dx and associated injuries:
-
longitudinal stress injuries;
- frx of base of second metatarsal;
-
cuboid frx;
-
navicular compression fractures;
-
rupture of posteior tib tendon;
-
compartment syndrome:
- prognosis:
- Lisfranc injuries w/o fracture have poor prognosis, with late midfoot collapse a common sequela;
-
metatarsalgia: may occur from displacement in the saggital plane;
-
posttraumatic arthritis and planovalgus deformity are common and may occur in upto 50%;
- however, x-ray findings may not correlate w/ clinical findings;
- w/ symptomatic posttraumatic arthritis, consider arthrodesis;
- Physical Exam:
- pain & swelling in midfoot w/ tenderness along Lisfranc's joint;
- tenderness w/ passive abduction &
pronation of forefoot w/ hindfoot held fixed in the examiner's opposite hand;
-
dorsalis pedis may be diminished or absent;
- always consider
compartment syndrome of the foot;
- Radiographs:
- fracture characteristics may be subtle;
- on non-stressed views, frx at base of 2nd metatarsal or anterior aspect of cuboid may most obvious
indications of Lisfranc injury;
- w/ questionable injury, consider wt bearing AP view to assess 1-2 interval;
- if standing AP is unacceptable to the patient then consider CT scan;
- intercuneiform region injuries: these may occur in upto 10-15 % of patients;
- lateral radiographs:
- lateral talometatarsal angle is formed by intersection of a line along the long axis of talus w/ long axis of 1st metatarsal and normally forms a straight line
- ref:
Prediction of Midfoot Instability in the Subtle Lisfranc Injury. Comparison of Magnetic Resonance Imaging with Intraoperative Findings
- Treatment of Sprains and Minimally Displaced Frx:
-
Subtle injuries of the Lisfranc joint
- Operative Treatment:
-
Closed Reduction Percutaneous Pinning:
-
Open Reduction Internal Fixation:
- fractures presenting w/ more than than 2 mm of displacement and greater than 15 deg of talometatarsal
angulation require operative treatment;
- young competitive atheletes may require anatomic reduction;
- disrupted skin and excessive swelling are relative contra-indications for ORIF;
- note that pure dislocations w/o fracture may have a worse outcome despite ORIF;
- Primary Arthrodesis:
-
Salvage of Lisfranc's tarsometatarsal joint by arthrodesis.
-
Severe lisfrancs injuries: primary arthrodesis or ORIF?
-
Open Reduction Internal Fixation Versus Primary Arthrodesis for Lisfranc Injuries: A Prospective Randomized Study
-
Treatment of Primarily Ligamentous Lisfranc Joint Injuries: Primary Arthrodesis Compared with Open Reduction and Internal Fixation.
-
post op:
- fixation must be rigid enough to prevent transverse plane & dorsoplantar motion of TMT joint and be
maintained for at least 12-16 weeks;
Isolated fracture-dislocations of the first tarsometatarsal joint.
Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment.
Lisfranc's fracture-dislocations: etiology, radiology, and results of treatment. A review of 20 cases.
The diagnosis and treatment of injuries to the Lisfranc joint complex.
Fractures and fracture-dislocations of the tarsometatarsal joint
Anatomical restraints to dislocation of the second metatarsophalangeal joint and assessment of a repair technique.
The treatment of tarsometatarsal injuries.
Fracture dislocations at the tarsometatarsal joints, end results correlated with pathology and treatment. Foot Ankle 1986;6:225-242. Myerson MS, Fisher RI, Burgess AR, et al:
Fractures and fracture dislocations of the tarsometatarsal joint. Arntz CT, Veith RG, Hansen ST: J Bone Joint Surg (Am) 1988;70A:173-181.
Functional outcome following anatomic restoration of tarsal-metatarsal fracture dislocation.
PLA screw fixation of Lisfranc injuries.
