High Yield Topics

Lisfranc Fracture-Dislocation

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Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
> Table of Contents > Lisfranc Fracture-Dislocation

Lisfranc Fracture-Dislocation
Simon C. Mears MD, PhD
Clifford L. Jeng MD
Basics
Description
  • Dislocation of the TMT joints of the foot (Fig. 1).
    • Can occur at any age
    • Often accompanied by fractures around the TMT joints
  • Classification (1):
    • Type A: Total incongruity of TMT joint
    • Type B: Partial incongruity of TMT joint complex, either medial or lateral
    • Type C: Divergent (1st metatarsal medial, 2nd–5th lateral)
Epidemiology
Incidence
Lisfranc injuries account for ~1/3 of midfoot injuries (2).
Risk Factors
  • Car accidents
  • Motorcycle accidents
Etiology
  • The mechanism of injury includes a wide
    spectrum of causes from low-energy compression and twisting to
    high-energy crush injuries.
  • Common cause: Car and motorcycle accidents (3):
    • Pressure on a brake pedal with a plantar flexed foot leads to the Lisfranc pattern of injury (4).
  • Sporting events (5)
Associated Conditions
  • Comminuted fractures of the metatarsal bases or cuneiforms
    Fig. 1. Lisfranc dislocation occurs at the midfoot joints, usually with substantial trauma.
  • Severe soft-tissue injury
  • Compartment syndrome
  • Open fractures
Diagnosis
Signs and Symptoms
  • Pain
  • Swelling
  • Deformity
  • Ecchymosis
  • Difficulty bearing weight
  • Tenderness over midfoot
  • Possible spontaneous reduction
Physical Exam
  • Rotational stress on the forefoot causes pain at Lisfranc joint.
  • Palpation over the 2nd metatarsal base also can cause pain.
Tests
Imaging
  • Radiography:
    • Plain films usually are diagnostic.
    • AP, lateral, and oblique projections are mandatory.
      • On the AP view, the medial margin of the 2nd metatarsal base should be aligned with the middle cuneiform.
      • On the oblique view, the medial base of the 4th metatarsal should be aligned with the medial margin of the cuboid.
      • On the lateral view, an unbroken line should run from the dorsum of the 1st and 2nd metatarsals to the corresponding cuneiform.
    • Avulsion fracture of the 2nd metatarsal
      base (“fleck” fracture) and compression fracture of the cuboid are
      pathognomonic of this condition (6).
    • If the diagnosis is uncertain on plain
      film, especially if the Lisfranc joint has reduced spontaneously,
      stress radiography with fluoroscopy may be helpful in further defining
      the instability pattern.
  • CT is an important adjunct to plain radiographs.
    • Shows small fractures and displacements that are not visible on plain films
    • In 1 study, radiographs missed the Lisfranc injury in 24% of cases and CT scan revealed the injury (7).
Differential Diagnosis
  • Soft-tissue contusion
  • Ligament sprain
  • Isolated metatarsal or midfoot fractures
Treatment
General Measures
  • Before the patient is taken to the operating room:
    • Compartment syndrome and neurovascular injury should be assessed.
    • The foot is splinted and kept elevated until surgery.
  • The goal of treatment is to achieve and maintain anatomic reduction of the joints while the ligaments heal.
    • Usually requires surgical intervention
  • Before and after surgery: Ice, elevation, and a compression dressing
  • Foot pumps may help reduce foot swelling.
Special Therapy
Physical Therapy
  • Patients should be referred for gait training on a nonweightbearing basis postoperatively.
  • Edema control and ROM of the toes and ankle are important to decrease late stiffness.
Surgery
  • Open reduction and internal fixation of joints:
    • Through 2–3 dorsal longitudinal incisions
    • Fixation may consist of Kirschner wires or 3.5-mm cortical screws.
      • If Kirschner wires are used as fixation,
        they can be removed in the office at 6 weeks, and the patient may begin
        protected weightbearing.
      • If screws are used as fixation,
        unprotected weightbearing is not permitted until the screws have been
        removed, at 10–12 weeks after surgery.
  • Fusion of the joints with 3.5-mm cortical screws has been advocated by some as primary treatment (8) or as a salvage procedure for later arthritis of the midfoot (9).

P.231


Follow-up
Prognosis
  • Patients with anatomic reduction generally have good results.
    • In 1 study, 11 of 24 patients had a good to excellent result (10).
  • Outcomes are worse with nonanatomic reduction and extensive joint injury (11).
  • Patients with worker compensation claims have poorer outcomes (12).
  • The role of joint fusion is controversial.
    • Recently, a randomized study showed that joint fusion gave better results than did reduction and fixation (8).
  • Patients with posttraumatic arthritis can undergo salvage procedures with arthrodesis.
Complications
  • Traumatic arthritis
  • Fixed deformity
  • For injuries diagnosed late (7–8 weeks):
    • Poor prognosis
    • Patients may be candidates for primary arthrodesis (13).
Patient Monitoring
Follow-up radiographs (at 1-month intervals) should be taken to check for maintained alignment of the Lisfranc complex.
References
1. Hardcastle
PH, Reschauer R, Kutscha-Lissberg E, et al. Injuries to the
tarsometatarsal joint. Incidence, classification and treatment. J Bone Joint Surg 1982;64B:349–356.
2. Richter
M, Wippermann B, Krettek C, et al. Fractures and fracture dislocations
of the midfoot: occurrence, causes and long-term results. Foot Ankle Int 2001;22:392–398.
3. Jeffers RF, Tan HB, Nicolopoulos C, et al. Prevalence and patterns of foot injuries following motorcycle trauma. J Orthop Trauma 2004;18: 87–91.
4. Smith BR, Begeman PC, Leland R, et al. A mechanism of injury to the forefoot in car crashes. Traffic Inj Prev 2005;6:156–169.
5. Nunley JA, Vertullo CJ. Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med 2002;30:871–878.
6. Pearse EO, Klass B, Bendall SP. The “ABC” of examining foot radiographs. Ann R Coll Surg Engl 2005;87:449–451.
7. Haapamaki VV, Kiuru MJ, Koskinen SK. Ankle and foot injuries: analysis of MDCT findings. AJR Am J Roentgenol 2004;183:615–622.
8. Ly
TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint
injuries: primary arthrodesis compared with open reduction and internal
fixation. A prospective, randomized study. J Bone Joint Surg 2006;88A:514–520.
9. Komenda GA, Myerson MS, Biddinger KR. Results of arthrodesis of the tarsometatarsal joints after traumatic injury. J Bone Joint Surg 1996;78A: 1665–1676.
10. O’Connor PA, Yeap S, Noel J, et al. Lisfranc injuries: patient- and physician-based functional outcomes. Int Orthop 2003;27:98–102.
11. Kuo RS, Tejwani NC, Digiovanni CW, et al. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg 2000;82A:1609–1618.
12. Calder JDF, Whitehouse SL, Saxby TS. Results of isolated Lisfranc injuries and the effect of compensation claims. J Bone Joint Surg 2004; 86B:527–530.
13. Aronow MS. Treatment of the missed Lisfranc injury. Foot Ankle Clin 2006;11:127–142.
Additional Reading
Sands AK, Grose A. Lisfranc injuries. Injury 2004;35:B71–B76.
Miscellaneous
Codes
ICD9-CM
825.25 Metatarsal fracture
Patient Teaching
Patients must be warned about the risks of traumatic arthritis and fixed deformity, which may require later arthrodesis.
FAQ
Q: How long will it take to recover from a Lisfranc injury?
A:
Lisfranc injuries are severe injuries to the midfoot and commonly
require surgery. Recovery takes at least a year. Patients may require
hardware removal. ~25% develop arthritis and may require later fusion.

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