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Lisfranc fracture dislocations – comprehensive notes

Lisfranc fracture dislocations – comprehensive notes

  • Overview and scope

    • Lisfranc injuries range from high-energy, highly disorganized midfoot injuries with multiple associated injuries to subtle sprains or subluxations that can be missed on initial evaluation.
    • High index of suspicion is essential because subtle injuries have a high potential for long-term disability if missed.
    • Energy can propagate through the entire tarsometatarsal (TMT) joints and may involve the intermetatarsal and intratarsal joints; instability can extend beyond the TMT joints.
    • Incidence is low in the general population: about 0.1\% - 2.4\% of all fractures, roughly 1:50{,}000 people, but misdiagnosis rates are high: about 20\% - 35\% misdiagnosed or unrecognized.
    • It is the second most common athletic foot injury; approximately 4\% of football players per year suffer a Lisfranc fracture dislocation.
    • Predominantly male patients (roughly 2-4\times more likely) with average age in the 30s.
    • Even with anatomic reduction, outcomes are not always good in severe comminution or crush injuries.

  • Historical context and evolution of understanding

    • First described by Jacques Louis Lisfranc (Napoleonic era field surgeon) in 1815, documenting amputations through the tarsometatarsal joints in soldiers.
    • Foundational classifications developed by Kinew and Cus (late 19th/early 20th century) and refined over time by Hartcastle et al.; vascular compromise with delayed reduction noted by Guislain (1951).
    • Emphasis on anatomic reduction in the 1950s–1970s; later debates on necessity of restoration vs nonoperative management for certain injuries.
    • 1982 review underscored prognosis depends on exact restoration of the medial and middle columns; this interpretation guides current treatment.

  • Anatomy and biomechanics of the Lisfranc joint

    • Lisfranc joint complex includes the tarsometatarsal (TMT) joints, with potential involvement of intermetatarsal and intratarsal joints; the Lisfranc joint separates the midfoot and forefoot.
    • Soft-tissue restraints include capsules and ligaments around the TMT joints; three articular components are medial, central, and lateral.
    • Mobility varies by location: the 5th TMT joint has the greatest sagittal plane motion (~10-20^{\circ}); medial rays are less mobile.
    • Keystone concept: a central stabilizer that helps support both longitudinal and transverse arches of the midfoot.
    • Dorsal artery and nerve (dorsalis pedis and deep peroneal nerve) at risk with high-energy trauma; anterior tibial tendon, peroneus longus tendon, interossei, and plantar fascia are important for surgical dissection and function.

  • Key osseous and ligamentous structures

    • Osseous components involved: medial cuneiform, intermediate cuneiform, lateral cuneiform, navicular, cuboid, and bases of the first–fifth metatarsals; energy can involve the cuboid and navicular-cuneiform joints.
    • Lisfranc ligament (interosseous) is between the medial cuneiform and the base of the second metatarsal; it's a strong stabilizer and is the primary restraint that, when injured, disrupts the medial and middle columns.
    • Ligamentous attachments and orientation:
    • Lisfranc ligament has plantar and dorsal components. Plantar fibrous bands insert to the plantar surfaces of the medial cuneiform and the bases of the 2nd and 3rd metatarsals; the dorsal portion runs dorsally across the joint.
    • Intermetatarsal ligaments are weaker than plantar intermetatarsal ligaments and lie between the bases of the lateral four metatarsals; there is no intermetatarsal ligament between the 1st and 2nd rays.
    • Plantar tarsometatarsal ligaments: short, oblique, and some longitudinal; stronger between the medial/lateral cuneiforms and the 1st–2nd bases, often contributing to stability.
    • Dorsal tarsometatarsal ligaments span the dorsal aspects of the distal tarsal bones to the base of the metatarsals and blend with the joint capsule.
    • Anatomical wedging and the second ray:
    • The second metatarsal base is recessed proximally relative to the 1st and 3rd rays, contributing to intrinsic stability.
    • In coronal view, about 8\text{ mm} proximal to the medial cuneiform and 4\text{ mm} proximal to the lateral cuneiform; this wedging reduces movement of the 2nd metatarsal and contributes to midfoot stability.
    • Variants related to predisposition:
    • Shallow first–second metatarsal mortise and shorter foot length-to-metatarsal length ratio may predispose to Lisfranc injuries.

  • Mechanisms of injury

    • General mechanism: hyperflexion, compression, and abduction moments transmitted through the forefoot into the TMT joints.
    • Energy spectrum:
    • Low-energy injuries: subtle sprains or subluxations; sometimes spontaneously reduce.
    • High-energy injuries: severely displaced fracture–dislocations; common causes include motor vehicle accidents (≈ half to two thirds of injuries) and crush injuries, falls from height or level, twisting injuries.
    • Indirect vs direct forces:
    • Direct force: force directed at the Lisfranc articulation (e.g., crush injuries); commonly presents with open wounds or vascular compromise and possible compartment syndrome; displacement direction is dictated by the applied force.
      • Typical pattern: dorsal dislocation of the metatarsals with plantar displacement.
    • Indirect force: longitudinal force with rotation and axial loading on a plantar-flexed foot; more common; rarely associated with open wounds or vascular compromise.
      • Dislocation tends to be dorsal due to stronger dorsal ligaments; may involve medial or lateral displacement depending on force vector.
    • Sub-mechanisms:
    • Twisting injuries: forceful abduction of the forefoot; can cause 2nd metatarsal base fracture and sometimes impaction of the cuboid; may cause isolated 2nd TMT dislocation.
    • Axial loading: heel contact with a fixed plantar-flexed foot or body weight on a plantar-flexed foot; causes dorsal dislocation and midfoot cavus.
    • Special populations:
    • Neuropathic patients may have Lisfranc injuries but with different treatment considerations; note marked swelling and inability to bear weight.
    • Clinical presentation nuances:
    • Subtle injuries: pain out of proportion to exam, plantar medial arch bruising, positive gap sign (diastasis between great toe and second toe).
    • Gross instability or deformity more likely to require surgery; plantar ligaments and capsule involvement more likely in lower-energy sprains; higher-energy cases involve stronger ligamentous structures and potential dislocations.

  • Clinical examination and physical signs

    • Positive gap sign: diastasis between the hallux and the second toe indicating midfoot instability.
    • Piano key test: stabilize the metatarsal head and apply a dorsal force while palpating the TMT joints to assess instability; displacement of 1st–2nd rays suggests instability requiring surgery.
    • Stress tests:
    • Dorsal stress/dorsolateral stress of 1st–2nd metatarsals to evaluate instability; may be performed intraoperatively under fluoroscopy.
    • Tarsometatarsal squeeze test: compression across the TMT joints to elicit pain and instability.
    • Abduction-pronation stress to assess forefoot stability; hindfoot positioning (inversion) used to reduce subtalar motion during evaluation (as described by Hardwood & Raiken).
    • Radiographic correlation with physical exam can be challenging in acute settings due to pain and guarding; stress radiographs may be needed to reveal instability.

  • Imaging and radiographic assessment

    • Initial imaging: non-weight-bearing X-rays in trauma, with potential weight-bearing views in subtle injuries; contralateral foot radiographs can be helpful for comparison.
    • Weight-bearing radiographs reveal diastasis/instability that may not be evident on non-weight bearing films due to spontaneous reduction.
    • Key radiographic views and what to assess:
    • AP view: assess alignment of first–second TMT articulation; be mindful of overlapping bones; evaluate for misalignment across multiple joints.
    • Medial oblique view: profile the lateral three TMT joints; evaluate second intermetatarsal space alignment with the corresponding intertarsal space; third intermetatarsal space alignment with the lateral cuneiform–cuboid articulation; fifth metatarsal–cuboid relationship varies.
    • Lateral view: assess dorsal alignment of metatarsals with dorsal cortex of corresponding tarsal bones; note that dorsal displacement of the metatarsals relative to cuneiforms indicates instability.
    • Normal alignment: first metatarsal aligns medially with the medial cuneiform; first intermetatarsal space corresponds to the first intertarsal space.
    • Specific radiographic signs of instability (five critical signs):
    • Sign 1: disruption of a line drawn medially from the base of the second metatarsal to the medial aspect of the intermediate cuneiform on AP/oblique views (first and most reliable sign).
    • Sign 2: widening of the first–second intermetatarsal space.
    • Sign 3: medial edge of the base of the 4th metatarsal lines up with the medial edge of the cuboid on the oblique view (soft sign; cross-section mismatch can create a false step-off due to beam angle).
    • Sign 4: on the lateral view, metatarsals should line up with the dorsal cortices of the cuneiforms; dorsal displacement suggests ligamentous injury.
    • Sign 5: disruption of the medial column line tangential to the navicular–cuneiform complex; disruption seen on weight-bearing AP view at intersection of the base of the 1st metatarsal and navicular/medial cuneiform region.
    • Additional radiographic findings and concepts:
    • Flex sign: small bony avulsion fragment (breakaway fragment) at the Lisfranc ligament insertion; pathognomonic for Lisfranc injury; indicates Lisfranc ligament avulsion.
    • Diastasis > 2\,\text{mm} between 1st and 2nd metatarsal bases on weight-bearing films suggests injury; average 1st–2nd base distance on weight-bearing films is about 2.5\ mm.
    • The “planar distance” between the plantar aspect of the 5th metatarsal base and the plantar aspect of the medial cuneiform on lateral weight-bearing views helps assess longitudinal arch collapse and predict prognosis.
    • Additional imaging modalities and their roles:
    • CT scan: second-line imaging to visualize TMT joints, detect minor static subluxations, and provide 3D reconstructions for surgical planning.
    • Ultrasound: useful for assessing ligamentous injury when available; can evaluate dorsal navicular–cuneiform ligaments and other soft tissue structures.
    • MRI: second imaging modality for ligamentous injury; superior for detecting subtle Lisfranc sprains/tears, bone contusions, occult fractures; high predictive value for midfoot instability.
    • Specific MRI features of the Lisfranc ligaments:
    • Interosseous Lisfranc ligament: thick, low-signal structure from the medial cuneiform to the base of the second metatarsal; best seen on long-axis/short-axis planes; can appear striated on some sequences.
    • Plantar component: low-signal structure extending from the plantar surface of the medial cuneiform to the plantar aspects of bases of the 2nd and 3rd metatarsals (best seen on short-axis imaging).
    • Dorsal component: thin, low-signal structure along the dorsal aspects of the medial cuneiform to the base of the second metatarsal (best seen on short-axis imaging).
    • MRI indicators of injury: increased T2-weighted signal within margins of Lisfranc ligament components, disrupted ligament fibers, avulsion from osseous attachments.

  • Classification systems for Lisfranc injuries

    • General approach: classify by radiographic findings and mechanism; classification guides treatment but not reliably prognostic outcomes.
    • Kinyu and Cus (early framework) with Hartcastle et al. modification; Meyerson et al. refinement:
    • Columns concept: medial column (1st ray: 1st MT base + 1st cuneiform + related navicular facet), middle column (2nd–3rd MT bases, 2nd–3rd cuneiforms, navicular facets), lateral column (4th–5th MT bases + cuboid).
    • Injury patterns based on incongruity and direction of displacement (three-column framework):
      • Homolateral: all five bases displaced in the same direction.
      • Isolated (partial incongruity): partial involvement of bases.
      • Divergence (complete incongruity): displacement of first ray with lateralTranslation of the others.
    • Meyerson classification (osseous-injury emphasis):
      • Type A: total incongruity of the TMT joint complex in one plane.
      • Type B1, B2: partial incongruity; B1 involves the first ray; B2 involves one or more lateral metatarsals (lateral column involvement).
      • Type C1, C2: divergence patterns; C1 is medialization of the first ray with partial lateral incongruity; C2 is divergent pattern with multiple components displaced.
    • Hartcastle/Meyerson additions emphasize different planes and patterns of injury across the TMT complex.
    • Nunnally and Vartolo midfoot sprains (2002): nondisplaced and displaced Lisfranc sprains; three-stage system based on weight-bearing radiographs:
    • Stage I: no displacement; Lisfranc ligaments sprained but intact; minimal instability.
    • Stage II: ligament rupture with 2–5 mm diastasis; no arch loss.
    • Stage III: arch loss; significant instability.

  • Indications for conservative vs surgical management

    • Conservative (nonoperative) indications:
    • Nondisplaced or purely ligamentous injury with minimal malalignment (<1\,\text{mm} displacement) and articular displacement <2\,\text{mm}.
    • Intact medial column and overall stability; no major associated midfoot injuries.
    • No vascular compromise or significant soft tissue injury.
    • Normal X-rays but patient with Lisfranc ligament abnormal signal on MRI.
    • Treatment: immobilization in CAM or short-leg cast; follow-up weight-bearing radiographs every 8\,\text{weeks}; gradual return to weight bearing as symptoms improve (typically ~4-6\ text{ weeks}).
    • Gradual progression to physical therapy, gait training, and possibly stiff-soled or carbon fiber insertions; return to pre-injury activity timelines vary, often around 4\text{ months} for athletes; full reintegration may take 6-9\text{ months}.
    • Surgical indications:
    • Malalignment > 1\,\text{mm} or articular incongruity > 2\,\text{mm}.
    • Soft tissue or bony fragments preventing reduction; medial column instability or shortening.
    • Associated multiple midfoot injuries or compartment syndrome/open fracture.
    • Instability in stress radiographs or subtler instability evident on dynamic testing.
    • Contraindications to surgery:
    • Non-ambulatory patients or significant vascular disease without severe deformity.
    • Severe peripheral neuropathy (e.g., Charcot neuropathy) where fixation is less reliable and soft tissue coverage is poor.
    • Isolated transverse-plane instability with otherwise stable medial column may be managed conservatively.
    • Goals of treatment: pain-free, durable, stable midfoot with preserved joints; anatomic reduction is a key determinant of outcome.
    • Timing considerations:
    • Soft-tissue edema and swelling can delay surgery by 1–3 weeks until skin tension lines recover.
    • Urgent surgery only for compartment syndrome, open injuries, irreducible dislocations, or deformities causing pressure necrosis.

  • Surgical treatment options and rationales

    • Open reduction and internal fixation (ORIF): common approach for many Lisfranc injuries, using transarticular screws or pins or bridge plating.
    • Transarticular screws: provide compression; risk of cartilage damage if across weight-bearing joints; can cause later arthritis.
    • Bridge plating: dorsal plating across the TMT joints to maintain reduction while avoiding direct transarticular cartilage injury; may reduce post-traumatic arthritis risk but requires more dissection and later hardware removal considerations.
    • K-wires historically used for SR (soft tissue) cases but largely fallen out of favor due to instability.
    • Primary arthrodesis (fusion): favored by some for purely ligamentous injuries or highly unstable patterns; preserves pain-free function with potential for better long-term outcomes in certain scenarios.
    • Rationale: medial column is more stable and less mobile; fusion may avoid post-traumatic arthritis and preserve function when motion is limited by instability.
    • Classic prospective randomized data (Coatsy/JBJS 2006) suggested better outcomes with primary arthrodesis for subacute purely ligamentous injuries compared to ORIF; long-term follow-up indicated higher return to pre-injury levels with fusion in certain cohorts.
    • Debates and evidence quality:
    • Literature is mixed; higher-quality randomized trials are limited; outcomes depend on injury pattern, columns involved, and compliance.
    • Meta-analyses suggest dorsal bridge plating may yield better functional outcomes and lower post-traumatic arthritis than transarticular screws, but randomized data are lacking.
    • Contemporary guidelines emphasize individualized treatment depending on pattern, soft-tissue condition, and patient factors, with a trend toward fusion in certain pure ligamentous injuries and ORIF when there are bony injuries with reducible patterns.

  • Surgical planning, timing, and perioperative considerations

    • Soft-tissue management: defer surgery for significant edema; aim for relaxed skin tension lines before incisions; plan incisions to maximize skin bridge and minimize necrosis; limit undermining.
    • Intraoperative philosophy:
    • Sequential reduction and fixation across involved joints with imaging confirmation in three planes.
    • Typical sequence (varies by injury pattern): address the medial column (1st–2nd TMT region) first, then 2nd–3rd TMT, then 4th–5th TMT as needed; sometimes NC (naviculo-cuneiform) or intercuneiform joints are stabilized if unstable.
    • For naviculo-cuneiform or intercuneiform instability, use screws to stabilize these joints as needed; then address the TMT joints.
    • Approaches and incisions:
    • Classic dorsal approach to midfoot/metatarsals with incisions between rays to access involved joints (e.g., between 1st–2nd rays to access 2nd MT base and 1st–2nd TMT region; between 4th–5th rays to access 4th–5th TMT region).
    • Extensile dorsal salvage incision (Ed’s Z or Zwipp) for complex or salvage cases.
    • Intraoperative fixation strategies:
    • Provisional reduction with K-wires as needed.
    • Address unstable cuneiforms (navicular-cuneiform, intercuneiform) with screws.
    • Address cuboid impaction or fracture with appropriate reduction and fixation or monorail support for lateral column stabilization.
    • Home run screw: a screw configuration commonly crossing from the medial cuneiform to the base of the second metatarsal (classic orientation); some series use medial cuneiform to second metatarsal base depending on surgeon preference.
    • If multiple levels are involved, progress from more medial structures outward; fix first TMT then proceed laterally, ensuring alignment before final fixation.
    • Arthrodesis approach (for primary fusion): similar incision planning; fusion targets include medial column joints (1st TMT, intercuneiform, navicular–cuneiform) as needed; plan for potential navicular–cuneiform (NC) fusion if instability persists.
    • Hardware considerations and biomechanical implications:
    • Transarticular screws provide compression but risk articular damage and later arthritis; plate constructs avoid transarticular cartilage injury but require more dissection.
    • Biomechanical studies show plate fixation can maintain reduction under cyclic loading; some data suggest non-inferiority or superiority for plate constructs in certain scenarios, but evidence quality varies.
    • Postoperative management after ORIF/arthrodesis:
    • Non-weight bearing for approximately 6-8\text{ weeks} or as surgeon dictates; DVT prophylaxis considered according to risk.
    • Hardware removal historically around 12\text{ weeks}, but many surgeons now leave hardware in place unless symptomatic.
    • Rehabilitation with early ROM exercises when safe; progressive weight bearing as healing allows.

  • Practical pearls and intraoperative tips

    • Maintain as much skin and soft-tissue integrity as possible; avoid extensive undermining; strive for full-thickness soft tissue dissection when feasible.
    • Map the neurovascular bundles preoperatively and intraoperatively to avoid iatrogenic injury, particularly around the dorsomedial foot where several nerve branches are at risk.
    • Consider staged reconstruction for severe injuries with significant swelling or soft-tissue concern.
    • For compartment syndrome signs or open injuries, fasciotomy and staged reconstruction with external fixation can be life- and limb-saving.
    • In complex cases, a staged approach with temporizing external fixation followed by definitive fixation can be beneficial.

  • Outcomes, prognosis, and evidence base

    • The prognosis hinges largely on correct reduction and stabilization of both medial and lateral columns; the extent of initial injury and secondary degenerative changes influence long-term function.
    • ORIF vs primary arthrodesis: historical data favored fusion for purely ligamentous injuries in some studies; modern practice often favors ORIF for injuries with significant bony injury and fusion for specific ligamentous-dominant patterns, with each approach yielding variable functional outcomes.
    • Across studies, even with good reduction, some patients have lingering pain or abnormal gait; radiographic alignment does not always correlate with perfect clinical outcome.
    • Systematic reviews (e.g., JFAS 2023–2024) suggest dorsal bridge plating may improve functional outcomes and reduce post-traumatic arthritis compared with transarticular screws, but higher-quality randomized trials are needed.
    • Important long-term concept: because the Lisfranc joint contributes to both longitudinal and transverse arch integrity, preserving motion in the medial column via ORIF can be beneficial in certain scenarios, but fusion may be advantageous when motion is limited or instability is severe.

  • Complications and adverse sequelae

    • Deformity and malunion in cases of misdiagnosis or inadequate reduction.
    • Post-traumatic arthritis, particularly with articular step-off or primary joint cartilage injury.
    • Vascular compromise and compartment syndrome (acute), potentially requiring fasciotomy.
    • Open fractures and infection risk; soft-tissue complications and necrosis.
    • Reflex sympathetic dystrophy (CRPS), chronic pain, and avascular necrosis of the second metatarsal head (rare but reported).
    • Salvage considerations: persistent deformity or instability may require secondary arthrodesis or revision surgeries.
    • Functional limitations: even with successful restoration, some patients experience persistent stiffness, abnormal gait, or activity restrictions, particularly in high-demand athletic or occupational groups.

  • Special clinical-pathophysiologic entities and variant scenarios

    • NC variant: navicular–cuneiform dislocation with TMT injury; NC dislocation reduced prior to TMT reduction.
    • Floating metatarsal injury: MPJ and TMT dislocations of the first ray may occur with lateral ray injuries; management involves sequential reduction and stabilization.
    • TMT instability patterns may involve intracuneiform and navicular–cuneiform joints in addition to primary TMT complexes; stability assessment should evaluate all three columns.

  • Summary take-home points

    • Lisfranc injuries span a broad spectrum from subtle ligament sprains to severe fracture–dislocations with soft-tissue injury and compartment syndrome; a high index of suspicion is essential for early recognition and optimal outcomes.
    • Accurate reduction of both medial and lateral columns is critical for long-term function; prognosis depends more on restoration of alignment than on injury severity alone.
    • Imaging is multi-modality: plain radiographs (with weight-bearing views when possible) are foundational; CT provides detailed anatomy for surgical planning; MRI and ultrasound can aid in ligamentous assessment and soft-tissue planning.
    • Treatment strategy should be individualized: conservative management for nondisplaced/ligamentous sprains with stable medial column vs surgical management for malalignment, instability, bony injuries, or complex injuries involving multiple columns.
    • ORIF vs primary arthrodesis remains debated; current evidence supports tailored approaches, recognizing medial column stability, energy of injury, and patient-specific needs; dorsal bridge plating may offer functional advantages in some series, though higher-quality data are needed.

  • References and further reading

    • Classic discussions and radiographic signs outlined in foundational papers (Kinyu & Cus; Hartcastle et al.; Meyerson et al.).
    • Notable randomized and comparative studies (Coatsy/JBJS 2006; Henning & Anderson/FAB 2009).
    • Systematic reviews and meta-analyses (e.g., JFAS 2024) on fixation methods (transarticular screws vs bridge plating) and their impact on outcomes.
    • Key imaging signs: flex sign (pathognomonic avulsion fragment), five critical radiographic signs of midfoot instability, and clinical tests (piano key test, stress maneuvers).

  • Quick practical algorithm (conceptual)

    • Suspect Lisfranc injury in midfoot trauma; obtain three-view radiographs (AP, medial oblique, lateral) with contralateral comparison if needed.
    • If high suspicion with nondiagnostic plain films, obtain weight-bearing views or stress radiographs; consider CT if radiographs are inconclusive.
    • If diastasis > 1\,\text{mm} or articular incongruity > 2\,\text{mm} or clinical instability is evident, plan for surgical stabilization.
    • If purely ligamentous and stable (Stage I/low-grade), conservative treatment may be appropriate with immobilization and planned return-to-sport/work timeline; monitor with serial imaging.
    • If malalignment or instability is demonstrated, proceed with ORIF (or primary arthrodesis in appropriate patterns), guided by the specific column involvement and soft-tissue status.
    • Postoperative care includes non-weight bearing for several weeks, gradual loading, physical therapy, and consideration of hardware removal based on symptoms and surgeon preference.

  • Contact and questions

    • For questions or clarifications, connect with the instructor; additional Q&A will follow.