Lisfranc Joint Injury

Tarsometatarsal (LISFRANC) joint Injury

Quenu and Kuss Classification

• Homolateral: All five metatarsals displaced in the same direction
• Isolated: One or two metatarsals displaced from the others
• Divergent: Displacement of the metatarsals in both the sagittal and coronal planes.

MYERSON classification

• Total incongruity       :Lateral and dorsoplantar
• Partial incongruity    :Medial and lateral
• Divergent:                    :Partial and total

 

Anatomy and Biomechanics:

• The Lisfranc joint complex has a relatively rigid medial column(1^st, 2^nd and 3^rd tarsometatarsal joints) and a mobile lateral column
• Dorsal based trapezoidal cross sectional shape of the medial metatarsal bases and their corresponding cuneiforms- this roman arch configuration imparts stability
• In the AP plane, the base of the second metatarsal (keystone) is recessed between the medial and lateral cuneiforms. This limits translation of the metatarsals in the frontal plane
• The second metatarsal is the apex of the osseous stability and is fractured at the time of injury
• Additional stability is produced by the capsuloligamentous structures including the dorsal, interosseous and plantar ligaments
• Strong intermetatarsal interosseous ligaments are present between each of the lateral four metatarsals but absent between 1^st and 2^nd metatarsals
• Base of the 2^nd metatarsal is connected to the medial cuneiform by the medial interosseous ligament (Lisfranc’s ligament) and connects the plantar aspect of the 2^nd Metatarsal base to the medial cuneiform.
• The absence of a direct ligamentous connection between the base of the 1^st and 2^nd metatarsals represent an inherent weakness in the Lisfranc joint

 

Mechanism of Injury:

• Injuries of the Lisfranc joint complex can result from either direct or indirect mechanisms.
• Direct injuries result from a dorsally applied force, which will result in plantar displacement of the metatarsals if the force is applied to the metatarsal base or dorsal metatarsal displacement if the force is applied to the cuneiforms.
• Indirect injuries occur from a combination of axial loading and twisting on an axially loaded, plantar flexed foot.
• The original injury, described by Napoleon’s field surgeon Lisfranc, was attributed to a soldier falling from his horse with his foot trapped in the stirrup

 

X-rays and Imaging:

AP, internal oblique (30°), and lateral foot radiographs

AP view:

• The first metatarsal aligns itself with the medial cuneiform both medially and laterally
• The medial border of the 2^nd metatarsal aligns exactly with the medial edge of the middle cuneiform

 

On the Internal oblique view

• The lateral border of the 3^rd metatarsal is aligned to the lateral edge of the lateral cuneiform.
• The medial border of the 4^th metatarsal forms a continuous straight line with the medial edge of the cuboid.
• The relationship of the 5^th metatarsal to the cuboid varies and is not reliable for diagnosing a Lisfranc injury

Lateral view:

• Dorsal displacement of the metatarsal is abnormal and is indicative of significant Lisfranc injury
• Slight plantar displacement of 1 mm or less can be a normal variation

 

Indications that an underlying injury to the Lisfranc’s joint maybe present include:

1. disturbances in the above normal relationships
2. avulsion fractures around the tarsometatarsal joints
3. widening of the first intermetatarsal or intertarsal spaces
4. fractures of the 2^nd metatarsal base-“fleck sign” in the medial cuneiform–second metatarsal space
5. compression fracture of the cuboid
6. subluxation of the naviculocuneiform articulation

When only subtle radiographic changes are present and a strong suspicion of Lisfranc injury is present, Stress views and weight bearing films prove to be helpful

CT scans are also helpful in these circumstances (Haapamaki V et al., Foot Ankle Int 2004; 25:614-619)

Treatment

Nonoperative Treatment

Nondisplaced or minimally displaced injuries.

Operative Treatment (for displaced fractures>2mm)

• ORIF is the standard of care with screw fixation of the medial column with 3.5mm cortical screws and temporary K wire fixation of the lateral column.
• Two dorsal longitudinal incisions: one along the interspace between the first and second metatarsals and another online with the 4^th metatarsal.
• Reduction is typically achieved from medial to lateral.
• Cannulated screws are placed from medial cuneiform to 2 metatarsal base, 1^st metatarsal base to medial cuneiform, medial cuneiform to middle cuneiform if there is an instability and third metatarsal to middle cuneiform if it is involved.
• If intercuneiform instability exists, one should use an intercuneiform screw

Anatomic open reduction and medial column arthrodesis has been advocated for pure tarsometatarsal ligament injuries of the medial column(Ly TV et al..)

Complications:

1. Compartment syndrome: high index of suspicion of compartment syndrome if severe swelling is present. An emergency fasciotomy is the treatment.

Three incisions are used:

• Manoli’s long medial incision: to decompress the abductor hallucis and deep compartments of the foot, including the calcaneal compartment.
• Two incisions—one between the second and third and one between the fourth and fifth metatarsals: to decompress the dorsal interosseous compartment

2. Posttraumatic deformity and arthritis:

• May present with gait problems, foot and ankle weakness, chronic pain and difficulty with footwear.
• Symptomatic arthritis and late deformity is initially treated with the use of an arch support and a rigid or rocker bottom shoe, followed by arthrodesis in patients whom conservative measures fail.

3. Malunion of the tarsometatarsal joint is most common, resulting in dorsolateral angulation of the metatarsal.

• Sequelae include arthritis of the tarsometatarsal joint, Loss of midfoot arch and transfer metatarsalgia at the adjacent metatarsal heads.
• Treatment involves shoe modification, selective midfoot fusion, metatarsal osteotomy and metatarsal head resection as required.

Ref

1. 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