Lisfranc Injury - Foot & Ankle (2024)

• account for 0.2% of all fractures

• males > females

• more common in the third decade

• mechanism of injury

  • MVAs, falls from height, and athletic injuries

  • injury cascade

    • mechanism is usually caused by indirect rotational forces and axial load through hyper-plantarflexed forefoot

      • hyperflexion/compression/abduction moment exerted on forefoot and transmitted to the TMT articulation

      • metatarsals displaced in dorsal/lateral direction

• pathoanatomy

  • unifying factor is disruption of the TMT joint complex

    • injuries can range from mild sprains to severe dislocations

  • may take form of purely ligamentous injuries or fracture-dislocations

    • ligamentous vs. bony injury pattern has treatment implications

• tarsal fractures

• proximal metatarsal fractures

  • Lisfranc equivalent injuries can present in the form of contiguous proximal metatarsal fractures or tarsal fractures

  • can involve multiple TMT joints

Osteology

• Lisfranc joint complex consists of three articulations including

  • tarsometatarsal articulation

  • intermetatarsal articulation

  • intertarsal or intercuneiform articulations

• columns of the midfoot

  • medial column

    • includes first tarsometatarsal joint

  • middle column

    • includes second and third tarsometatarsal joints

  • lateral column

    • includes fourth and fifth tarsometatarsal joints (most mobile)

• Lisfranc ligament

  • an interosseous ligament that goes from medial cuneiform to base of 2nd metatarsal on plantar surface

  • critical to stabilizing the 1st and 2nd tarsometatarsal joints and maintenance of the midfoot arch

  • Lisfranc ligament tightens with pronation and abduction of forefoot

• plantar tarsometatarsal ligaments

  See Also

  Lisfranc Injury: Symptoms & TreatmentLisfranc (Midfoot) Injury - OrthoInfo - AAOSLisfranc Surgery Procedure & RecoveryLisfranc Fracture: Causes, Symptoms, and Treatments

  • injury of the plantar ligament between the medial cuneiform and the second and third metatarsals along with the Lisfranc ligament is necessary to give transverse instability.

• dorsal tarsometatarsal ligaments

  • dorsal ligaments are weaker and therefore bony displacement with injury is often dorsal

• intermetatarsal ligaments

  • between second-fifth metatarsal bases

  • no direct ligamentous attachment between first and second metatarsal

• Lisfranc joint complex is inherently stable with little motion due to

  • stable osseous architecture

    • second metatarsal fits in mortise created by medial cuneiform and recessed middle cuneiform, "keystone configuration"

  • ligamentous restraints

    • see individual ligaments above

• history of high energy trauma or sporting accident

• severe midfoot pain

• inability to bear weight

• inspection & palpation

  • medial plantar ecchymosis

  • swelling throughout midfoot

  • tenderness over tarsometatarsal joint

• motion

  • instability test

    • grasp metatarsal heads and apply dorsal force to forefoot while other hand palpates the TMT joints

      • dorsal subluxation suggests instability

      • if first and second metatarsals can be displaced medially and laterally, global instability is present and surgery is required

    • when plantar ligaments are intact, dorsal subluxation does not occur with stress exam and injury may be treated nonoperatively

• provocative tests

  • may reproduce pain with pronation and abduction of forefoot

• recommended views

  • AP

  • lateral

  • oblique

  • weight-bearing with comparison view

    • may be necessary to confirm diagnosis

• findings

  • five critical radiographic signs that indicate presence of midfoot instability

    • discontinuity of a line drawn from the medial base of the 2nd metatarsal to the medial side of the middle cuneiform

      • seen on AP view

      • diagnostic of Lisfranc injury

    • widening of the interval between the 1st and 2nd ray

      • seen on AP view

      • may see bony fragment (fleck sign) in 1st intermetatarsal space

        • represents avulsion of Lisfranc ligament from base of 2nd metatarsal

        • diagnostic of Lisfranc injury

    • dorsal displacement of the proximal base of the 1st or 2nd metatarsal

      • seen on lateral view

    • medial side of the base of the 4th metatarsal does not line up with medial side of cuboid

      • seen on oblique view

    • disruption of the medial column line (line tangential to the medial aspect of the navicular and the medial cuneiform)

      • seen on oblique view

• indications

  • useful for preoperative planning in the setting of comminuted bony injuries

  • can help identify subtle injuries

• indications

  • can be used to confirm presence of purely ligamentous injury

• metatarsal base fracture

• metatarsal stress fracture

• tarsal fracture

• cast immobilization for 8 weeks

  • indications

    • certain non-displaced injuries that are stable with weight bearing

    • nonoperative candidates

      • nonambulatory patients

      • presence of serious vascular disease

      • severe peripheral neuropathy

  • outcomes

    • significantly lower functional and radiographic outcomes noted with non-operative management of displaced or transverse unstable injuries

• temporary percutaneous pinning and delayed ORIF or arthrodesis

  See Also

  Lisfranc Injury to the Midfoot May Need Surgery as a Treatment

  • indications

    • displaced Lisfranc fracture dislocation injury with significant soft tissue swelling

  • outcomes

    • temporizing reduction and pinning and delayed definitive management with ORIF/arthrodesis has been shown to have decreased risk of wound infection in some low level studies.

• open reduction and rigid internal fixation

  • indications

    • any evidence of instability (> 2mm shift)

    • favored in bony fracture dislocations as opposed to purely ligamentous injuries

  • outcomes

    • anatomic reduction required for a good result

    • excluding hardware removal, no difference in complications or functional outcomes between ORIF and arthrodesis

• primary arthrodesis of the first, second and third tarsometatarsal joints

  • indications (controversial)

    • purely ligamentous arch injuries

    • delayed treatment

    • chronic deformity

    • complete Lisfranc fracture dislocations (Type A or C2)

  • outcomes

    • function outcomes

      • level 1 evidence demonstrates equivalent functional outcomes compared to primary ORIF

      • medial column tarsometatarsal fusion shown to be superior to combined medial and lateral column tarsometatarsal arthrodesis

      • some studies have shown that primary arthrodesis for complete Lisfranc fracture dislocations (Type A or C2) results in improved functional outcomes and quality of reduction compared to ORIF

    • complications

      • excluding hardware removal, no difference in complications between ORIF and arthrodesis

• midfoot arthrodesis

  • indications

    • destabilization of the midfoot's architecture with progressive arch collapse and forefoot abduction

    • chronic Lisfranc injuries that have led to advanced midfoot arthrosis and have failed conservative therapy

• close followup with repeat radiographs should be performed to ensure no displacement with weightbearing with non-operative management

• technique

  • reduce medial and lateral columns and stabilize with k-wires

  • K-wires left in place until soft tissue swelling subsides

  • can proceed with K-wire removal and ORIF/arthrodesis when soft tissues allow

• timing to definitive surgery

  • can delay up to 2-3 weeks for soft tissue swelling to improve

• timing

  • within 24 hours or delay operative treatment until soft tissue swelling subsides (up to 2-3 weeks)

• approach

  • single or dual longitudinal incisions can be used based on injury pattern and surgeon preference

  • longitudinal incision made in the web space between first and second rays

  • first TMT joint is exposed between the long and short hallux-extensor tendons

• reduction & fixation

  • reduce intercuneiform instability first

  • fix first through third TMT joints with transarticular screws

    • screw fixation is more stable than K-wire fixation

    • can also span TMT joints with plates if MT base comminution is present

• postoperative care

  • early midfoot ROM, protected weight bearing, and hardware removal (k-wires in 6-8 weeks, screws in 3-6 months)

  • gradually advance to full weight bearing at 8-10 weeks

  • if patient is asymptomatic and screws transfix only first through third TMT joints, they may be left in place

  • preclude return to vigorous athletic activities for 9 to 12 months

Primary arthrodesis of the first, second and third tarsometatarsal joints

• arthrodesis & fixation

  • expose TMT joints and denude all joint surfaces of cartilage

  • use cortical screws or square plate to fuse joints

  • in the presence of both medial and lateral column dislocation, temporary lateral column pinning is recommended over lateral column arthrodesis

• postoperative care

  • apply cast or splint for 6 weeks

  • progress weight bearing between 6 and 12 weeks in removable boot

  • full weight bearing in standard shoes by 12 weeks post-op

• arthrodesis & fixation

  • expose TMT joints and midfoot and remove cartilage from first, second, and third TMT joints

  • add bone graft

  • reduce the deformity using windlass mechanism

  • variety of definitive fixation constructs exist

• postoperative care

  • apply cast or splint for 6 weeks

  • progress weight bearing between 6 and 12 weeks in removable boot

  • begin weight bearing as tolerated at 12 weeks if evidence of healing is noted on radiographs

• incidence

  • most common complication

• risk factors

  • delayed treatment

  • ORIF

    • up to 80% risk with non-anatomic ORIF

      • 54% of patients have symptomatic OA at ~10 years followed ORIF

• treatment

  • treat advanced midfoot arthrosis with midfoot arthrodesis

• risk factors

  • non-anatomic ORIF of Lisfranc injury

• treatment

  • shoe modifications (cushioned heel with rocker sole)

    • indications

      • nonsurgical candidate

  • malunion correction with primary arthrodesis

    • indications

      • surgical candidate that has failed non-operative treatment

• risk factors

  • smoking

• treatment

  • revision arthrodesis with bone grafting

    • indicated unless patient is elderly and low demand

• incidence

  • ~75% of patients who undergo ORIF

    • often a planned secondary procedure, required to allow the TMT joints to return to motion

  • ~20% of patients following arthrodesis

• incidence

  • 3-4%

• risk factors

  • significant soft tissue swelling at time of definitive surgery

• treatment

  • irrigation and debridement, possible hardware removal.

• risk factors

  • non-operative management

  • non-anatomic reduction following ORIF

• significant variability regarding return to full activity given heterogenous group of patients in nearly all studies

  • in the military population, at ~3 year follow-up, ~70% patients undergoing ORIF or primary arthrodesis were able to resume occupationally required daily running.

Poor prognostic variables

• missed diagnosis

  • easily missed and diagnosis is critical

  • missed injuries can result in progressive foot planovalgus deformity

    • result in chronic pain and ambulatory dysfunction