Bala Katyal

Trainee Advanced Practitioner Plain Film Reporting

May 2011
Lisfranc Fracture-Dislocation









History

Definition
Clinical presentation
Mechanism of Injury
Classifications
Imaging
Treatment
Conclusion
History

Jacques Lisfranc
Definition

Where the metatarsals dislocate from their normal

articulation with the mid-tarsal bones
1
st

2
nd
Most commonly involves the

and the medial cuneiform
and

metatarsals

Incidence is 1 in 55,000 people

each

year

Easily missed on initial x-
rays
Can be difficult to diagnose
Clinical

Presentation

Swelling

midfoot
and large lump in the

Unable to weight bear

Tenderness along the tarso-metatarsal joints
Tenderness with passive abduction
and pronation of the forefoot withthe
hindfoot held f lexed
Clinical Presentation

Instability of the Lisfranc
Joint

Plantar midfoot
ecchymosis

Mechanism Of Injury

Hyper-extending the forefoot

Catching the forefoot in a hole in the ground
Horseback rider falling and hanging the
forefootin the stirrup
Commonly seen as a Charcots Joint in diabetic
Patients
RTAs especially when foot is trapped in dorsi-
f lexion under the foot pedal
Crush injuries



Mechanism Of Injury

Placing the foot into

extreme plantar f lexion
with an axial load
Classification

Sprains are the most common injury to the
tarso- metatarsal ligament, it is graded I, II and
III (Burroughs et al 1998)
Grade I - Pain at the joint, minimal swelling and
no instability of the joint
Grade II Increased pain and swelling of the
joint, with mild laxity but no instability
Grade III Complete ligamentous disruption and
may represent a fracture-dislocation
Classification

Classification

Adam and Dixon 2008, say there are 2 basic types
of
Lisfranc injuries, homolateral and divergent:
Homolateral Where the metatarsals are shifted
laterally
Divergent The first metatarsal shifts medially and
the
remainder of the forefoot shifts laterally
Classification

Classification

Myerson 1986, identifies 3 classifications of
Lisfranc Injuries:
Total incongruity

displaced
Can be either medially or laterally

Medial Lateral
Classification

Partial incongruity Either medial (Type B1)or lateral
(Type
B2),

the

most common

type

Type B2 (complete)
Type B1 Type B2 (partial)
Classification

Divergent displacement
Either partial (type C1) or

total

(type
C2)

Type C1 Type C2
Imaging

First investigation is a plain film x-ray AP and
Oblique
Imaging

Plain film plays a very important role in diagnosing
Lisfranc fracture-dislocations
To look for alignment
On the AP, the lateral border of the
1
st
metatarsal is aligned with the
Lateral border of the medial
cuneiform
Imaging

On the AP the

medial border of

2
nd
the

metatarsal is in line with

the medial border of the

intermediate

cuneiform

Imaging

On the oblique view
Medial and lateral borders of

the lateral cuneiform should
align with the medial and lateral
3
rd
borders of the

metatarsal

Imaging

Also on the oblique
Medial border of the cuboid should

align with the medial border of the
4
th

metatarsal

Imaging

Radiology.com 2006
Imaging

Radiology.com 2006
Imaging

Patients still may need further plain
film

views
Weight-bearing AP
Weight-bearing lateral
Stress views done under anaesthetics
Imaging

CT plays an important role in looking at the widening of the
joint spaces
CT also can detect associated
fractures
Help with confirming the
diagnosis
Help to formulate the surgical
treatment plan
Imaging

MRI can

damage
be

useful to evaluate the

soft

tissue

Looks at

the Lisfranc ligament

Not routinely used

Imaging

Doppler ultrasound may be used to look at the

dorsalis pedis artery if it can not

be felt by hand

Nuclear medicine could be used

distinguish any fractures
but you could not

Fractures Associated

Dislocations

with

Lisfranc

2
nd

Base of

Cuboid
metatarsal

Fractures of the
shafts

of the metatarsals

1
st

2
nd

Dislocations of
the

(medial) and

(middle) and cuneonavicular joints

Navicular
Treatment

For a Lisfranc sprain:

Non-weight bearing
In a cast or
removable
4-6 weeks recovery
Physiotherapy
boot

Gradual return to
activity

Treatment

For a Lisfranc fracture-dislocation,

surgery
ORIF
K-Wires
Arthrodesis
it

is

usually



Complications

Can take up to
with surgery

1 year to recover
Examples of Lisfranc Injuries 1

Examples of Lisfranc Injuries 1

Examples of Lisfranc Injuries 2

Examples of Lisfranc Injuries 3

Example of Lisfranc Injuries 3

Conclusion

Serious injury
Difficult to diagnose
Can lead to compartment syndrome
Can have vascular compromise if not treated
quickly
A quick and accurate diagnosis can allow the
appropriate treatment to take place efficiently
Can take a long time to recover
Complications that may lead to further surgery
Advance practice plays an important role
References

ADAM, A and DIXON, A.K. (2008) Grainger and Allisons Diagnostic

5
th

Radiology. A textbook of Medical Imaging. Edition, volume 2 in
GRAINGER, R.G. and ALLISON, D.J. (eds.).
London:Churchill Livingstone
AMERICAN COLLEDGE OF FOOT AND ANKLE SURGEONS (2009)
Lisfranc Injuries.

22
nd

Accessed April 2010)
BURROUGHS, K.E. and REIMER, C.D. and FIELDS, K.B. (1998). Lisfranc
injury of the foot: A commonly Missed diagnosis. Published by the American
Academy of Family Physicians
2
nd

CHAN, O. (2007) ABC of Emergency Radiology.
Oxford:Blackwell Publishing
Edition. BMJ Books.
FOOT EDUCATION (2009) Lisfranc Fracture ORIF.
www.footeducation.com/lisfranc-fracture-orif (Accessed 14th May 2010)
2
nd
HELMS, C.A. (1995) Fundamentals of Skeletal Radiology.
London:W.B. Saunders Company
Edition.
References

HOWELL, G.A. (2009) Lisfranc Ligament Tear.
www.radsource.us/clinic/0908 (Accessed 14th May 2010)
LARSEN, D. And MORRIS, P. (2006) Limb X-Ray Interpretation.
London:Whurr Publishers
LEARNING RADIOLOGY.COM (2006) Lisfranc Fracture-Dislocation.

22
nd
www.learningradiology.com (Accessed April 2010)
Edition. 3
rd
LISLE, D.A. (2007) Imaging for students:
London: Hodder Arnold
McCONNELL, J. AND EYRES, R. AND NIGHTINGALE, J. (2005)
Interpreting Trauma Radiographs.
Oxford:Blackwell Publishing
MYERSON (1986) cited in East Lancashire Foot and Ankle Hyperbook,
Lisfranc Injuries

23
rd

www.foothyperbook.com (Accessed May 2010)
RABY, N. And BERMAN, L. And DE LACY, G. (2009) Accident and
2
nd

Emergency Radiology. A survival Guide.
London:Elsevier Saunders
Edition.
References

THE CENTRE FOR ORTHOPAEDICS AND SPORTS
MEDICINE
(2000) Lisfranc Fracture-Dislocation
22
nd
(Accessed April 2010)
TREVINO, S.G. (2009) Lisfranc Fracture
Dislocation
23
rd
www.emedicine.medscape.com (Accessed
VANDERHEIDEN, T. (2008) Lisfranc Injury.
May 2010)
15
th
www.about.com (Accessed May 2010)
WATURA ET AL. BJR 77 (Supplement 1):S46 Figure
10.
22
nd
www.BJR.com (Accessed April 2010)
WHEELESS, C.R. (2009) Lisfrancs Fracture/Tarso-
metatarsal
Injuries. Duke Orthopaedics presents Wheeless Textbook of
Orthopaedics.
14
th
www.wheelessonline.com (Accessed May 2010)

Any Questions