Injury to the Tarsometatarsal Joint Complex

Michael C. Thompson, MD, and Matthew A. Mormino, MD

Abstract
Tarsometatarsal joint complex fracture-dislocations may result from direct or in- ment and treatment of injuries. Sta-
direct trauma. Direct injuries are usually the result of a crush and may involve as- bility of the complex is achieved by
sociated compartment syndrome, significant soft-tissue injury, and open fracture- a combination of bony architecture and
dislocation. Indirect injuries are often the result of an axial load to the plantarflexed ligamentous support. The medial, mid-
foot. Midfoot pain after even a minor forefoot injury should raise suspicion; up to dle, and lateral cuneiforms articulate
20% of tarsometatarsal joint complex injuries are missed on initial examination. distally with the first, second, and third
An anteroposterior radiograph with abduction stress may reveal subtle injury, but metatarsals, respectively14 (Fig. 1, A).
computed tomography is the preferred imaging modality. The goal of treatment is The cuboid articulates distally with
the restoration of a pain-free, functional foot. The preferred treatment is open re- the fourth and fifth metatarsals. The
duction and internal fixation, using screw fixation for the medial three rays and middle cuneiform is recessed proxi-
Kirschner wires for the fourth and fifth tarsometatarsal joints. Satisfactory outcome mally relative to the medial and lat-
can be expected in approximately 90% of patients. eral cuneiforms. This mortise config-
J Am Acad Orthop Surg 2003;11:260-267 uration accommodates the base of the
second metatarsal and lends additional
osseous stability at this articulation.
In the coronal plane, stability is fur-
Lisfranc described amputations through painful posttraumatic arthritis and pla- ther enhanced by the so-called Roman
the tarsometatarsal (TMT) joint for the novalgus deformity.3,4 A high index arch configuration of the metatarsal
treatment of severe, gangrenous mid- of suspicion should be maintained when bases, with the second metatarsal base
foot injuries, and his name has been examining a patient with an injured acting as the keystone (Fig. 1, B).
associated with many different inju- foot because delayed or missed diag- Ligaments supporting the TMC
ries to this region.1 Myerson2 described nosis occurs in up to 20% of cases.5-7 are grouped according to anatomic lo-
such injuries as involving the tarsometa- The goal of treating TMC injury is cation (dorsal, plantar, and in-
tarsal complex (TMC), which includes to obtain a plantigrade, stable, pain- terosseous). The lesser metatarsals are
the metatarsals and TMT joints, the less foot. Successful outcome largely bound together by dorsal and plan-
cuneiforms, the cuboid, and the na- is related to obtaining and maintain- tar intermetatarsal ligaments (Fig. 1,
vicular.2 The spectrum of TMC injury ing an anatomic reduction.5,6,8,9 Ear- A). Similarly, dorsal and plantar in-
ranges from low-energy trauma, such ly studies documented the failure of tertarsal ligaments hold the cunei-
as a misstep, to high-energy crush in- closed reduction to maintain an an- forms and cuboid together. There are
juries characterized by extensive os- atomic reduction.10-12 In 1982, Hard-
seous comminution and soft-tissue com- castle et al13 reported that open tech-
promise. Accordingly, the pattern of niques with temporary, nonrigid Dr. Thompson is Chief Resident, Department of
TMC injury is highly variable and may fixation occasionally resulted in late Orthopaedic Surgery and Rehabilitation, Creighton-
Nebraska Health Foundation, University of Ne-
involve purely ligamentous disrup- displacement. Rigid screw fixation, the
braska Medical Center, Omaha, NE. Dr. Mormino
tions without fracture, associated meta- technique reported by Arntz et al6 in is Assistant Professor and Director, Orthopaedic
tarsal fractures, or fractures of the cu- 1988, has become the preferred meth- Trauma, Department of Orthopaedic Surgery and
neiforms, cuboid, or navicular. od for stabilization of these injuries.5 Rehabilitation, University of Nebraska Medical
Accurate diagnosis of these inju- Center.
ries is paramount. Although only min-
Reprint requests: Dr. Mormino, 981080 Nebraska
imal displacement may be present on Anatomy and Medical Center, Omaha, NE 68198-1080.
initial radiographs, severe ligamen- Biomechanics
tous disruption might still exist. Left Copyright 2003 by the American Academy of
untreated, such disruption may result Understanding the anatomy of the Orthopaedic Surgeons.
in marked disability characterized by TMC is imperative for accurate assess-

260 Journal of the American Academy of Orthopaedic Surgeons

 Michael C. Thompson, MD, and Matthew A. Mormino, MD

no ligamentous connections between at the third TMT joint is approximately

Figure 1 A, Anteroposterior view of the
bony and ligamentous anatomy of tarsometa-
tarsal joint complex. I through V = metatar-
sal bones. (Adapted with permission from
Myerson MS: Fractures of the midfoot and
forefoot, in Myerson MS: Foot and Ankle Dis-
orders. Philadelphia, PA: WB Saunders, 2000,
vol 2, pp 1265-1296.) B, Coronal section
through the metatarsal bases illustrating the
Roman arch configuration. (Adapted with
permission from Lenczner EM, Waddell JP,
Graham JD: Tarsal-metatarsal [Lisfranc] dis-
location. J Trauma 1974;14:1012-1020.)
the first and second metatarsal bases.
The largest and strongest interos-
seous ligament in the TMC is the so-
called Lisfranc ligament, which aris-
es from the lateral surface of the
medial cuneiform and inserts onto the
medial aspect of the second metatar-
sal base near the plantar surface.14 The
first metatarsal base is anchored to the
dorsal and plantar aspects of the me-
dial cuneiform by two longitudinal
ligaments. The peroneus longus and
tibialis anterior tendon insertions fur-
ther stabilize the first TMT joint. A
variable network of longitudinal and
oblique ligaments secures the remain-
der of the metatarsals to the cunei-
forms and cuboid on the dorsal and
plantar aspects of the complex. In
general, the dorsal ligaments are
weaker than their plantar counter-
parts. To a lesser extent, the plantar
fascia and intrinsic musculature of the
foot add stability to the TMC.
Because of the unique bony and lig-
amentous anatomy of the TMC, nor-
mal motion of the individual compo-
nents varies. Having articular contact
with all three cuneiforms, the base of
the second metatarsal demonstrates
very little motion under normal cir-
cumstances, with an average dorsi-
flexion-plantarflexion arc of 0.6°.15 In
comparison, dorsiflexion-plantarflexion
1.6°, and, at the first joint, 3.5°. The
fourth and fifth TMT joints are the most
mobile, demonstrating an average
of 9.6° and 10.2° of dorsiflexion-
plantarflexion, respectively.15
Injury to the
Tarsometatarsal Joint
Complex
The overall annual incidence of TMC
injuries is approximately 1 per 60,000
persons,13,16 and the injury is two to
three times more common in males
(Table 1). Motor vehicle accidents are
the most frequently cited mechanism,
accounting for about 40% to 45% of
injuries. Low-energy mechanisms ac-
count for approximately 30%. Falls
from a height and crush injuries are
also commonly reported causes.
The mechanism of TMC injury may
be either direct or, more commonly,
indirect trauma. The direct mechanism
involves high-energy blunt trauma,
usually applied to the dorsum of the
foot. Crush injuries constitute most of
these injuries, and many are associ-
ated with notable soft-tissue trauma.
Associated compartment syndromes
and open fracture-dislocations are
more often present with direct inju-
ry mechanisms. In part as a result of

Table 1
Tarsometatarsal Joint Complex: Mechanisms of Injury

No. of Injuries (%)

No. of Patients/ Motor Vehicle Fall From

Study Injuries (M/F) Accident Height Crush Other

Kuo et al5 48/48 (32/16) 20 (42) 7 (14.5) 6 (12.5) 15 (31)

Arntz et al6 40/41 (28/12) 21 (51) 7 (17) 0 (0) 13 (32)
Vuori et al16 66/66 (46/20) 22 (33) 9 (14) 14 (21) 21 (32)
Myerson et al9 52/55 (NA) 34 (62) 8 (14.5) 8 (14.5) 5 (9)
Hesp et al36 23/23 (16/7) 19 (83) 3 (13) 1 (4) 0 (0)
Hardcastle et al13 119/119 (86/33) 48 (40.3) 16 (13.5) 0 (0) 55 (46.2)
Wilppula et al12 26/26 (21/5) 7 (27) 0 (0) 8 (31) 11 (42)
NA = not available.

Vol 11, No 4, July/August 2003 261

Injury to the Tarsometatarsal Joint Complex

the associated soft-tissue trauma and
greater degree of articular injury, di-
rect injuries often result in a worse clin-
ical outcome compared with indirect
injuries.8,9
The indirect mechanism of injury
usually involves axial loading of the
plantarflexed foot. An example is a
football player falling onto the heel
of another player whose foot is planted
and plantarflexed. This type of injury
also can occur with soccer, basketball,
and gymnastics.17 Falls from a height
may result in forefoot plantarflexion
at the time of impact. In automobile
accidents, injury to the plantarflexed
foot occurs with a combination of de-
celeration and floorboard intrusion.
Less commonly, violent abduction or
twisting of the forefoot may result in
fracture-dislocation around the TMC.
The fracture pattern and direction
of dislocation in direct injuries are
highly variable and depend on the
force vector applied. In contrast, the
most frequent pattern seen in indirect
injuries involves failure of the weak-
er dorsal TMT ligaments in tension,
with subsequent dorsal or dorsolat-
eral dislocation of the metatarsals. Mi-
nor displacement at the TMT joint
level results in a marked reduction in
articular contact. Dorsolateral dis-
placement of the second metatarsal
base of 1 or 2 mm results in the re-
duction of the TMT articular contact
area by 13.1% and 25.3%, respective-
ly.18 Although fractures of the cune-
iforms are relatively common, the
most frequent fracture in TMC inju-
ries involves the second metatarsal
base.16 Less common are associated
fractures of the cuboid, navicular, or
other metatarsals.
subcutaneous tissue. Inspection of the
foot may reveal gross morphologic ab-
normalities such as widening or flat-
tening. A gap between the first and
second toes is suggestive of intercu-
neiform disruption as well as TMT
joint injury.19,20 Palpation of the dor-
salis pedis artery may not be pos-
sible, depending on the extent of
swelling and deformity. Although dis-
ruption of the dorsalis pedis artery has
been reported, the incidence of vas-
cular injury appears to be rare.7,21,22
Significant pain on passive dorsiflex-
ion of the toes in a tensely swollen foot
is suggestive of a compartment syn-
drome; however, evaluation may be
hampered by pain associated with the
osseous injury.23,24 When there is un-
certainty about the presence of a com-
partment syndrome, pressures should
be measured. An absolute pressure >40
mm Hg is diagnostic and an indica-
tion for emergent compartment re-
lease. Particularly in the hypotensive
patient, a compartment pressure with-
in 30 mm Hg of the diastolic pressure
also is an indication for release.
Findings after a low-energy TMC
injury may be relatively subtle. Ahigh
index of suspicion should be main-
tained in the patient with forefoot
pain after even a minor traumatic
event. Patients usually have notable
pain on weight bearing or are unable
to bear weight on the affected foot.
Swelling is present to a variable ex-
tent, and ecchymosis occasionally is
found along the plantar aspect of the
midfoot.25 Palpation of the affected
TMT joints usually reveals tender-
ness. Notable pain on passive abduc-
tion and pronation of the forefoot also
is suggestive of TMC injury.17
The initial radiographic examina-
tion should include anteroposterior,
lateral, and 30° oblique views of the
foot. To visualize the Lisfranc joint in
the tangential plane, the anteropos-
terior radiograph should be taken
with the beam approximately 15° off
vertical. Standing radiographs are
ideal but may be difficult to obtain
secondary to pain (Fig. 2, A and B).
If weight-bearing views are not pos-
sible, a stress view with the forefoot
in abduction often will reveal subtle
instability, especially at the first TMT
joint.17,26 All radiographs should be
evaluated for signs of instability. On
the anteroposterior view, the distance
between the first and second metatar-
sal bases varies among uninjured in-
dividuals, with up to 3 mm consid-

Diagnosis
The diagnosis of high-energy or crush
injuries to the TMC is relatively
straightforward. Examination typical-
ly reveals moderate to severe swell-
ing of the forefoot and, in open inju-
ries, disruption of the skin and
Figure 2 A, Anteroposterior non–weight-bearing radiograph of a patient with forefoot pain
after an axial load injury. Note the subtle widening (arrow) between the bases of the first and
second metatarsals. B, Anteroposterior standing view of the same patient as in Panel A dem-
onstrating subluxation (arrow) at the base of the second metatarsal. C, Anteroposterior view
of a patient with avulsion of the Lisfranc ligament, or fleck sign (arrow), at the base of the
second metatarsal.

262 Journal of the American Academy of Orthopaedic Surgeons

 Michael C. Thompson, MD, and Matthew A. Mormino, MD

ered normal.26,27 In subtle cases,

radiographs of the contralateral foot
should be obtained for comparison.
Stein28 reviewed 100 radiographs
of normal feet and noted several con-
stant anatomic relationships. On the
anteroposterior view, the medial bor-
der of the second metatarsal is in line
with the medial border of the mid-
dle cuneiform, the first metatarsal
aligns with the medial and lateral bor-
ders of the medial cuneiform, and the
first and second intermetatarsal space
is continuous with the intertarsal space
of the medial and middle cuneiforms
(Fig. 1, A). On the 30° oblique view,
the medial border of the fourth meta-
tarsal is in line with the medial bor-
der of the cuboid, the lateral border
of the third metatarsal is aligned with
the lateral border of the lateral cune-
iform, and the third and fourth inter-
metatarsal space is continuous with Figure 3 Medial column line. On an anteroposterior radiograph with the forefoot stressed
the intertarsal space of the lateral cu- in abduction (dashed outline of first metatarsal), a line is drawn tangential to the medial bor-
neiform and the cuboid.28 ders of the navicular and medial cuneiform (heavy dashed line). Failure of this line to in-
tersect the base of the first metatarsal is strongly suggestive of TMC injury. A, Normal foot.
Other radiographic findings may B, First, second, and third TMT joint disruption (heavy dark line). Arrows indicate direction
assist with diagnosis. The fleck sign, of forces. (Adapted with permission from Coss HS, Manos RE, Buoncristiani A, Mills WJ:
or avulsion of Lisfranc’s ligament at Abduction stress and AP weightbearing radiography of purely ligamentous injury in the tar-
sometatarsal joint. Foot Ankle Int 1998;19:537-541.)
the base of the second metatarsal, is
diagnostic of TMC injury9 (Fig. 2, C).
Analysis of the medial column line on dislocations, a preoperative CT may published classification system, pub-
an anteroposterior abduction stress facilitate surgical planning by delin- lished by the Orthopaedic Trauma
view may reveal subtle injury26 (Fig. eating the extent of osseous injury. Association,35 is similar to the orig-
3). Flattening of the longitudinal arch The role of magnetic resonance im- inal Quenu and Kuss classification.
may suggest injury to the TMC and aging (MRI) in evaluating TMC inju- These classification systems are all
can be evaluated by comparing the ries has yet to be defined. MRI is more based on the congruency of the TMT
weight-bearing lateral view to that of sensitive than plain radiographs in joints and the direction of displace-
the uninjured foot.29 detecting small fractures and joint ment of the metatarsal bases. Com-
Computed tomography (CT) has malalignment and in assessing liga- mon to all classification systems is
proved to be a valuable tool in the di- mentous structures around the that none appears to be helpful in
agnosis of injuries to the TMC. It is TMC.33,34 However, with regard to di- terms of management or prognosis.9
more sensitive than plain radiographs agnosis and decision-making, CT is
in detecting minor displacement and superior to MRI.30 Therefore, MRI is
small fractures.30-32 Displacement of not routinely recommended in the as- Management
up to 2 mm may not be detectable on sessment of these injuries.
plain radiographs but is visible on Nonsurgical management of TMC in-
CT.31 Axial and coronal views of both juries should be limited to those that
feet should be made for comparison. Classification are without fracture, nondisplaced,
Subtle widening or dorsal sublux- and stable under radiographic stress
ation of the metatarsals are CT find- The earliest classification system was examination. As little as 2 mm of dis-
ings suggestive of TMC disruptions, published in 1909 by Quenu and placement or the presence of a frac-
and avulsion fracture of the second Kuss12 and subsequently modified by ture within the TMC warrants fixa-
metatarsal base is diagnostic of in- Hardcastle et al13 in 1982 and Myer- tion. Nondisplaced, stable ligamentous
jury33 (Fig. 4). In high-energy fracture- son et al9 in 1986. The most recently injuries may be treated in a non–

Vol 11, No 4, July/August 2003 263

Injury to the Tarsometatarsal Joint Complex
Figure 4 A, Coronal CT scan demonstrating subtle widening (arrow) of the first and sec-
ond metatarsal bases. B, Coronal CT scan showing an avulsion fracture (arrow) of the sec-
ond metatarsal base.
weight-bearing short leg cast for a
minimum of 6 weeks. Radiographic
examination should be done 1 to 2
weeks after injury to ensure that align-
ment and stability are maintained.
Gradual weight bearing in a protec-
tive brace may begin at 6 weeks. Per-
mission for unrestricted activity, such
as running and jumping, should be
withheld for 3 to 4 months.
Although displaced or unstable
TMC injuries have been treated by
closed reduction and casting, loss of
reduction was common and outcomes
were variable, with a high incidence
of poor results. Currently accepted sur-
gical techniques involve either closed
reduction with percutaneous Kirsch-
ner wire (K-wire) or screw fixation2
or open reduction with screw and/
or K-wire fixation.4-6 For fixation of
the medial three TMT joints, screw fix-
ation may be preferable to K-wires be-
cause ligamentous healing may re-
quire as much as 12 to 16 weeks of
immobilization to occur, and K-wires
can become loose, necessitating re-
moval as early as 6 weeks. Regard-
less of the technique used, the goal
should be anatomic reduction of the
affected joints because numerous stud-
ies have documented that clinical out-
come correlates with accuracy of
reduction.1,5-9,12,21,36,37
264
Ideally, surgical management of
closed injuries is undertaken when
soft-tissue swelling is at a minimum,
either immediately or after swelling
has abated. This delay may take up
to 2 weeks and can be identified by
the return of wrinkles to the skin. The
initial incision is made dorsally be-
tween the first and second web space.
The extensor hallucis longus tendon,
deep peroneal nerve, and dorsalis pe-
dis artery are identified and retract-
ed as a unit, allowing deep, sharp dis-
section to expose the first and second
TMT joints. Small, irreducible bone
fragments are débrided from the
joints. The reduction should begin
medially and progress laterally.
Aligning the medial aspect of the first
metatarsal and the medial cuneiform
reduces the first TMT joint. The en-
tire medial aspect of this joint is ex-
posed to ensure that plantar gapping
is not present. The reduction is pro-
visionally held with a K-wire, and the
joint is stabilized with a countersunk
3.5- or 2.7-mm screw placed from the
base of the first metatarsal into the
medial cuneiform. Using fully thread-
ed cortical screws placed for position-
ing, rather than compression, is pref-
erable. Screws crossing otherwise
normal joints result in little, if any,
long-term morbidity. If rotational in-
Journal of the American Academy of Orthopaedic Surgeons
stability of the first TMT joint persists
after placement of the first screw, a
second screw or K-wire may be
placed from the medial cuneiform
into the base of the first metatarsal.
The second metatarsal is then re-
duced to the medial border of the
middle cuneiform and temporarily
held with a K-wire. Definitive fixation
follows with a 3.5- or 2.7-mm coun-
tersunk screw directed from the base
of the second metatarsal into the mid-
dle cuneiform. A 3.5-mm screw is
usually appropriate for most patients;
a 2.7-mm screw may be used for pa-
tients of small stature or when there
is concern about the size of the 3.5-
mm screw relative to the diameter of
the second metatarsal. Medial column
fixation is then completed by placing
a 3.5- or 2.7-mm screw from the me-
dial cuneiform into the base of the
second metatarsal.
If the third TMT joint is disrupted
and remains unstable after fixation of
the first and second TMT joints, a sec-
ond dorsal incision is made between
the third and fourth metatarsals to ex-
pose the third TMT joint. This joint
is similarly reduced and fixed with a
3.5- or 2.7-mm screw directed from
the base of the third metatarsal into
the lateral cuneiform. Reduction of
the fourth and fifth TMT joints usu-
ally occurs with reduction of the me-
dial three TMT joints and is secured
with percutaneous K-wire fixation
(Fig. 5). Alternative fixation, although
typically unnecessary, is done with
screw fixation.
Occasionally, an associated impact-
ed (nutcracker) fracture of the cuboid
may require treatment. The technique
described by Sangeorzan and Swiont-
kowski38 involves restoration of cuboid
length by distraction bone grafting and
plating. Failure to restore length re-
sults in lateral column shortening and
a persistently abducted and pronated
forefoot. A distractor or external fix-
ator may be used intraoperatively to
facilitate distraction before plating (Fig.
6). Associated fractures of the navicu-
lar may be exposed and stabilized by

Figure 5 Typical fixation scheme for a TMC
disruption.
extending the dorsal medial incision
proximally. In most cases, fragments
are large enough to accommodate 3.5-
or 2.7-mm screws placed using a lag
technique.
Rarely, severely comminuted or
contaminated injuries of the TMC may
not be amenable to internal fixation
using standard techniques. Temporary
or definitive spanning external fixa-
tion is an option for these difficult cas-
es. Limited percutaneous fixation with
K-wires or screws may augment sta-
bilization but should be used with cau-
tion in contaminated cases.
Wound closure should be accom-
plished with meticulous soft-tissue
handling and closure. Ashort leg, non–
weight-bearing cast is maintained for
6 weeks. Any percutaneous pins are
then removed, and the patient is ad-
vanced to full weight bearing in a
walking boot for an additional 4 to 6
weeks. The indication for screw re-
moval remains controversial.2,5 Most
authors recommend routine remov-
al of the screws either on weight bear-
ing or approximately 16 weeks after
fixation.2 We prefer to remove screws
only if patients are symptomatic but
no sooner than 16 weeks postopera-
Vol 11, No 4, July/August 2003
Michael C. Thompson, MD, and Matthew A. Mormino, MD
tively. Broken screws seem to occur
in only a minority of patients. Further-
more,affectedpatientsareoftenasymp-
tomatic, although broken screws may
be problematic if salvage by fusion is
necessary.
When a compartment syndrome is
diagnosed at the initial evaluation, emer-
gent fasciotomy should be done.23 Us-
ing the two dorsal incisions described,
the interosseous compartments are each
released. Dissection between the meta-
tarsals is done to achieve release of
the medial, central, and lateral com-
partments (Fig. 7). Rarely, associated
hindfoot injuries such as a calcaneus
fracture may be present and may re-
quire release of the calcaneal compart-
ment. This may be achieved through
a longitudinal medial incision over the
compartment. After fasciotomy, defin-
itive fixation should be done. Fascial
compartments and wounds should be
left open, and the patient may undergo
redébridement and attempted wound Figure 6 Restoration of cuboid length with
bone graft and a plate. An external fixator or
closure within 48 to 72 hours. Delayed distractor may be used intraoperatively to fa-
primary wound closure may not be cilitate distraction. (Adapted with permission
possible, and coverage with split- from Hansen ST Jr: Acute fractures in the foot,
in Hansen ST Jr: Functional Reconstruction of
thickness skin graft may be necessary.23,24 the Foot and Ankle. Philadelphia, PA: Lippin-
Open TMC fracture-dislocations cott Williams & Wilkins, 2000, pp 65-103.)
should be treated as surgical emergen-
cies. Débridement and irrigation should
be done within 6 hours of injury, if Results
possible. In addition to tetanus pro-
phylaxis, Gustilo and Anderson type In 1986, Myerson et al9 published a
I and II open injuries should receive retrospective study of 76 TMT joint
a first-generation cephalosporin, with injuries treated over a 10-year peri-
an aminoglycoside added for type III od. Six open injuries were included.
injuries. Severe contamination or vas- Treatment methods comprised immo-
cular compromise requires adding pen- bilization alone, closed reduction and
icillin G to the antibiotic regimen. casting, closed reduction and percu-
Wounds are left open and covered with taneous K-wire fixation, and open re-
saline gauze or an equivalent dress- duction followed by K-wire fixation.
ing. Repeat débridement and irriga- Fifty-five injuries were followed up
tion are done every 48 hours until a at a mean of 4.2 years (range, 1.6 to
clean, viable wound bed is achieved. 11 years). Immobilization alone or
Ideally, wound closure is achieved by closed reduction and casting result-
delayed primary closure. In the foot, ed in 0 of 5 and 3 of 15 (20%) good
however, this is often not possible. and excellent results, respectively. In
Coverage may be achieved by split- contrast, good to excellent clinical re-
thickness skin graft, free tissue trans- sults were documented in 9 of 17 pa-
fer, or local rotation flaps, according tients (53%) who underwent closed
to surgeon preference and institution reduction and percutaneous pinning
capabilities. as well as in 14 of 18 patients (78%)
265
Injury to the Tarsometatarsal Joint Complex
Figure 7 Release of compartment syndrome through dorsal incisions. (Adapted with per-
mission from Myerson MS: Experimental decompression of the fascial compartments of the
foot: The basis for fasciotomy in acute compartment syndromes. Foot Ankle 1988;8:308-314.)
treated with open reduction and
K-wire fixation. Seven of the eight di-
rect crush injuries had fair to poor
functional outcomes (88%). Overall,
the quality of reduction, which was
a subjective assessment of TMT joint
alignment, correlated with the clin-
ical result. Good to excellent results
were achieved in 22 of 26 patients
(85%) with an acceptable reduction
and in only 5 of 29 patients (17%) with
an unacceptable reduction. The au-
thors concluded that the major deter-
minants of unacceptable results are
the damage to the articular surface
at the time of injury and the quality
of the initial reduction.9
In 1988, Arntz et al6 published their
results of 41 TMC injuries in 40 pa-
tients treated with open reduction and
screw fixation. Seven of the injuries
were open fracture-dislocations.At sur-
gery, intra-articular fracture or peri-
articular comminution was noted in
54% of injuries (22/41). Anatomic re-
duction (within 2 mm) was achieved
in 97% of the closed injuries (33/34)
and in 88% overall (36/41). Hardware
was removed from all patients at a min-
imum of 12 weeks. Thirty-four patients
(35 injuries) were followed up at a
266
mean of 3.4 years after injury. Good
or excellent functional results were re-
ported for 93% of closed injuries (27/
29). In contrast, four of the six patients
with open fractures had a fair or poor
functional result. In all patients, the
presence of degenerative changes on
follow-up radiographs negatively cor-
related with functional outcome. Ra-
diographic evidence of posttraumatic
degenerative changes was absent or
minimal in 26 of the 30 injuries with
an anatomic reduction (87%). Con-
versely, all five injuries with nonana-
tomic reduction after surgery devel-
oped moderate or severe posttraumatic
arthritis. In general, patients who sus-
tained open injuries were more likely
to have periarticular comminution
noted intraoperatively, more advanced
posttraumatic degenerative changes
at follow-up, and a worse functional
outcome. The authors concluded that
injury to the articular cartilage and fail-
ure to achieve an anatomic reduction
were the most important determinants
in the development of posttraumatic
arthritis. Furthermore, they stressed
the importance of open anatomic re-
duction followed by rigid screw fix-
ation in optimizing outcome.6
Journal of the American Academy of Orthopaedic Surgeons
More recently, Kuo et al5 reported
on 92 TMC injuries treated over a
7-year period. Six open injuries were
included in the study. All patients
were treated surgically with the me-
dial three joints stabilized with screws
and the fourth and fifth joints, with
Kirschner wires. Postoperatively,
screws were removed only when
painful. Forty-eight patients were ex-
amined at a mean of 4.3 years after
injury (range, 1.1 to 9.5 years), for a
follow-up rate of 52%. The prevalence
of radiographic posttraumatic arthri-
tis was significantly (P = 0.004) lower
in patients with an anatomic reduc-
tion within 2 mm (6/38 [16%]) com-
pared with those with nonanatomic
reduction (6/10 [60%]). In addition,
patients with anatomic reduction had
a statistically significant (P = 0.05) bet-
ter average functional score, as mea-
sured by the American Orthopaedic
Foot and Ankle Society score for the
midfoot. Purely ligamentous injuries
tended to have a higher prevalence
of osteoarthritis, but without statis-
tical significance. The authors con-
cluded that the overall outcomes af-
ter surgical treatment of these injuries
are good and that anatomic reduction
is important for long-term outcome.5
Complications
Posttraumatic arthritis remains the
most common complication after TMC
injury. Not all patients who develop
degenerative radiographic changes are
symptomatic.9 In the series by Kuo et
al,5 12 of 48 patients (25%) had symp-
tomatic arthritis at final follow-up. Of
these, six underwent arthrodesis.Arntz
et al6 reported moderate to severe de-
generative changes on follow-up ra-
diographs in 9 of 35 patients (26%).
Cushioned inserts, shoe modifications,
and nonsteroidal anti-inflammatory
medications are the mainstay of non-
surgical treatment for posttraumatic
arthritis after TMC injury. If these mo-
dalities fail, arthrodesis of the affected
joints is the treatment of choice.

Other complications occur with
less frequency. Arntz et al6 and Kuo
et al5 reported an incidence of broken
screws of 2% and 25%, respectively.
Superficial infection, residual dyses-
thesias, late displacement, and deep
vein thrombosis have been reported
in <4% of cases.5,6,9
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