Professional Documents
Culture Documents
Lisfranc Fracture - Current Concepts 2010
Lisfranc Fracture - Current Concepts 2010
Abstract
Troy S. Watson, MD Injuries to the tarsometatarsal joint complex, also known as the
Paul S. Shurnas, MD Lisfranc joint, are relatively uncommon. However, the importance of
an accurate diagnosis cannot be overstated. These injuries,
Jacques Denker
especially when missed, may result in considerable long-term
disability as the result of posttraumatic arthritis. A high level of
suspicion, recognition of the clinical signs of injury, and appropriate
radiographic studies are needed for correct diagnosis. When
surgery is indicated, closed reduction with percutaneous screw
fixation should be attempted. If reduction is questionable, open
reduction should be performed. Screw fixation remains the
traditional fixation technique.
Figure 1 Figure 2
the dorsal ligaments. These results American football players when they TMT injuries, prognosis depended
confirmed the observations of de are lying prone on the ground and more on joint incongruity than on
Palma et al10 and Sarrafian.13 Thus, another player falls on the prone ath- mechanism of injury.
ligamentous disruption typically be- lete’s heel. External rotation on a In 1986, Myerson et al7 proposed a
gins with the weaker dorsal liga- pronated forefoot is responsible for a scheme based on these previous sys-
ments, followed by the plantar liga- substantially unstable Lisfranc liga- tems to aid in clinical decision mak-
ments, and, finally, the Lisfranc mentous injury.7,20 The injuries can ing. They classified injuries as fol-
ligament.17 Structural stability to the be largely secondary to an abduction lows: type A, total incongruity of the
transverse arch is enhanced by the stress to the midfoot. This injury pat- TMT joint; type B1, partial incon-
short plantar muscles as well as by tern is best seen in sports that require gruity affecting the first ray in rela-
tive isolation (ie, partial medial
the muscular and tendinous support use of a stirrup, such as equestrian
incongruity); type B2, partial incon-
of the peroneus longus and the tibia- events and windsurfing. In cases such
gruity in which the displacement af-
lis anterior and tibialis posterior. as these, the forefoot is abducted
fects one or more of the lateral four
around a fixed hindfoot, causing dis-
MTs (ie, partial lateral incongruity);
location of the second MT and lat-
Mechanism of Injury and type C1 and C2, a divergent pat-
eral displacement of the remaining
tern, with partial or total displace-
MTs.
Most injuries to the TMT complex ment7 (Figure 3). These same authors
Direct injuries are usually associ-
can be designated as indirect or di- coined the phrase tarsometatarsal
ated with a crush injury. Depending
rect. Indirect injuries can be high en- joint complex in favor of older desig-
on the location of force applied to
ergy, as in motor vehicle accidents nations such as Lisfranc or TMT in-
the TMT joint complex, the MTs can
and falls from a height, or caused by juries because the former describes
undergo plantar or dorsal displace-
low-energy forces, such as those in- all bones and joints involved in TMT
ment.7 These fracture-dislocations
curred during athletic activity.3 Most fracture-dislocation, including the in-
are often associated with significant
commonly, indirect injuries are asso- tercuneiform and naviculocuneiform
soft-tissue trauma, vascular com-
ciated with a longitudinal force ap- joints.7
promise, and compartment syn-
plied to the forefoot, which is then In 2001, Chiodo and Myerson23
drome.15,21
subjected to rotation and compres- presented a columnar classification
sion.18 Excessive plantar flexion and of TMT joint injury based on the
abduction forces are the most com- Classification three mechanical columns of the foot
mon individual indirect mechanisms to aid in treatment planning. The
leading to midfoot disruption. As the Several classification systems have first TMT and medial naviculocunei-
second MT dislocates or fractures, been developed and updated in the form joints make up the medial col-
the MTs move laterally.19 past century, with the authors dis- umn. The middle column includes
Two different plantar flexion playing a tendency toward using the articulations between the second
mechanisms lead to dorsal joint fail- joint incongruity rather than mech- and third TMT joints and those be-
ure. The first occurs in ankle equinus anism of injury as a basis for treat- tween the middle and lateral cunei-
and metatarsophalangeal joint plan- ment and prognosis.2 These classifi- form with the navicular bone. The
tar flexion, with the Lisfranc joint cation systems are inherently lateral column consists of articula-
engaged along an elongated lever effective in standardizing terminol- tions between the cuboid and the
arm.2 The joint is “rolled over” by ogy and allowing for the description fourth and fifth MTs. Midfoot mo-
the body; this commonly occurs of both high- and low-impact inju- tion is highlighted in this system,
when a person misses a step or unex- ries; however, they may fall short in with strong prognostic implications.
pectedly catches the heel or latter determining management and pre- Komenda et al11 reported that post-
half of the foot on the curb as he or dicting clinical outcome. traumatic arthritis is more common
she is stepping down.8 Dorsal dis- In 1909, Quenu and Kuss22 first at the base of the second MT, sug-
placement caused by plantar flexion described injuries to the TMT joint gesting that incongruity is better tol-
can also occur when a force is ap- based on the direction of MT dis- erated at the medial and lateral col-
plied along the long axis of the foot placement. Several modifications fol- umns. The lateral column, which has
with the foot plantarflexed and the lowed, with the most comprehensive the greatest amount of sagittal plane
knee anchored on the ground.18 This being described by Hardcastle et al2 motion, is the least likely to be in-
is a common mechanism seen in in 1982. In their experience with volved in posttraumatic arthritis.
Figure 3
Classification of tarsometatarsal joint injury. The shaded areas represent the injured or displaced portion of the foot.
A, Type A, total incongruity, which involves displacement of all five metatarsals (MTs) with or without fracture at the
base of the second MT. The usual displacement is lateral or dorsolateral, and the MTs move as a unit. These injuries
are “homolateral.” B, In type B injuries, one or more articulations remain intact. Type B1 represents partial incongruity
with medial dislocation. Type B2 represents partial incongruity with lateral dislocation; the first MT cuneiform joint may
be involved. C, Type C injuries are divergent, with either partial (C1) or total (C2) displacement. The arrows in C2
represent the forces through the foot leading to a divergent pattern. (Redrawn with permission from Myerson MS,
Fisher RT, Burgess AR, Kenzora JE: Fracture-dislocations of the tarsometatarsal joints: End results correlated with
pathology and treatment. Foot Ankle 1986;6:225-242.)
Additional Imaging
Additional studies may be helpful,
including bone scans, MRI, and CT.
Bone scans are typically reserved for
patients with a midfoot injury but
with negative radiographic find-
ings.24 When plain radiographs and
the physical examination are equivo-
cal, MRI can be used to provide ex-
cellent depiction of the soft tis-
sues.6,32 Additionally, in the high-
level athlete, MRI may provide
information to help the treating phy-
sician make a determination on
return-to-play status. In a recent
study evaluating the predictive value
of MRI for midfoot instability, Rai-
kin et al6 found that MRI demon- A, AP weight-bearing radiograph following injury to the midfoot in a 45-year-
strating a rupture or grade 2 sprain old woman. Note the displacement of the second metatarsal (MT) base
laterally and the fleck sign between the first and second MT bases. This is a
of the plantar ligament between the
type B2 fracture. B, AP weight-bearing radiograph following open reduction
first cuneiform and the bases of the and internal fixation. C, AP weight-bearing radiograph following hardware
second and third MTs is highly pre- removal. Note the reduction of the second MT into the keystone.
dictive of midfoot instability, and
these patients should be treated with
Other factors, such as energy of the feel that, when possible, a diagnosis
surgical stabilization. CT is recom-
injury, cartilage damage, and soft- should be made without subjecting a
mended in patients presenting with
tissue injuries, can compromise the patient to anesthesia. The last resort,
high-energy injuries in which im-
final outcome. Most of the literature stress examination under anesthesia,
proved detection and delineation of
supports that anatomic alignment is is rarely required. Patient consent
fractures is required. However, sub-
necessary, and good or excellent re- should be obtained for possible open
tle displacement may not be demon-
sults have been achieved in 50% to reduction and internal fixation
strated because this is a non–weight-
95% of patients with anatomic (ORIF) if a stress examination is
bearing study. These images may
alignment, compared with 17% to deemed to be necessary.
demonstrate comminution and intra-
30% of patients with nonanatomic The patient with minimal ambula-
articular extension or interposed soft
alignment.2,7,27,34 tory ability, an insensate foot, or pre-
tissues not appreciated on the initial
radiographic assessment.33 existing inflammatory arthritis may
Nonsurgical be best treated nonsurgically. Recon-
Any measurable disturbance in nor- struction with midfoot arthrodesis
Management mal radiographic anatomy may be can be performed later if pain per-
an indication of instability and the sists. The authors prefer to use a
The key to successful management is need for surgical consideration. The CAM walking boot for 6 to 10
the determination whether to use key to selecting a nonsurgical option weeks in patients with stable injuries
surgical stabilization. Regardless of lies in ensuring that surgical inter- that can be managed nonsurgically.
the severity of injury, the goal of vention is not necessary. Table 1 lists Weight bearing is allowed as toler-
treatment is a painless, plantigrade, five steps that can be used to deter- ated, and follow-up weight-bearing
stable foot. Maintenance of ana- mine whether a patient requires sur- radiographs are obtained 2 weeks af-
tomic alignment seems to be the crit- gical treatment. Evaluation of subtle ter injury to ensure there are no
ical factor in achieving a satisfactory Lisfranc injury is time-consuming changes in alignment. Subsequently,
result, but it does not guarantee it. and potentially expensive, but we a brief 3- to 6-week course of physi-
Table 1
Stepwise Evaluation of a Patient With Lisfranc Injury to Determine Whether to Perform Nonsurgical or Surgical
Treatment
Step Study Result Recommendation Rationale
1 Physical examination Plantar bruising, painful Obtain weight-bearing radio- Weight-bearing radiographs are
piano key test, midfoot graphs unless injury is obvi- always useful, but oblique views
swelling ous with non–weight- may be helpful for the tentative
bearing images patient
2 Radiography Loss of arch on compara- ORIF is indicated with posi- Any measurable subluxation is an
tive weight-bearing lateral tive results. External rota- indication for ORIF. When in
radiograph, widening be- tion views are necessary doubt, proceed with further tests.
tween the first and second when there is uncertainty On MRI, edema indicates midfoot
metatarsal bases on com- based on plain radiographs injury, and subluxation confirms
parative AP views, fleck or the patient cannot bear Lisfranc injury.
sign weight. When uncertainty
remains, MRI is useful.
3 MRI Edema at the tarsometatar- If edema but no ligament tear MRI is more sensitive to edema in
sal joint, bone bruise, sub- or subluxation, then CT is subtle injuries. CT may better
luxation, or ligament tear recommended. Perform illustrate subluxation, but MRI
ORIF in the presence of may show both.
subluxation or a clear liga-
ment tear.
4 CT 1 mm of subluxation Strong evidence for Lisfranc MRI with edema and no ligament
injury when edema is noted tear combined with normal CT
on MRI and subluxation on requires stress examination under
CT. ORIF is indicated. anesthesia, with possible ORIF
5 Stress examination Subluxation ORIF When negative, treat as a sprain
cal therapy to work on gait training jury, as there are often distracting in- primary factors for our preference
and balance is often helpful. We have juries that may delay the diagnosis. for ORIF. The midfoot TMT joints
found it of help to transition these The timing of surgery is predicated have poor tolerance to mild mal-
patients into a comfort supportive on resolution of swelling, when the alignment35 as joint contact area is
shoe with a full-length total contact skin begins to wrinkle. In more se- reduced, predisposing to arthritis.
orthosis. It typically takes approxi- vere injuries, 3 weeks of bulky Jones Moreover, closed reduction may be
mately 4 months for these patients to splinting and elevation is required blocked or inhibited by bone frag-
recover from a nonsurgical Lisfranc before it is safe to perform surgery. ments or soft tissue, and the accu-
injury; patients should be informed Commercially available ice therapy racy of assessing 1 to 2 mm of sub-
of this time frame at the onset of units can be placed over the splint luxation radiographically is limited.
treatment. and may help expedite local pain re- Some authors believe closed reduc-
lief and reduction in swelling, before tion under fluoroscopic guidance
Surgical and after surgery. Ideally, Lisfranc in- should be attempted first because
Unstable injuries, even subtle ones, juries are best managed within the percutaneous screw fixation has
are managed surgically. Subtle Lis- first 2 weeks following the inciting been used successfully in the past.19
franc injuries are occurring with in- event, but we have treated many in- Dorsal incisions centered over the
creasing frequency, likely because of juries up to 6 weeks posttrauma with involved joints are used to approach
greater participation in high-demand successful anatomic reduction and the midfoot; small bone fragments
sports. Obvious injuries in multiple outcome. are excised, and larger pieces may be
trauma patients are not often missed, ORIF is our preferred technique fixed.7,12,27,34 Many forms of fixation
but more subtle injuries are a com- for subtle and obvious injuries. The are available depending on the na-
mon source of continued disability. presence of osteochondral fragments, ture of the injury and surgeon prefer-
Careful examination of the trauma soft-tissue interposition, and clear vi- ence.
patient is required with any foot in- sualization of the reduction are the For more obvious Lisfranc
References
functioning foot that is completely through the medical history before 4. Trevino SG, Kodros S: Controversies in
tarsometatarsal injuries. Orthop Clin
pain free even after the most severe making a final decision. Relative North Am 1995;26(2):229-238.
injury. In reality, following ORIF us- contraindications for surgical inter-
5. Vuori JP, Aro HT: Lisfranc joint injuries:
ing any of various internal fixation vention may include insensate feet Trauma mechanisms and associated
techniques, patients can expect to (eg, Charcot midfoot), inflammatory injuries. J Trauma 1993;35(1):40-45.
have a well-aligned foot that is stable arthritis, nonambulatory status, and 6. Raikin SM, Elias I, Dheer S, Besser MP,
but potentially stiff, with a variable severe medical comorbidity. Even pa- Morrison WB, Zoga AC: Prediction of
midfoot instability in the subtle Lisfranc
amount of residual pain. The patient tients treated nonsurgically require injury: Comparison of magnetic
likely will be able to perform most appropriate immobilization, physical resonance imaging with intraoperative
findings. J Bone Joint Surg Am 2009;
activities that he or she enjoys, but therapy, and orthotic support. 91(4):892-899.
perhaps not all of them. A thorough When surgery is indicated, an at-
7. Myerson MS, Fisher RT, Burgess AR,
discussion regarding the length of re- tempt at closed reduction under fluo- Kenzora JE: Fracture dislocations of the
covery, the magnitude of the injury, roscopy with percutaneous screw tarsometatarsal joints: End results
correlated with pathology and treatment. 19. Myerson MS, Cerrato RA: Current 31. Faciszewski T, Burks RT, Manaster BJ:
Foot Ankle 1986;6(5):225-242. management of tarsometatarsal injuries Subtle injuries of the Lisfranc joint.
in the athlete. J Bone Joint Surg Am J Bone Joint Surg Am 1990;72(10):1519-
8. Curtis MJ, Myerson M, Szura B: 2008;90(11):2522-2533. 1522.
Tarsometatarsal joint injuries in the
athlete. Am J Sports Med 1993;21(4): 20. Shapiro MS, Wascher DC, Finerman GA: 32. Potter HG, Deland JT, Gusmer PB,
497-502. Rupture of Lisfranc’s ligament in Carson E, Warren RF: Magnetic
athletes. Am J Sports Med 1994;22(5): resonance imaging of the Lisfranc
9. Meyer SA, Callaghan JJ, Albright JP, 687-691.
Crowley ET, Powell JW: Midfoot sprains ligament of the foot. Foot Ankle Int
in collegiate football players. Am J 21. Myerson MS: The diagnosis and 1998;19(7):438-446.
Sports Med 1994;22(3):392-401. treatment of injury to the
33. Thordarsen DB: Fractures of the midfoot
tarsometatarsal joint complex. J Bone
10. de Palma L, Santucci A, Sabetta SP, and forefoot, in Myerson MS, ed: Foot
Joint Surg Br 1999;81(5):756-763.
Rapali S: Anatomy of the Lisfranc joint and Ankle Disorders. Toronto, Canada,
complex. Foot Ankle Int 1997;18(6): 22. Quenu E, Kuss G: Study on the WB Saunders, 1999, vol 2, pp 1265-
356-364. dislocations of the metatarsal bones 1296.
(tarsometatarsal dislocations) and
11. Komenda GA, Myerson MS, Biddinger diastasis between the 1st and 2nd 34. Arntz CT, Veith RG, Hansen ST Jr:
KR: Results of arthrodesis of the metatarsals [French]. Rev Chir 1909;39: Fractures and fracture-dislocations of the
tarsometatarsal joints after traumatic 281-336, 720-791, 1093-1134. tarsometatarsal joint. J Bone Joint Surg
injury. J Bone Joint Surg Am 1996; Am 1988;70(2):173-181.
78(11):1665-1676. 23. Chiodo CP, Myerson MS: Developments
and advances in the diagnosis and treat- 35. Ebraheim NA, Yang H, Lu J, Biyani A:
12. Goossens M, De Stoop N: Lisfranc’s ment of injuries to the tarsometatarsal Computer evaluation of second
fracture-dislocations: Etiology, radiology, joint. Orthop Clin North Am 2001; tarsometatarsal joint dislocation. Foot
and results of treatment. A review of 20 32(1):11-20. Ankle Int 1996;17(11):685-689.
cases. Clin Orthop Relat Res 1983;
(176):154-162. 24. Nunley JA, Vertullo CJ: Classification, 36. Ly TV, Coetzee JC: Treatment of
investigation, and management of primarily ligamentous Lisfranc joint
13. Sarrafian S: Syndesmology, in Sarrafian midfoot sprains: Lisfranc injuries in the
SK, ed: Anatomy of the Foot and Ankle: injuries: Primary arthrodesis compared
athlete. Am J Sports Med 2002;30(6): with open reduction and internal
Descriptive, Topographic, Functional, ed 871-878.
2. Philadelphia, PA, Lippincott, 1993, pp fixation. A prospective, randomized
204-207. 25. Ross G, Cronin R, Hauzenblas J, Juliano study. J Bone Joint Surg Am 2006;88(3):
P: Plantar ecchymosis sign: A clinical aid 514-520.
14. Peicha G, Labovitz J, Seibert FJ, et al: to diagnosis of occult Lisfranc
The anatomy of the joint as a risk factor 37. Henning JA, Jones CB, Sietsema DL,
tarsometatarsal injuries. J Orthop Bohay DR, Anderson JG: Open
for Lisfranc dislocation and fracture- Trauma 1996;10(2):119-122.
dislocation: An anatomical and reduction internal fixation versus
radiological case control study. J Bone 26. Davies MS, Saxby TS: Intercuneiform primary arthrodesis for lisfranc injuries:
Joint Surg Br 2002;84(7):981-985. instability and the “gap” sign. Foot A prospective randomized study. Foot
Ankle Int 1999;20(9):606-609. Ankle Int 2009;30(10):913-922.
15. Wiley JJ: The mechanism of tarso-
metatarsal joint injuries. J Bone Joint 27. Arntz CT, Hansen ST Jr: Dislocations 38. Bellabarba C, Barei DP, Sanders RW:
Surg Br 1971;53(3):474-482. and fracture dislocations of the Dislocations of the foot, in Coughlin MJ,
tarsometatarsal joints. Orthop Clin Mann RA, Saltzman CL, eds: Surgery of
16. Solan MC, Moorman CT III, Miyamoto North Am 1987;18(1):105-114. the Foot and Ankle, ed 8. Philadelphia,
RG, Jasper LE, Belkoff SM: Ligamentous PA, Mosby, 2007, pp 2137-2197.
restraints of the second tarsometatarsal 28. Stein RE: Radiological aspects of the
joint: A biomechanical evaluation. Foot tarsometatarsal joints. Foot Ankle 1983; 39. Alberta FG, Aronow MS, Barrero M,
Ankle Int 2001;22(8):637-641. 3(5):286-289. Diaz-Doran V, Sullivan RJ, Adams DJ:
Ligamentous Lisfranc joint injuries: A
17. Cain PR, Seligson D: Lisfranc’s fracture- 29. Aronow MS: Treatment of the missed biomechanical comparison of dorsal
dislocation with intercuneiform Lisfranc injury. Foot Ankle Clin 2006; plate and transarticular screw fixation.
dislocation: Presentation of two cases an 11(1):127-142. Foot Ankle Int 2005;26(6):462-473.
a plan for treatment. Foot Ankle 1981;
2(3):156-160. 30. Coss HS, Manos RE, Buoncristiani A, 40. Panchbhavi VK, Vallurupalli S, Yang J,
Mills WJ: Abduction stress and AP Andersen CR: Screw fixation compared
18. Hatem SF, Davis A, Sundaram M: Your weightbearing radiography of purely with suture-button fixation of isolated
diagnosis? Midfoot sprain: Lisfranc ligamentous injury in the tarsometatarsal Lisfranc ligament injuries. J Bone Joint
ligament disruption. Orthopedics 2005; joint. Foot Ankle Int 1998;19(8):537- Surg Am 2009;91(5):1143-1148.
28(1):2, 75-77. 541.