Orthopedic Pitfalls in the ED: Lisfranc Fracture-Dislocation

ANDREW D. PERRON, MD, WILLIAM J. BRADY, MD, AND THEODORE E. KEATS, MD

Lisfranc fracture-dislocation of the foot is an injury that carries a high incidence of chronic pain and disability. Its emergency department presentation can be subtle, and more frequent than previously believed. This review article examines the clinical presentation, historical factors, diagnostic techniques, and management options applicable to the emergency practitioner. (Am J Emerg Med 2001;19:71-75. Copyright 2001 by W.B. Saunders Company)

The articulation between the tarsal and metatarsal bones in the foot is named after Jacques Lisfranc, a French physician and eld surgeon in Napoleons army who was the rst to described amputations through this joint. Injuries to this region commonly result from falls and motor vehicle or industrial accidents, ranging from mild sprains to severe dislocations and fracture-dislocations. Because Lisfranc joint fracture-dislocations and sprains carry such a high risk of chronic pain and functional disability if they go unrecognized and hence untreated,1-4 emergency physicians should maintain a high index of suspicion for these injuries. Historically, Lisfranc injuries were thought to be a rare problem accounting for less than 1% of all orthopedic trauma; the overall incidence, however, is increasing and more common than initially recognized.1,5-6 The complex bony and ligamentous anatomy of this joint and the multiple patterns and mechanisms of injury make radiographic interpretation challenging and diagnosis difcult. It is estimated that the diagnosis is missed on initial presentation to the emergency department in approximately 20% of cases.1,5-8 Emergency physicians should be familiar with the presentation of Lisfranc injuries. Early recognition and timely orthopedic referral is essential for optimal treatment and outcome. ILLUSTRATIVE CASES Case 1 A 30-year-old man presented to the emergency department with a complaint of left foot pain. He related that he had jumped from a boat to a dock from a height of approximately 8 feet. He landed primarily on the left foot, and had no other complaints.
From the Department of Emergency Medicine, and the Department of Radiology, University of Virginia Health System, Charlottesville, VA. Manuscript received May 3, 2000, accepted June 6, 2000. Address reprint requests to Andrew D. Perron, MD, Assistant Professor of Emergency Medicine, Department of Emergency Medicine, Box 800699, University of Virginia Health System, Charlottesville, VA 22908. E-mail: adp9b@virginia.edu Key words: Lisfranc injury, fracture-dislocation. Copyright 2001 by W.B. Saunders Company 0735-6757/01/1901-0019$10.00/0 doi:10.1053/ajem.2001.19990

Examination of the left foot revealed moderate swelling over the dorsum of the midfoot, and exquisite tenderness to palpation. He could weight-bear only with signicant pain. The skin was intact, and his neurovascular examination was normal. Radiographic evaluation showed an oblique fracture in the midportion of the second metatarsal that extended to the articular surface (Fig 1). Fractures were also noted to extend horizontally through the base of the third and fourth proximal metatarsal heads. The rst through the fth proximal metatarsal heads are all shifted laterally with respect to the associated cuneiforms (Fig 2), indicating a Lisfranc type dislocation in addition to the fractures. Orthopedic consultation was obtained, and the patient was taken to the operating room the following day for open reduction, internal xation of the fracture/dislocation. At 1-year follow-up the patient was pain free and had returned to his usual activities. Case 2 A 22-year-old weightlifter was transferring a 100-lb weight plate from a barbell to a rack when he lost his grip and the plate fell onto the dorsum of his left foot. The patient had immediate pain and swelling, and could not bear weight. Examination showed impressive swelling throughout the left foot, with diffuse pain. Pain was maximal with palpation of the proximal second and third metatarsal heads. His neurovascular examination was normal. Radiographs were obtained which showed a divergent Lisfranc dislocation. Metatarsals 2 through 5 are displaced laterally, whereas the rst metatarsal is medially shifted (Fig 3). Dorsal dislocation of the proximal second metatarsal is evident on the lateral radiograph (Fig 4). No fractures are seen. The patient was consulted to orthopedic surgery, and he underwent open reduction, internal xation of the foot that same evening. At 2 years out from his injury, he continued to have pain with ambulation and occasional swelling in the foot. PATHOPHYSIOLOGY Lisfranc injuries can be caused by either direct or indirect trauma. Direct or crush injuries to the dorsum of the foot are rare and are often complicated by contamination, vascular compromise, and compartment syndrome.5 The displacement of the metatarsal bases may occur in either the plantar or dorsal direction depending on the direction of force at the time of injury; and no distinctive pattern of injury exists for this mechanism. Indirect forces constitute the vast majority of injuries, resulting from either a rotational force applied to
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a deformity. Plantar ecchymosis may also be noted, and if found should prompt aggressive search for Lisfranc joint injury.10 If the mechanism of injury is severe or deformity is obvious, manipulation of the foot should be kept to a minimum to prevent further displacement. A broadened foot, shortening in the anteroposterior plane, or a pathologic range of motion suggest severe fracture dislocation.7 Vascular compromise at the level of the Lisfranc joint rarely results in ischemic injury to the foot, but severe fracture dislocations can damage vessels or cause vascular spasm at the level of the ankle (posterior tibial artery), jeopardizing the foot. Serial vascular examinations are important when this injury is suspected. Tense swelling of the foot with diminished pulses suggests compartment syndrome and in these cases immediate surgical intervention is necessary to save the extremity.5,9 In a multiply injured, unconscious patient, the injury is easily missed because more life-threatening issues preclude full evaluation of the extremities. After the patients condition has improved, stability of the tarsometatarsal joint should be evaluated.

FIGURE 1. Patient 1. Internal oblique view of the foot. Spiral fracture of the proximal second metatarsal, with transverse fractures extending horizontally through the base of the third and fourth proximal metatarsals.

the forefoot with a xed hindfoot or axial loading on a plantar exed, xed foot. The longitudinal force results in metatarsal dislocation dorsally at the site of least resistance while the rotational force causes dislocation medially or laterally. In that tremendous energy is required for dislocation, these injuries are frequently associated with multiple fractures and signicant soft tissue injury.9 Common causes of indirect trauma include falls from a height, motor vehicle accidents or motorcycle accidents, equestrian accidents, and athletic injuries.1-3,6 Lisfranc injuries range from mild, undetectable subluxations to obvious fracture-dislocations. The clinical presentations are as varied as the patterns of injury. For this reason, the emergency physician should always maintain a high index of suspicion whenever evaluating an injured foot. After a signicant tarsometatarsal injury, patients generally present with complaints of midfoot pain, swelling, and difculty with weight bearing. In milder injuries, the patient may be able to bear weight acutely and be surprisingly active despite the pain. Tenderness along the Lisfranc joint is common and passive pronation with abduction of the forefoot with the hindfoot held xed will elicit pain; this maneuver is specic for tarsometatarsal injuries.9 The foot may appear normal or markedly deformed depending on the severity of the injury. Intense swelling of the foot may mask

FIGURE 2. Patient 1. AP view of the foot. The proximal second metatarsal does not line up with the medial edge of the second cuneiform. A small piece of bone, the eck sign is noted where the second metatarsal normally articulates with the second cuneiform.

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border of the second metatarsal base and the middle cuneiform and the medial border of the fourth metatarsal base and cuboid should form a straight, unbroken line. Any disruption of these lines or fracture fragments around the base of the second metatarsal or along the lateral border of the cuboid is indicative of signicant tarsometatarsal injury. Other consistently normal ndings include a straight line formed by the lateral border of the base of the third metatarsal and lateral border of the lateral cuneiform. On the lateral lm, a metatarsal shaft should never be more dorsal than its respective tarsal bone.6 A fracture of the cuboid, cuneiforms, navicular or metatarsal shafts is suggestive of disarticulation of the tarsometatarsal joint. In minor subluxation injuries, the key to diagnosis is the mortise congu-

FIGURE 3. Patient 2. AP view of the foot. A divergent Lisfranc dislocation. The rst metatarsal is shifted medially, while the second through fth metatarsals are shifted laterally.

DIAGNOSIS Proper radiographic evaluation and interpretation of the foot is the key to diagnosis of Lisfranc injuries. A knowledge of the normal anatomic relationships at the Lisfranc joint is vital to radiographic interpretation (see Fig 5). Similarly, familiarity with the mechanism of Lisfranc injury and common radiologic presentation will help the clinician in making the diagnosis (see Fig 6). The tarsometatarsal trauma series should include accurate radiographs with three views of the injured footanteroposterior (AP), lateral, and oblique views. Comparison radiographs of the contralateral foot may be helpful in detecting subtle injuries. Major fracture/dislocations are easily recognized and rarely missed on roentgenogram.11 Sprain injuries without dislocation, however, are difcult to diagnose radiographically even though physical examination ndings are highly suggestive of tarsometatarsal involvement. Weight-bearing lms (AP and lateral) should be obtained if the diagnosis is suspected but the plain lm series is not diagnostic.1,6,12-13 Radiographs of the tarsometatarsal joint may be daunting at rst glance because of confusion caused by overlapping bony articulations. The second metatarsal base should always be carefully evaluated for fracture, avulsions and displacement. On AP and oblique radiographs, the medial

FIGURE 4. Patient 2. Lateral view of foot. Dorsal displacement of the proximal second metatarsal is clearly evident.

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outcome.1-4,6,8 The denitive treatment of these fractures usually involves surgical intervention, although there is some controversy in the literature in this regard.2,9,16 The physicians responsibility in the emergency department is to suspect the diagnosis, conrm the injury radiographically, and to recognize the potential compartment syndrome, which may be associated with the fracture. If orthopedic consultation is not immediately available, the emergency physician can attempt closed reduction by hanging the foot by the toes using nger traps. If reduced, a bulky compressive dressing is then applied with a posterior splint. These injuries almost always warrant acute orthopedic evaluation. The goal in treating this injury is to reestablish a painless, stable, and functional joint. To do this, precise anatomic reduction is necessary.3,7,16 KEY POINTS FOR LISFRANC FRACTURE/DISLOCATION

Any foot with pain and swelling following trauma must be suspected of having a Lisfranc fracture/dislocation. The anatomic relationship of the tarsal/metatarsal joint should be examined carefully in any patient with a suspicious history and/or physical examination

FIGURE 5. Dorsal AP view of the foot, showing the Lisfranc joint complex. Note the alignment of the second metatarsal with the second cuneiform, and its keystone wedging into the 3 cuneiforms. Illustration by Marsha J. Dohrman. Reprinted with permission from Burroughs KE, Reimer CD, Fields KB: Lisfranc Injury of the Foot: A Commonly Missed Diagnosis. Am Fam Phys 1998;58:118-124.1

ration of the second metatarsal. Separation between the base of the rst and second metatarsal or between the medial and middle cuneiforms is strongly suggestive of subluxation.7,9 Widening can also occur between the second and third metatarsal or middle and lateral cuneiforms. A minor displacement of the three lateral metatarsal bones may be missed on AP and lateral lms but are often obvious on 30-degree oblique views.7 If plain lms and weight-bearing lms do not yield the diagnosis, magnetic resonance imaging or computed tomography can be used to denitively rule in or out the diagnosis.12-14 Displacement of a Lisfranc injury is described as homolateral or divergent. The homolateral type has lateral displacement of the rst through fth metatarsal heads. In the divergent type, the rst metatarsal (and occasionally the second metatarsal) dislocates medially or stays xed in place, while the more lateral metatarsals are displaced laterally.15 TREATMENT Early diagnosis of a Lisfranc joint injury is imperative for proper management and the prevention of a poor functional

FIGURE 6. Common mechanism for Lisfranc fracture-dislocation. An axial load is placed on the plantar-exed foot, with dorsal dislocation of the proximal second metatarsal head. Illustration by Marsha J. Dohrman. Reprinted with permission from Burroughs KE, Reimer CD, Fields KB: Lisfranc Injury of the Foot: A Commonly Missed Diagnosis. Am Fam Phys 1998;58:118-124.1

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A fracture at the base of a metatarsal bone should heighten the suspicion for a Lisfranc joint injury. A delay in the diagnosis or treatment of a Lisfranc fracture/dislocation can result in long-term morbidity of pain, arthrosis, and disability.

REFERENCES
1. Burroughs KE, Reimer CD, Fields KB: Lisfranc injury of the foot: A commonly missed diagnosis. Am Fam Phys 1999;58:118-124 2. Buzzard BM, Briggs PJ: Surgical management of acute tarsometatarsal fracture dislocation in the adult. Clin Orthop 1998;353: 125-133 3. Mulier T, Reynders P, Sioen W, et al: The treatment of Lisfranc injuries. Acta Orthop Belg 1997;63:82-90 4. Rabin SI: Lisfranc dislocation and associated metatarsophalangeal joint dislocations. A case report and literature review. Am J Orthop 1996;25:305-309 5. Arntz CT, Hansen ST: Dislocations and fracture dislocations of the tarsometatarsal joints. Orthop Clin North Am 1987;18:105-114 6. Englenhoff G, Anglin D, Hutson HR: Lisfranc fracture dislocation: A frequently missed diagnosis in the emergency department. Ann Emerg Med 1995;26:229-233 7. Goosens M, DeStoop N: Lisfrancs fracture dislocations: Etiology, radiology, result of treatment. Clin Orthop 1983;176:154-62

8. Vuori JP, Aro HT: Lisfranc joint injuries: Trauma mechanisms and associated injuries. J Trauma 1993;35:40-45 9. Myerson M: The diagnosis and treatment of injuries to the Lisfranc joint complex. Orthop Clin North Am 1989;20: 655-664 10. Margolis M, McLennan MK: Radiology rounds. Tarsometatarsal fracture dislocation. Can Fam Physician 1994;40:1103, 11081110 11. Potter HG, Deland JT, Gusmer PB, et al: Magnetic resonance imaging of the Lisfranc ligament of the foot. Foot Ankle Int 1998;19: 438-446 12. Lu J, Ebraheim NA, Skie M, et al: Radiographic and computed tomographic evaluation of Lisfranc dislocation: a cadaver study. Foot Ankle Int 1997;18:351-355 13. Ross G, Cronin R, Hauzenblas J, et al: Plantar ecchymosis sign: A clinical aid to diagnosis of occult Lisfranc tarsometatarsal injuries. J Orthop Trauma 1996;10:119-122 14. Wartella J, Cohen R, Schwartz DT: The Foot, in Schwartz DT, Reisdorff E (eds): Emergency Radiology. New York, McGraw-Hill, 2000, pp 135-156 15. Rosenberg GA, Patterson BM: Tarsometatarsal (Lisfrancs) fracture-dislocation. Am J Orthop 1995;7-16 (suppl) 16. Preidler KW, Peicha G, Lajtai G, et al: Conventional radiography, CT, and MR imaging in patients with hyperexion injuries of the foot: Diagnostic accuracy in the detection of bony and ligamentous changes. Am J Roentgenol 1999;173:1673-1677