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Lisfranc fracture dislocation
This document discusses Lisfranc injuries, which involve fracture or ligament disruption of the tarsometatarsal joint complex. It describes the anatomy of the Lisfranc joint and surrounding ligaments. Common mechanisms of injury are twisting of the forefoot or axial loading of a fixed foot. Clinical evaluation looks for foot deformity, swelling, and tenderness. Radiographs are used to diagnose and classify the injury based on displacement patterns. Treatment options include casting for nondisplaced injuries or open reduction and internal fixation for displaced fractures. Complications can include arthritis, stiffness, and neurovascular problems.
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Lisfranc fracture dislocation
- 1.
- 2. ANATOMY • In theAP plane, the base of the second metatarsal is recessed between the medial and lateral cuneiforms. This limits translation of the metatarsals in the frontal plane. • In the coronal plane, the middle three metatarsal bases are trapezoidal, forming a transverse arch that prevents plantar displacement of the metatarsal bases.
- 3. • The secondmetatarsal base is the keystone in the transverse arch of the foot. • There is only slight motion across the tarso- metatarsal joints, with 10 to 20 degrees of dorsoplantar motion at the fifth metatarso- cuboid joint and 20 degrees plantar flexion at the first metatarso-cuneiform joint
- 4. • The ligamentoussupport begins with the strong ligaments linking the bases of the second through fifth metatarsals. • The most important ligament is Lisfranc ligament, which attaches the medial cuneiform to the base of the second metatarsal.
- 6. MECHANISM • Twisting • Axialloading • Crushing
- 7. • Twisting: Forcefulabduction of the forefoot on the tarsus results in fracture of the base of the second metatarsal and shear or crush fracture of the cuboid. • Most common mechanism
- 8. • Axial loadingof a fixed foot may be seen with extreme ankle equinus with axial loading of the body weight, such as a missed step off a curb or landing from a jump during a dance maneuver. • Crushing mechanisms are common in industrial injuries to Lisfranc joint, often with soft tissue compromise, and compartment syndrome
- 9.
- 10. CLINICAL EVALUATION • Patientspresent with variable foot deformity, pain, swelling, and tenderness on the dorsum of the foot. • Diagnosis requires a high degree of clinical suspicion. • Often missed or misdisgnosed as a simple sprain
- 11. • Careful neurovascularexamination is essential • Maybe assosiated with laceration of the dorsalis pedis artery. • Severe swelling of the foot is common and compartment syndrome of the foot must be ruled out
- 12. RADIOGRAPHIC EVALUATION • Themedial border of the second metatarsal should be colinear with the medial border of the middle cuneiform on the AP view • The medial border of the fourth metatarsal should be colinear with the medial border of the cuboid on the oblique view
- 15. • Dorsal displacementof the metatarsals on the lateral view is indicative of ligamentous compromise. • Fleck fractures around the base of the second metatarsal are indicative of disruption of Lisfranc joint.
- 16. • Weight-bearing radiographsprovide a stress film of the joint complex. • Stress views can be obtained. • CT scan to assess intraarticular comminution.
- 17.
- 18. OUENU AND KUSS CLASSIFICATION •Homolateral: All five metatarsals displaced in the same direction • Isolated: One or two metatarsals displaced from the others • Divergent: Displacement of the metatarsals in 2 planes
- 20. MYERSON CLASSIFICATION • Totalincongruity: Lateral and dorsoplantar • Partial incongruity: Medial and lateral • Divergent: Partial and total
- 22.
- 23. NON OPERATIVE • Injuriesthat present with painful weight bearing, and tenderness but fail to exhibit any signs of instability should be considered a sprain. • <2mm displacement of tarsometatarsal joint • Patients with nondisplaced/ ligamentous injuries should be placed in a short leg cast
- 24. • Initially, thepatient is kept non weight bearing with crutches and is permitted to bear weight as comfort allows. • Repeat x-rays are necessary once swelling decreases, to detect osseous displacement.
- 25. OPERATIVE MANAGEMENT • Thisshould be considered when displacement of the tarsometatarsal joint is >2 mm. • The best results are obtained through anatomic reduction and stable fixation. • The most common approach is using two longitudinal incisions.
- 27. • The firstis centered over the first/second intermetatarsal space allowing identification of the neurovascular bundle and access to the medial two tarsometatarsal joints. • A second longitudinal incision is made over the fourth metatarsal
- 28. • The keyto reduction is correction of the fracture-dislocation of the second metatarsal base. • Once reduction is accomplished, fixation is maintained by kirschner wires or screw fixation
- 29. • The lateralmetatarsals frequently reduce with reduction of the medial column • If intercuneiform instability exists, an intercuneiform screw / k wire can be used. • Stiffness from ORIF is not of significant concern because of the already limited motion of the tarsometatarsal joints.
- 34. COMPLICATIONS • Posttraumatic arthritis •Compartment syndrome • Infection • CRPS/RSD • Neurovascular injury • Hardware failure
- 35.
Editor's Notes
- #14 The medial border of the second metatarsal should be colinear with the medial border of the middle cuneiform on the AP view The medial border of the fourth metatarsal should be colinear with the medial border of the cuboid on the oblique view
- #15 The medial border of the second metatarsal should be colinear with the medial border of the middle cuneiform on the AP view The medial border of the fourth metatarsal should be colinear with the medial border of the cuboid on the oblique view
- #31 ■ With the patient under a regional or general anesthetic, make a dorsal incision lateral to the extensor hallucis longus tendon over the interval between the base of the first and second metatarsals, slightly more lateral if access to the third tarsometatarsal joint is necessary. At the distal extent of the excision, preserve the most medial branch of the dorsal medial cutaneous nerve. ■ A second incision may be needed more laterally if open reduction of the fourth and fifth tarsometatarsal joints is necessary (Fig. 88-66A). ■ Locate and incise the inferior extensor retinaculum
- #32 . ■ Isolate the dorsalis pedis artery and deep peroneal nerve, and use a vessel loop for retraction of these structures medially or laterally to allow inspection of different areas of the Lisfranc joint
- #33 ). ■ Remove any debris from the Lisfranc region between the base of the second metatarsal and the medial cuneiform to allow the space to be reduced. Reduce thefirst tarsometatarsal joint and hold it with guidewires for cannulated screws. Place a screw from the dorsal aspect of the first metatarsal into the medial cuneiform
- #34 ■ Under fluoroscopic guidance, pass a guidewire from the medial cuneiform into the base of the second metatarsal while holding the reduction with a towel clip. Place the appropriate 4.0-mm cannulated screw over the guidewire