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- 1. Lisfranc Injuries: Diagnosisand Management Summary of Key Concepts from EFORT Open Review 2019
- 2. Introduction • Lisfranc injuryinvolves displacement of one or more metatarsals. • Named after Jacques Lisfranc, a French surgeon in 1815.
- 3. • Can resultfrom low-energy sports injuries or high-energy trauma. • Infrequent, at approximately 0.2% of all fractures, although in 20% of cases missed . • Early and accurate diagnosis is essential.
- 4. Anatomy of theLisfranc Joint • Formed by five metatarsals, three cuneiforms, and the cuboid. • The first three cuneiform- metatarsal joints have high stability. • The fourth and fifth metatarsals have greater mobility. • Stability is maintained by the transverse arch and Lisfranc ligament.
- 5. Ligamentous Structures • Dorsaland plantar TMT ligaments stabilize each joint. • Inter-metatarsal ligaments connect the second to fifth metatarsals. • The Lisfranc ligament is the strongest . • Lack of an inter-metatarsal ligament between the first and second metatarsals is a key feature.
- 6. Clinical Presentation • Painand swelling in the midfoot. • High-energy injuries often present with deformity and inability to walk. • Low-energy injuries may be subtle and require careful examination. • Look for plantar ecchymosis, tenderness, and positive provocation tests.
- 7. Radiological Diagnosis • StandardX-rays: AP, lateral, and oblique views. • Look for malalignment, diastasis, and the ‘fleck sign’ (avulsion fracture). • MRI detects ligamentous injuries and instability.
- 8. CT scan isuseful for subtle fractures and surgical planning.
- 9. Classification of LisfrancInjuries • Quenu and Kuss (1909) – Homolateral, isolated, and divergent types.
- 10. • Hardcastle (1982)– Total, partial, or divergent incongruence. • Myerson (1986) – Modification of Hardcastle classification. • Nunley and Vertullo (2002) – Classification for subtle injuries.
- 12. Subtle Lisfranc Injuries •Common in athletes with axial load injuries. • Patients may report a ‘pop’ in the midfoot. • Look for pain with abduction/pronation stress. • Weight-bearing X-rays and MRI help detect subtle instability.
- 13. Treatment Overview • Goal:Achieve anatomic reduction and maintain stability. • Non-surgical treatment for stable, non-displaced injuries. • Surgery indicated for displaced or unstable injuries. • Early intervention prevents long-term complications.
- 14. Surgical Treatment • Openreduction and internal fixation (ORIF) is the standard. • Temporary K-wires or external fixation for severe injuries. • Definitive surgery is delayed for 10-15 days to allow soft tissue healing. • Surgery involves stabilization with screws or dorsal plates.
- 15. Surgical Approach &Fixation • Double Incision Approach for complex injuries • 1st incision: First intermetatarsal space • 2nd incision: Along the fourth metatarsal • Stepwise Reduction & Fixation • K-wires & 3.5-mm screws for medial column • 4-4.5 mm screws for 1st to 2nd metatarsal stabilization • Lateral column (4th & 5th metatarsals) stabilized with K- wires
- 16. Surgical Techniques • ORIFwith screws or dorsal plates for comminuted fractures. • Lisfranc screw between 1st cuneiform and 2nd metatarsal. • Double incision technique for unstable 4th /5th rays. • Immobilization for 6-8 weeks.
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- 22. Fixation Techniques &Considerations • ✅ Transarticular Screws: Strong fixation but risk of joint damage • ✅ Dorsal Bridge Plates: Preserve cartilage, better functional outcomes • ✅ Plantar Plates: Greater stability & soft tissue protection in arthrodesis • ✅ K-wires: Reserved for lateral column injuries (risk of displacement)
- 23. Clinical Outcomes &Complications • Arthrodesis: Better functional recovery in ligamentous injuries (92% vs 65%) • ORIF: Higher risk of post-traumatic OA, but faster return to activity
- 24. Post-Surgical Rehabilitation • Non-weight-bearingin a walker boot for 6 weeks. • Progressive weight-bearing allowed with insoles. • Return to sports in 8-12 months based on healing. • Hardware removal not routinely performed.
- 25. Complications • Wound healingissues (0-13%)Sensory changes (25%) & soft tissue necrosis (8%) • Post-traumatic osteoarthritis (50% ). • Midfoot instability and chronic pain. • Revision surgery- non union or maluion. • Neuropathy of the deep peroneal nerve.
- 26. Current Controversies • ORIFvs. primary arthrodesis for ligamentous injuries. • Screws vs. dorsal plates for stabilization. • Timing of surgery in high-energy trauma cases. • Role of early weight-bearing in recovery.
- 27. Conclusion • Lisfranc injuriesrequire a high index of suspicion. • Early and accurate diagnosis improves outcomes. • Treatment depends on stability and displacement. • ORIF is the standard, but controversies remain. • Rehabilitation is key for long-term function.