Case Discussion. [39] in a group of 10 patients (11 feet) with midfoot open injuries treated with uniplanar EF, maintained for a mean duration of 9 weeks (range 6-15 weeks), experienced a high rate of complications including residual pain and foot and ankle function, ability to stand on tiptoe, presence of a limp, deformity of plantar arch, range of motion of the ankle, subtalar and metatarsophalangeal joints. High-energy injuries also require careful soft tissue examination (to select appropriate treatment, timing for surgery and minimize postoperative skin and wound complications), and if the evidence leads to a high suspicion of compartment syndrome a surgical fasciotomy is required [4,37]. Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). official website and that any information you provide is encrypted The approach was a viable option with complication rates similar to previous approaches. When Lisfranc joint complex injury is suspected, palpation of the foot should begin distally and continue proximally to each tarsometatarsal articulation. First of all it is necessary to distinguish between high and low energy injuries, in order to approach them with the correct imaging examinations up to the appropriate treatment (non-surgical or surgical), as shown in Figure 3 in the flow-chart for management and treatment of Lisfranc complex injuries. [44] TAS and DP showed similar ability to resist TMT joint displacement with weight-bearing load. Images must be recorded in AP, lateral, and 45 internal oblique views with associated weight-bearing views. 8. Crim J. MR imaging evaluation of subtle Lisfranc injuries: the midfoot sprain. (2004) ISBN:0781750067. If CT is not readily available, stress x-rays can be used. Case study, Radiopaedia.org (Accessed on 02 Jun 2023) https://doi.org/10.53347/rID-88084, see full revision history and disclosures. 11. High-energy injuries are more common than low-energy injuries which in most cases involve sports activities, usually occurring during football, gymnastic and running [4]. A recent systematic review has shown how with the use of CT, compared to X-ray, it is possible to detect 60% more metatarsal fractures and twice the tarsal fractures and joint misalignments [18]. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. {"url":"/signup-modal-props.json?lang=us"}, Knipe H, Lisfranc injury (weightbearing x-rays). Gallagher SM, Rodriguez NA, Andersen CR, Granberry WM, Panchbhavi VK. In that setting, they generally require a cast or splint and no weight bearing for several weeks to months. A diagram of the structure of the Lisfranc joint complex is shown in Figure 1. 55 Fruit Street MA Pain can localize to the medial or lateral aspect of the foot at the tarsometatarsal region on direct palpation, or it can be produced by abduction and pronation of the forefoot while the hindfoot is held fixed.[3]. A weight-bearing radiograph is necessary, because a non weight-bearing x-ray may not reveal any injury[3]. ADVERTISEMENT: Supporters see fewer/no ads. Weight Bearing X-Ray : LisfrancClub 5 Posted by u/sterekstyles 7 months ago Weight Bearing X-Ray So not a good story, 31/03/21 was coming in from the garden didn't lift my foot high enough, badly stubbed my toe on the bottom of the door and rolled my whole foot. Note: this service is provided by a third party, we do not collect your information in any way. view original journal article Subscription may be required, Journal Article Published: February 19, 2022 Dates of Study: July 1, 1991 - October 31, 2018, Learn more about the Foot and Ankle Research and Innovation Lab, Refer a patient to the Foot and Ankle Service, Chief, Foot & Ankle Service and Vice-Chair for Academic Affairs, Team Physician, Boston College Athletics; Consultant Team Physician, U.S. Intercuneiform instability and the gap sign. Treatment of Lisfranc Joint Injury: Current Concepts. [4], The injury was first noticed in the early 1800s by the French surgeon Jacques Lisfranc. . As a library, NLM provides access to scientific literature. J Ultrasound Med. Injuries to the tarsometatarsal joint. What are you searching for? In stable lesions and in those without dislocation, conservative treatment with immobilization and no weight-bearing is indicated for a period of 6 weeks. Weatherford BM, Bohay DR, Anderson JG. The most common symptoms are [13]: Differential diagnosis to Lisfranc injury includes: midfoot sprain, metatarsal fracture, cuboid fracture, posterior tibialis tendon dysfunction, and compression injuries to the navicular. Lisfranc injury recovery time. Ski Team, Professor of Orthopaedic Surgery, Harvard Medical School, Foot and Ankle Orthopaedic Surgeon, Assistant Professor of Orthopaedic Surgery, Harvard Medical School, Foot & Ankle Orthopaedic Surgeon, Sports Medicine Physician. Lisfranc (tarsometatarsal) injuries cover a spectrum of injuries that may include any combination of: Also, there may be associated injuries in both the forefoot, hindfoot, and ankle. Bone stability is determined by the trapezoidal shape of the base of the M1-M2-M3, with their respective cuneiform bones forming a stable arch known as a transverse arch or Roman arch with the second TMT joint as the keystone [7,8]. This study compared six articles to 193 patients. Controversies remain as to which internal fixation implants are most appropriate. As many as 20 percent of the Lisfranc joint injuries are missed on initial anteroposterior and oblique radiographs. Search There is a high incidence amongst football players. At the time the case was submitted for publication Henry Knipe had no recorded disclosures. {"url":"/signup-modal-props.json?lang=us"}, Knipe H, Lisfranc injury (weightbearing x-rays). Kirzner N, Zotov P, Goldbloom D, Curry H, Bedi H. Dorsal bridge plating or transarticular screws for Lisfranc fracture dislocations: a retrospective study comparing functional and radiological outcomes. Reference article, Radiopaedia.org (Accessed on 02 Jun 2023) https://doi.org/10.53347/rID-1590, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":1590,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/lisfranc-injury/questions/1576?lang=us"}, Figure 4: Nunley-Vertullo classification of Lisfranc injuries (illustrations), Figure 6: Myerson classification - illustrations, Figure 7: Nunley-Vertullo classification - illustrations, Case 5: traumatic homolateral LisFranc fracture dislocation, View Frank Gaillard's current disclosures, View Leonardo Lustosa's current disclosures, see full revision history and disclosures, Gustilo Anderson classification (compound fracture), Anderson and Montesano classification of occipital condyle fractures, Traynelis classification of atlanto-occipital dissociation, longitudinal versus transverse petrous temporal bone fracture, naso-orbitoethmoid (NOE) complex fracture, cervical spine fracture classification systems, AO classification of upper cervical injuries, subaxial cervical spine injury classification (SLIC), thoracolumbar spinal fracture classification systems, AO classification of thoracolumbar injuries, thoracolumbar injury classification and severity score (TLICS), Rockwood classification (acromioclavicular joint injury), Neer classification (proximal humeral fracture), AO classification (proximal humeral fracture), AO/OTA classification of distal humeral fractures, Milch classification (lateral humeral condyle fracture), Weiss classification (lateral humeral condyle fracture), Bado classification of Monteggia fracture-dislocations (radius-ulna), Mason classification (radial head fracture), Frykman classification (distal radial fracture), Hintermann classification (gamekeeper's thumb), Eaton classification (volar plate avulsion injury), Keifhaber-Stern classification (volar plate avulsion injury), Judet and Letournel classification (acetabular fracture), Harris classification (acetebular fracture), Young and Burgess classification of pelvic ring fractures, Pipkin classification (femoral head fracture), American Academy of Orthopedic Surgeons classification (periprosthetic hip fracture), Cooke and Newman classification (periprosthetic hip fracture), Johansson classification (periprosthetic hip fracture), Vancouver classification (periprosthetic hip fracture), Winquist classification (femoral shaft fracture), Schatzker classification (tibial plateau fracture), AO classification of distal femur fractures, Lauge-Hansen classification (ankle injury), Danis-Weber classification (ankle fracture), Berndt and Harty classification (osteochondral lesions of the talus), Sanders CT classification (calcaneal fracture), Hawkins classification (talar neck fracture), anterior superior iliac spine (ASIS) avulsion, anterior cruciate ligament avulsion fracture, posterior cruciate ligament avulsion fracture, avulsion fracture of the proximal 5th metatarsal, direct crush injury or an indirect load onto a plantarflexed foot, forefoot abduction-type injuries where the hindfoot is fixed and there is rotation around the joint such as changing direction with a foot planted firmly i.e. Injuries to the joint are often missed due to anatomical complexity and rarity. Fracture dislocations of the tarsometatarsal joints: analysis of interrater reliability in using the modified hardcastle classification system. The degree of malalignment is somewhat subtle but can be typical for these injuries. Outcomes after nonoperatively treated non-displaced Lisfranc injury: a retrospective case series of 55 patients. The surgeon should have a low threshold for ordering a CT scan when in doubt. 4. An additional abnormality is diastasis >2 mm between the 1st and 2nd metatarsal bases 10. It is commonly misdiagnosed as a sprain, particularly if the mechanism of injury is a simple twist and fall. I'm almost 3 weeks post surgery - 4 fractures which required 2 plates , a screw and 2 wires to be put in . Recently, a fourth category to Myersons modified Hardcastle classification (type D injury) has been introduced, which corresponds to the partial injury of the Lisfranc joint [28]. Patients present swelling of the midfoot region associated with pain on weight bearing activity [12]. : a systematic review and meta-analysis of current literature presenting outcome after surgical treatment for Lisfranc injuries. Hunter TB, Peltier LF, Lund PJ. Typically, conventional radiography of the foot is utilized with standard non-weight bearing views, supplemented by weight bearing views which may demonstrate widening of the interval between the . At the time the case was submitted for publication Henry Knipe had no recorded disclosures. [3][4], While transverse ligaments connect the bases of the lateral four metatarsals, no transverse ligament exists between the first and the second metatarsal bases. and transmitted securely. When this is successful, patients can start doing exercises while standing up. 5. Comparison of magnetic resonance imaging with intraoperative findings. MRI may be indicated for the identification of pure ligamentous injuries. The Piano Key test: Exacerbation of pain with dorsal and plantar flexion of each digit (, Single limb heel raise: Exacerbation of pain when patient stands on one leg and then on tip toes (places significant strain on injured area), Patients may not meet Ottawa ankle/foot imaging rules. 1. First level examination is X-ray, performed in 3 non-weight-bearing projections (AP, oblique, lateral) which in some cases is enough to make a diagnosis. If the injury is severe and its believed that the damage is beyond repair, a fusion may be recommended as the initial surgical procedure. Desmond EA, Chou LB. Tafur M, Rosenberg ZS, Bencardino JT. In a study involving 25 patients [43] that compared PA to ORIF, PA showed better results in terms of reduced foot deformity, biomechanical and function of the foot, complications and surgical duration of the procedure. A prospective, randomized study. However, the severity of the injury and a quick diagnosis are the main determinant of the biomechanical and functional long-term outcomes. Rhodes D, Leather M, Parker R. Case study: the conservative management of a complex mid foot injury in an elite professional footballer. Lisfranc complex injuries management and treatment flowchart. MRI of injuries to the first interosseous cuneometatarsal (Lisfranc) ligament. 12. Divided into D1 type in which distance between C1 bone and M2 is 2 mm and not require surgical fixation and D2 type with this distance >2 mm, with the need for surgical fixation (D2 further divided into purely ligamentous D2L and with bone avulsion D2B). Old healed fracture of the left 5th metatarsal. Kalia V, Fishman EK, Carrino JA, Fayad LM. The foot can be subdivided into three parts: the forefoot area which contains the toes, the midfoot area consisting the small bones called navicular, cuneiform and cuboid. FOIA In a study of Alberta et al. The mechanism of tarso-metatarsal joint injuries. [1]. Range of motion exercises: Plantarflexion, dorsiflexion, inversion, eversion and writing the alphabet with your toes. Medially displaced fracture of the medial base of the right 2nd metatarsal, in keeping with a Lisfranc ligament avulsion fracture. A direct trauma is can be caused when an external force works on the foot, for example when you drop something heavy on it. Talarico RH, Hamilton GA, Ford LA, Rush SM. The name is attributed to a French surgeon of the Napoleonic era, which in 1825 was the first to describe injuries and amputations at this level of the foot [1]. Bethesda, MD 20894, Web Policies Loss of alignment between the medial edges of Cu and M4 (on oblique view); 3. Treatment may be non-operative or operative, with the aim being to have a painless, plantigrade and stable foot 12. Closed reduction and K-wire percutaneous fixation can also be used for definitive fixation, but screw fixation has been shown to provide better biomechanical stability of the medial and middle columns. If stable, injuries can be treated conservatively in a non-weight bearing cast for 6 weeks . International Journal of Physiology, Pathophysiology and Pharmacology. Supporting the clinical utility of those measurements, their interpretation was more reliable on WB than NWB X-rays: When compared with the cut-off value of 2 mm diastasis that's commonly used to diagnose Lisfranc instability: Thus, if a surgeon had applied the conventional threshold and used only NWB films, half of the patients with Lisfranc instability would have gone undiagnosed based on C1-M2 diastasis measurements. Weight-bearing x-rays are an alternative to MRI to assess the integrity of the Lisfranc joint. You can use Radiopaedia cases in a variety of ways to help you learn and teach. In elderly patients and athletes, Lisfranc injuries may occur after low-energy rotational events. {"url":"/signup-modal-props.json?lang=us"}, Knipe H, Lisfranc injury (weightbearing x-rays). The most common complications of ankle and foot fractures are non-union and post-traumatic arthritis. Lisfranc complex injuries subsequent to high-energy trauma, often with fractures-dislocations, present clinical and imaging evidence that make it unlikely to miss. The key finding is malalignment of the second tarsometatarsal joint, such as lateral displacement of the second metatarsal base on AP view and/or dorsal step-off sign on lateral view 10. However, Lisfranc did not describe the injury patterns or mechanisms of injury that occur at this articulation. Remember that Lisfranc injuries frequently involve high energy, which dissipates through the soft tissues, and therefore they may be associated with a compartment syndrome. Woodward S, Jacobson JA, Femino JE et-al. The team also identified a control group of 26 patients with fifth metatarsal zone I avulsion fractures. [6] They may be caused by a low-energy injury such as a simple twist or fall. Conclusion: Primary partial arthrodesis produces well clinical and patient based outcomes. Johnson A, Hill K, Ward J, Ficke J. Anatomy of the lisfranc ligament. Perisano C, Greco T, Vitiello R, Maccauro G, Liuzza F, Tamburelli FC, Forconi F. Mueller-Weiss disease: review of the literature. Philpott et al. Sivakumar BS, An VVG, Oitment C, Myerson M. Subtle Lisfranc injuries: a topical review and modification of the classification system. Lisfranc injuries: an update. Nonoperative, open reduction and internal fixation or primary arthrodesis in the treatment of Lisfranc injuries: a prospective, randomized, multicenter trial - study protocol. Then they start with more difficult exercises (cycling, rowing, stepping). Since Lisfranc injuries may represent instability without frank displacement, ER x-rays (which are often non-weight bearing) may not show the extent of the injury. Preidler KW, Brossmann J, Daenen B et-al. This explains why the dislocation is often dorsal; ii. 1996;167 (5): 1217-22. Subtle lisfranc subluxation: results of operative and nonoperative treatment. Management of Lisfranc injuries depends on the severity of the trauma, with the primary goals of treatment being pain relief and foot stability preventing later OA and disability. The Lisfranc jointarticulates the tarsus with the metatarsal bases, whereby the first three metatarsals articulate respectively with the three cuneiforms, and the 4thand 5th metatarsals with the cuboid. Patients with stage III injuries have M1-M2 diastasis greater than 5 mm on AP weightbearing view and loss of midfoot arch height, showing a decreased distance M5-C1 on lateral X-ray [29]. Boston, Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. The sensitivity of X-ray in the diagnosis of tarsometatarsal joint injury was weak, while weight-bearing CT could show a displacement of more than 2 mm between the first and second metatarsal joint, indicating avulsion of the Lisfranc ligament. The joint capsule and dorsal ligaments form the only minimal support on the dorsal surface of the Lisfranc joint. However, based on our clinical experience and above all on the available literature, conservative treatment is indicated only for stable and non-displaced injuries with pure ligament sprains (stage I according to Nunley and Vertullo) [29]. The degree of malalignment is somewhat subtle but can be typical for these injuries. Still, subtle injuries may be missed and require further imaging such as CT, MRI or radiographic stress views with forefoot abduction. If you suspect an occult injury, insist on a weight-bearing film within the patient's tolerance. Associated fractures most often occur at the base of the second metatarsal, seen as the fleck sign. The two main mechanisms of injury are direct forces (crush injuries, fall from and height) and indirect forces (bending and torsion of the tarsus) [5]. Hardcastle PH, Reschauer R, Kutscha-lissberg E et-al. An injury at the Lisfranc joint is mostly the result of the combined external rotation and compression force. The use of suture endobutton fixation has also been described, placed along the path of the Lisfranc ligament (C1 to M2 base). 1985;144 (5): 985-90. Different surgical procedures have been proposed from closed reduction and percutaneous surgery with K-wire or external fixation (EF), to open reduction and internal fixation (ORIF) with transarticular screw (TAS), to primary arthrodesis (PA) with dorsal plate (DP), up to a combination of these last 2 techniques. Radiologic outcomes after Lisfranc fracture dislocation. Sheibani-Rad S, Coetzee JC, Giveans MR, DiGiovanni C. Arthrodesis versus ORIF for Lisfranc fractures. This can cause chronic pain in the injured joint. Haapamaki VV, Kiuru MJ, Koskinen SK. First of all, theyll need a walker. They commonly occur when a person stumbles over the top of a plantar flexed foot. 2010;34(8):1083-91. Lateral displacement of 2nd metatarsal on middle cuneiform, 3. Lisfranc fracture-dislocations: current management. with cleats or football boots (this is the classic 'horse stuck in stirrup mechanism), forced plantar-flexion where the plantarflexed foot undergoes significant axial loading. Shapiro MS, Wascher DC, Finerman GA. Rupture of Lisfrancs ligament in athletes. Up to 20% of Lisfranc fractures are unnoticed or diagnosed late, above all low-energy trauma, mistaken for simple midfoot sprains. Open reduction and temporary screws or K-wire fixation is in this case the treatment of choice. In suspected Lisfranc injuries,use of imaging modalities is warranted. In patients with suspicious mechanism, have a low threshold to image. In a prospective randomized study analyzing 101 patients with purely ligamentous injuries, 92% of the patients treated with PA achieved previous level of activity in the postoperative period. [11] The incidence of the Lisfranc joint fracture dislocations is one case per 55,000 persons each year. A metatarsal shaft should never be more dorsal than its respective tarsal bone, Presence of an avulsion fracture, called the fleck sign, Carefully perform neuromuscular examination with, Any of the following conditions requires emergent reduction and orthopedic consultation, Improved visualization particularly when X-rays equivocal but continued suspicion (i.e. The second imaging level is Computed Tomography (CT). Orthopedics About. Therefore serious complications such as post-traumatic osteoarthritis and foot deformities are not uncommon. The most common causes of re-surgeries are post-traumatic OA in patients treated with ORIF and non-union in those treated with PA. During the initial evaluation, up to 20% of Lisfranc fracture-dislocations are missed. MRI is the gold standard for ligament injuries. At the time the article was created Frank Gaillard had no recorded disclosures. The site is secure. MR imaging of the tarsometatarsal joint: analysis of injuries in 11 patients. Check for errors and try again. Typically occurs when an axial load is applied to a plantar-flexed foot. (2018) Orthopedics. J Bone Joint Surg Br. Hi everyone - just wanting to ask when you were allowed to weight bear ? Welck MJ, Zinchenko R, Rudge B. Lisfranc injuries. Current concepts review: Lisfranc injuries. HHS Vulnerability Disclosure, Help Low-energy mechanism (with high clinical suspicion of Lisfranc injury): Weight-bearing AP views of the foot can help make the diagnosis if the initial foot x-ray is normal. On standard X-ray the signs consistent with a diagnosis of Lisfranc injuries are: 1. No other bony abnormality. Sripanich Y, Weinberg MW, Krahenbuhl N, Rungprai C, Haller J, Saltzman CL, Barg A. Surgical outcome of chronic Lisfranc injury without secondary degenerative arthritis: a systematic literature review. Lisfranc Fracture-Dislocation: A Frequently Missed Diagnosis in the Emergency Department. 9. These can be divided into joint saving or joint sacrificing. A fusion is a "welding" process in which the idea is to fuse together the damaged bones so that they heal into a single, solid piece. Open reduction and internal fixation versus primary arthrodesis for Lisfranc injuries. the contents by NLM or the National Institutes of Health. MRI is the gold standard to detect ligament injuries. Required fields are marked *. Epidemiology, imaging, and treatment of Lisfranc fracture-dislocations revisited. To identify the affected TMT joint is useful the piano key test, consisting in moving the head of the affected metatarsal holding the midfoot and hindfoot firmly [13]. [38] on 22 patients, with open Lisfranc injuries (all type IIIa and IIIb according to Gustilo-Anderson classification [40]) and a mean age of 36 years, treated with multiple K-wire fixation, found at a 56 months of follow-up a mean American Orthopaedic Foot & Ankle (AOFAS) score of 82 (range 59-100) and mean wound healing time of 16 days (range 10-30). Nithyananth et al. Lateral displacement of 3rd metatarsal on the lateral cuneiform. If the diagnosis is in doubt, it may be useful to obtain weight-bearing x-rays and comparison views of the contralateral side 11. Nithyananth M, Boopalan PR, Titus VT, Sundararaj GD, Lee VN. Treatment of Lisfranc fracture-dislocations with primary partial arthrodesis. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. Incidence, classification and treatment. The tarsometatarsal joint is named after Jacques Lisfranc de Saint-Martin (1787-1847), a French army field surgeon who described a forefoot amputation through the first tarsometatarsal joint ( 1, 2 ). Weight-bearing x-rays showed a subtle Lisfranc injury in the right foot with widening between the first and second rays and a disruption involving the overlapping bases of the lesser metatarsals as well as a left comminuted fracture of the proximal third and fourth . The term Lisfranc injuries refers to a range of midfoot and tarsometatarsal (TMT) joint lesion that can vary from a simple single joint injury to a complex lesion that disrupts multiple different joints with multiple fractures [1], depending on the severity of the trauma. The injury can be potentially career ending.[12]. Greenspan A. Orthopedic imaging, a practical approach. Incidence, classification and treatment. 41 (2): e168-e175. Joint saving surgery includes temporary fixation whilst awaiting definitive management and ORIF. [49] found a statistically significant difference in patient-reported outcomes scores (PROMs), as measured by the AOFAS score, in favor of PA for the treatment of Lisfranc injuries. Missed on first evaluation in 20% of cases (, No validated formal classification scheme exists for assessing the severity or management of a Lisfranc injury. After the primary partial arthrodesis patients need a plaster cast. DeOrio M, Erickson M, Usuelli FG, Easley M. Lisfranc injuries in sport. Computed tomography should be reserved for questionable cases such as the severely injured foot where adequate positioning cannot be obtained or cases where the multiplicity of fractures and dislocations makes complete evaluation difficult. Case study, Radiopaedia.org (Accessed on 02 Jun 2023) https://doi.org/10.53347/rID-88084, see full revision history and disclosures. However, conventional radiography is a 2D technique that can neither display nor measure the true dimensions of a detailed 3D object, such as the tarsal bones in the foot. Ponkilainen VT, Partio N, Salonen EE, Laine HJ, Maenpaa HM, Mattila VM, Haapasalo HH. Lisfranc injury: a review and simplified treatment algorithm. Although conventional radiography can usually demonstrate these complications' features, CT is the better technique for delineating their details. In 2002 Nunley and Vertullo [29] proposed a classification for low-energy injuries, focused on clinical features, weight-bearing foot X-ray and bone scintigraphy (BS). 2010;18(12):718-28. Ann Emerg Med 1995: 26 (2); 229-233. Lisfranc injury of the foot: a commonly missed diagnosis. It can be difficult to see, even to someone trained to look for it. Typical features of an avulsion fracture at the main insertion of the Lisfranc ligament. Crates JM, Barber FA, Sanders EJ. Methods: Sixteen human cadaveric lower limbs were placed in weight-bearing radiolucent frame for CT scanning. government site. A Lisfranc injury, also known as Lisfranc fracture, . Nunley JA, Vertullo CJ. Performed by stabilizing the heel with one hand and twisting the forefoot with the other. Thirty articles were subdivided by imaging modality: conventional radiography (17 articles), ultrasonography (six articles), computed tomography (CT . CT evaluation of tarsometatarsal fracture-dislocation injuries. Clinically, with the calcaneus held stable, abduction or pronation of the forefoot will produce pain over the midfoot. Subsequent conversion should be scheduled 10-15 days later, once soft tissues are back in good condition [38], and the wrinkles sign can be helpful [39]. ADVERTISEMENT: Supporters see fewer/no ads. The lesions were classified as homolateral, isolated and divergent. Following ORIF, the foot is usually immobilized for 8-12 weeks.[9]. Figure 3: An x-ray of a LisFranc injury. 8600 Rockville Pike Macmahon PJ, Dheer S, Raikin SM et-al. According to Lau et al. Moracia-Ochagavia I, Rodriguez-Merchan EC. In addition, MRI could further evaluate the injury degree of Lisfranc ligament. MR Imaging of the midfoot including chopart and Lisfranc joint complexes. All authors agree that the severity of the injury, a quick diagnosis and anatomical reduction are the main determinants of the biomechanical and functional long-term outcomes. The AOFAS-score of patients with primary partial arthrodesis was 88% within one year of follow-up. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); NYU Langone Health is one of the nations premier academic medical centers whose mission is to serve, teach, and discover. Three-dimensional (3-D) CT imaging provides a complete assessment of the lesion and associated with multiplanar reconstructions provides anatomical details, including neurovascular ones, that increase optimal surgical pre-operative planning [19]. Available from: Medscape. Unable to process the form. Chandran et al. The Lisfranc ligament connects directly between the medial cuneiform and the second metatarsal (photo above). The DP group had a mean AOFAS score of 82.5 points, compared with 71.0 for the TAS group and 63.3 for the combination group (P<0.001). However, in relation to the Lisfranc joint complexity, the sensitivity of the standard X-ray is about 84.4% according to Rankine et al. Weight-bearing x-rays should be obtained if tolerated, to assess the extent of displacement, angulation and shortening on each view. Surgery is usually performed with patient in supine position and knee at 90 of flexion. In mild to moderate sprains, the lower extremity may be immobilized for approximately six weeks. In particular, in the senior author's experience, C1-M2 and C1-C2 significant diastasis are often found to require surgical stabilization once directly visualized in the operating room. Now automobile accidents, falls and sport injuries can also lead to an injury on the Lisfranc joint. Those adults had purely ligamentous Lisfranc injuries, surgically proven instability without complete tarsometatarsal (TMT) joint dislocation, and both preoperative WB and NWB radiographs available. Unable to process the form. In 1909, Quenu and Kuss [25] classified Lisfranc lesions based on the three-column concept. Does open reduction and internal fixation versus primary arthrodesis improve patient outcomes for Lisfranc trauma? Rankine JJ, Nicholas CM, Wells G, Barron DA. Raikin SM, Elias I, Dheer S, Besser MP, Morrison WB, Zoga AC. Exercise Program after a Lisfranc Fracture and Dislocation (Starting an Exercise Program After a Lisfranc Fracture) October 29, 2017. Definition/Description Lisfranc injuries involve the displacement (or dislocation) of the metatarsal bones from the tarsus, particularly as it relates to the second tarsometatarsal (tarsometa-tarsal) joint and the Lisfranc ligament. Asymmetric widening between the right 1st and 2nd metatarsal bases. Prediction of midfoot instability in the subtle Lisfranc injury. Injuries can be caused by either direct or indirect trauma. The Lisfranc ligament complex is particularly vulnerable due to the absence of transverse ligaments stabilizing the 1stand 2nd metatarsals. Stage II sprains are lesions with M1-M2 diastasis between 1 and 5 mm on AP weight bearing X-ray due to the Lisfranc ligament injury, without loss of arch height on weight bearing lateral view. Lisfranc complex injuries are a spectrum of injuries of the TMT joints, ranging from purely ligamentous sprains, usually occurring in athletes, to fracture dislocations, commonly a consequence of high-energy trauma. [16], therefore about 20% of lesions remain undiagnosed. It is named after Jacques Lisfranc De Saint Martin (1790-1847), the chief of surgery at the Hpital de la Pitie in Paris 2. Diagram showing the evolution of the Lisfranc joint complex injuries classification. Screws, plates and screws or even pins . Ly TV, Coetzee JC. You can use Radiopaedia cases in a variety of ways to help you learn and teach. Subtle x-ray findings suggestive of a clinically significant Lisfranc injury: In this classification, stage I is a Lisfranc ligament sprain without diastasis or loss of arch height on lateral X-ray but increased uptake on BS. A Lisfranc fracture is a type of broken foot. The initial radiographs of a suspected Lisfranc joint injury should include weight-bearing anteroposterior and lateral views, as well as a 30-degree oblique view. inability to bear weight), Obtaining CT in ED will depend on department resources and orthopedic referral availability, Strict non-weight bearing (NWB) on crutches, Orthopedic or podiatry follow-up within one week for possible surgical reduction and fixation, When initially misdiagnosed/untreated, Lisfranc injuries carry a poor prognosis, often resulting in deformity, functional deficit, and chronic pain, When diagnosed appropriately, patients who undergo open reduction and internal fixation of fractures have superior outcomes to those with purely ligamentous injury (, Patients with no fracture on CT and no displacement on weight-bearing films generally are managed non-operatively, A Lisfranc injury must be part of the differential for any midfoot trauma because of the significant morbidity associated with missed diagnosis, Physical exam findings, including deformity, swelling and ecchymosis, may be subtle or absent, Normal foot x-rays do not rule out a Lisfranc injury, weight-bearing views or CT are essential. Weight-bearing x-rays are an alternative to MRI to assess the integrity of the Lisfranc joint. The injury was caused when soldiers were thrown of their horses and their foot was stuck into the stirrup. Based on biomechanical studies, there are no differences between the use of TAS and DP. And how can we improve? . Hence the results on conservative treatment of nonoperative treatment are based on a few retrospective case series, without widely extended consent on the indications [10]. After surgery, you will not be allowed to bear weight for six to eight weeks and your foot will be in a cast or cast boot. severe vascular disease, peripheral neuropathy) or pre-existing inflammatory arthritis 12. Benirschke SK, Meinberg E, Anderson SA, Jones CB, Cole PA. Fractures and dislocations of the midfoot: lisfranc and Chopart injuries. The degree of malalignment is somewhat subtle but can be typical for these injuries. Unable to process the form. {"url":"/signup-modal-props.json?lang=us"}, Gaillard F, Lustosa L, Murphy A, et al. That is usually the journal article where the information was first stated. American Academy of Orthopaedic Surgeon. [2], The Lisfranc ligament is a large band of plantar collagenous tissue that spans the articulation of the medial cuneiform and the second metatarsal base. An injury can be caused by an indirect or direct trauma. "In earlier research, we showed that using weight-bearing CT scans gave a diagnostic accuracy of about 79% in cases with subtle syndesmotic instability or 82% in subtle Lisfranc instability," says Dr. Ashkani. Wedmore, I. et al. Key parameters measured on the radiographs of both groups were: Within the Lisfranc cohort, C1-M2 distance and C2-M2 alignment were significantly larger in WB than in NWB films (mean differences 1.77 and 1.58 mm, respectively; P<0.001 for both). Post-traumatic arthritis mimics degenerative arthritis, but its course is accelerated because of severe injury. Lisfranc injuries. Conservative management of subtle Lisfranc joint injury: a case report, Controversies in tarsometatarsal injuries, Lisfranc fracture-dislocation: a frequently missed diagnosis in the emergency department, https://www.youtube.com/watch?v=f26KukNYsWA, Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete, Lisfranc fracture-dislocations: current management, Lisfranc injury of the foot: a commonly missed diagnosis, Plantar dislocation of lateral tarsometatarsal joint: a case of subtle Lisfranc injury, http://orthopedics.about.com/cs/footproblems/a/lisfranc.htm, http://emedicine.medscape.com/article/1236228-overview, https://www.verywell.com/lisfranc-injury-p2-1337782, The diagnosis and treatment of injuries to the Lisfranc joint complex, Lisfranc fracture-dislocations: report of two cases. [15][16], Medical management to Lisfranc injuries may be operative or non-operative depending on severity. Diagram of Lisfranc joint complex. Old healed fracture of the left 5th metatarsal. The projection is utilized to assess the joint under stress and better demonstrate structural and functional deformities. Vascular lesions are rare, in relation to which compartment syndromes or lesions of the deep peroneal nerve can occur [15]. Qiao YS, Li JK, Shen H, Bao HY, Jiang M, Liu Y, Kapadia W, Zhang HT, Yang HL. The most common complication is post-traumatic arthritis of the joint. The space between the 1st and 2nd rays is larger. The researchers identified 26 patients in the Mass General Brigham patient data registry who presented with a Lisfranc injury between July 1991 and October 2018. Asymmetric widening between the right 1st and 2nd metatarsal bases. As previously mentioned, fractures at the base of the second metatarsal should raise suspicion for Lisfranc injury. Arthrodesis versus ORIF for Lisfranc fractures. Rome, Italy. Jones EA, Manaster BJ, May DA et-al. Clinically presenting with evident swelling of the midfoot and pain, often associated with joint instability of the midfoot. Radiologic history exhibit. The intertarsal ligaments, dorsal and plantar tarsalmetatarsal (TMT) ligaments, and transverse ligaments provide soft tissue stability. Read more, Physiopedia 2023 | Physiopedia is a registered charity in the UK, no. Case study, Radiopaedia.org (Accessed on 02 Jun 2023) https://doi.org/10.53347/rID-88084, see full revision history and disclosures. First level of examination is X-Ray performed in 3 projections. AJR Am J Roentgenol. Virtually none would have been diagnosed based on C2-M2 alignment. Injury mechanisms are varied and include: Tarsometatarsal dislocation may also occur in the diabetic neuropathic joint (Charcot). Some potential radiographic abnormalities suggested in other research weren't evident in this studyC1-C2 (intercuneiform) distance, C3-M3 and C4-M4 alignment, plantar gapping at the first TMT, arch height loss and dorsal step-off at the second TMT. Check for errors and try again. 02114 In two recent studies [45,46] three different types of surgery were compared: ORIF with TAS, PA with DP and a combination of the two techniques, concluding that functional outcomes mainly depend on the quality of the anatomical reduction and not on the choice of the fixation implant used, significant differences was reported only for the reoperation rate for the removal of the implant. Ankle and foot strengthening exercises: These exercises are the same exercises as the range of motion exercises, but with a resistance band. ADVERTISEMENT: Supporters see fewer/no ads. Comparison of arthrodesis and non-fusion to treat Lisfranc injuries. http:///index.php?title=Lisfranc_Injuries&oldid=313682, Not being able to put any weight on the injured foot. Foot and ankle surgeons at Massachusetts General Hospital determined that, during the arthroscopic evaluation of the distal tibiofibular articulation, sagittal plane fibular translation is more accurate for diagnosing syndesmotic instability than coronal plane diastasis. Loss of alignment between the medial edges of C2 and M2 (on AP view); 2. Peicha G, Labovitz J, Seibert FJ, Grechenig W, Weiglein A, Preidler KW, Quehenberger F. The anatomy of the joint as a risk factor for Lisfranc dislocation and fracture-dislocation. Ms, Wascher DC, Finerman GA. Rupture of Lisfrancs ligament in athletes, and. Provided by a third party, we do not collect your information in any way,! Of malalignment is somewhat subtle but can be difficult to see, even to someone trained to look it! 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