Recommended
More Related Content
What's hot
What's hot (20)
Viewers also liked
Similar to Lisfranc Injury: Understanding the Anatomy, Mechanism, Classification and Management
Similar to Lisfranc Injury: Understanding the Anatomy, Mechanism, Classification and Management (20)
Recently uploaded
Recently uploaded (20)
Lisfranc Injury: Understanding the Anatomy, Mechanism, Classification and Management
- 2. DEFINITION : LISFRANC INJURY is basically known as fracture dislocation of tarsal and metatarsal joint complex, which includes tarsal bones articulating with cuneiform & cuboid. The metatarsals dislocate from their normal articulation with the mid-tarsal bones. Ligamentous injury involving the tarsometatarsal joint complex.
- 3. HISTORY - Jacques Lisfranc de St. Martin (French surgeon) (April 2, 1790 – May 13, 1847) Lisfranc described an amputation involving the tarsometatarsal joint due to a severe gangrene that developed when a soldier fell from a horse with his foot caught in a stirrup.
- 4. ANATOMY Lisfranc joint complex consists of three articulations including Tarsometatarsal articulation. Intermetatarsal articulation. Intertarsal articulations. The bony architecture is composed of 5 MTs and their respective articulations with the cuneiforms medially and the cuboid laterally. The TMT joint complex represents the dividing line between the midfoot and the forefoot
- 5. In AP plane, the base of the second metatarsal is recessed between the medial and lateral cunieforms. This limits translation of the metatarsals in the frontal plane In Coronal plane, middle three metatarsal bases are trapezoidal that form a transverse arch that prevents plantar displacement of metatarsal bases. The second metatarsal base is the keystone in the transverse arch of the foot.
- 6. LIGAMENT: Ligamentous support begins with the strong ligamentous linking at the bases of the 2nd through 5th metatarsals. Most important ligament is the lisfranc ligament that attaches from the plantar aspect of medial cuneiform to the base of second metatarsal.
- 7. Ligamentous, bony and soft tissue support provides intrinsic stability across the plantar aspect of lisfranc joint. Dorsal aspect is not reinforced like the plantar aspect. There is no ligamentous connection between the 1st and 2nd metatarsals which allows for frequently seen divergent injury Dorsalis pedis artery dives between the first and second metatarsals at lisfranc joint, may be damaged during injury, approach or reduction. Deep peroneal nerve runs alongside the artery Motion across tarsometatarsal joints - 10-20 degree of dorsal plantar motion at the 5th metatarso-cuboidal joint 20 degree of plantar flexion from neutral at the metatarso-cuneiform
- 9. INCIDENCE Incidence is 1 in 55,000 people each year. Most commonly involves the 1st and 2nd metatarsals and the medial cuneiform. Approximately 4% of professional football players sustain Lisfranc injuries each year.
- 10. MECHANISM OF INJURY 3 most common mechanisms : Twisting Axial loading of a fixed foot Crush injury
- 11. TWISTING: Forceful abduction of the forefoot on the tarsus results in fracture of the second metatarsal and shear or crush fracture of the cuboid. Commonly seen in horse riders, equestrian accidents when a rider fell from a horse with the foot engaged in the stirrup. Nowadays seen most commonly in motor vehicle accidents.
- 12. AXIAL LOADING OF A FIXED FOOT : Two different plantar flexion mechanisms lead to dorsal joint failure. The first occurs in ankle equinus and metatarsophalangeal joint plantar flexion, with the Lisfranc joint engaged along an elongated lever arm. The joint is “rolled over” by the body Placing the foot into extreme plantar flexion with an axial load
- 14. CRUSH INJURY: Most common in industrial type of injuries to lisfranc joint, often with sagittal plane displacement, soft tissue compromise and compartment syndrome.
- 15. CLASSIFICATION Classification schemes for lisfranc injuries guides in defining the extent and pattern of injury.
- 16. QUENU AND KUSS Commonly observed pattern of injury. HOMOLATERAL: all five metatarsals displaced in the same direction. ISOLATED: one or two metatarsals displaced from the others. DIVERGENT: displacement of the metatarsals in both the sagittal and coronal planes
- 18. MYERSON CLASSIFICATION Based on commonly observed patterns of injury with regard to treatment. TOTAL INCONGRUITY: lateral and dorsoplantar PARTIAL INCONGRUITY: medial and lateral DIVERGENT: partial and total
- 19. Homolateral or Total Incongruity: • All 5 metatarsals displace in common direction •Fracture base of 2nd metatarsal common
- 20. Isolated Partial Incongruities: • Displacement of 1 or more metatarsals away from the others
- 21. Divergent: • Lateral displacement of lesser metatarsals with medial displacement of the 1st metatarsal • May have extension of injury into cuneiforms or talonavicular joint
- 23. Nunley and Vertullo Athletic Injuries(2002) 3-stage diagnostic classification. Stage I - A tear of dorsal ligaments and sparing of the Lisfranc ligament Stage II - Direct injury to the Lisfranc ligament with elongation or rupture(Radiographic diastasis of 1 to 5 mm greater than the contralateral foot ) Stage III - A progression of the above, with damage to the plantar TMT ligaments and joints, along with potential fracture
- 25. CLINICAL PRESENTATION Midfoot pain with difficulty in weight bearing Swelling across the dorsum of the foot Deformity variable due to possible spontaneous reduction. Plantar Ecchymosis is the pathognomic for a lisfranc injury.
- 26. Careful neurovascular examination to elicit dorsalis pedis artery injury, compartment syndrome must be ruled out and monitoring for compartment syndrome is necessary. PIANO KEY SIGN: Stressing the second tarsometatarsal joint by elevating and depressing the second metatarsal head relative to the first metatarsal head elicits pain at the Lisfranc joint. Cant be elicited in acute condition.
- 27. IMAGING First investigation is a plain film x-ray AP, 30 ̊ Oblique & Lateral
- 28. IN AP XRAY On the AP, the lateral border of the 1st metatarsal is aligned with the Lateral border of the medial cuneiform. On the AP the medial border of the 2nd metatarsal is in line with the medial border of the intermediate cuneiform
- 29. IN OBLIQUE XRAY Medial and lateral borders of the lateral Cuneiform should align with the medial and lateral borders of the 3rdmetatarsal. Medial border of the cuboid should align with the medial border of the 4th metatarsal
- 30. STRESS RADIOGRAPHS Radiographs must be obtained with the patient bearing weight in case of subtle injuries.
- 31. LATERAL XRAY The dorsal surface of the 1st and 2nd metatarsals should be level to the corresponding cuneiforms
- 32. Lisfranc Injury
- 33. A “fleck sign” should be sought in the medial cuneiform–second metatarsal space. This represents an avulsion of the Lisfranc ligament. Myerson et al 1986
- 34. CT SCAN CT plays an important role in looking at the widening of the joint spaces CT also can detect associated fractures Help with confirming the diagnosis Help to formulate the surgical treatment plan
- 35. 3D CT
- 36. MRI MRI has an advantage in identifying partial ligament injuries and subtle ligament injuries. Especially useful in low velocity injuries and in settings of Normal radiographs. MRI can be useful to evaluate the soft tissue damage. Looks at the Lisfranc ligament Not routinely used
- 38. Doppler ultrasound may be used to look at the dorsalis pedis artery if it can not be felt by hand
- 39. FRACTURES ASSOCIATED WITH LISFRANC DISLOCATIONS Base of 2nd metatarsal Cuboid Fractures of the shafts of the metatarsals Navicular
- 40. MANAGEMENT The key to successful outcome in Lisfranc injuries is anatomical alignment of the involved joints. Non-operative Operative
- 41. NON OPERATIVE: INDICATIONS <2mm displacement of the tarsometatarsal joint in any plane Injuries that present with painful weight bearing, pain with metatarsal motion, tenderness on palpation but fail to exhibit instability should be considered sprain.
- 42. Patient with nondisplaced ligamentous injury with or without small plantar avulsion fractures of the metatarsal or tarsal bones should be placed in a below knee cast Injuries can be treated with a non–weight bearing cast for 6 weeks followed by a weight bearing cast for an additional 4 to 6 weeks. Repeat x-rays are necessary once swelling decreases, to detect osseous displacement
- 43. OPERATIVE: Operative management should be considered when displacement of the tarsometatarsal joint is > 2mm. Fixation should be used to maintain the reduction. Best results are obtained through anatomic reduction and stable fixation.
- 44. Most common approach is using two longitudinal incisions.
- 46. A dorsal 5 cm longitudinal incision is made just lateral to the EHL, extending from the navicular to the first metatarsal space. Sharp dissection with minimal soft tissue disruption should be carried out. The EHL is retracted medially and the dorsalis pedis artery and the deep peroneal nerve is retracted laterally, use a vessel loop for retraction.
- 47. The capsule over the base of second metatarsal was incised and the articular surface of the middle cuneiform was identified. The first and second TMT joints is reduced checking for both rotational and angular alignment. Provisional stabilization is performed using the threaded guide wires and the fixation is done with C.C. Screws
- 48. A second incision is made from the cuboid to the third web space distally. The superficial peroneal nerve is protected. The lateral border of the third metatarsal is reduced to the lateral border of the lateral cuneiform. A guide wire is used to fix the lateral column going from the fourth metatarsal to the cuboid and C.C. Screw fixation is done.
- 49. PRE OPERATIVE:
- 50. POST OPERATIVE:
- 51. POST-OP MANAGEMENT Foot is immobilized in a non-weight bearing cast for 6weeks. Progressive weight bearing is then allowed after 6weeks. Cast removal is done once pain free full weight bearing is achieved. Lateral column stabilization is removed at 8 to 12 weeks. Medial column stabilization should not be removed until 6 months, better leaving screws indefinitely unless symptomatic.
- 52. Complications The major complications of this fracture complex are incomplete reduction, loss of reduction or post-traumatic arthropathy Post traumatic arthritis: The x-ray appearance of degeneration of the joint is not unusual with this injury and does not co-relate well with clinical symptoms. Anatomic reduction of the joint complex with medial column arthrodesis is the treatment of choice for symptomatic arthropathy
- 53. Compartment syndrome: A tense swollen foot may hide a serious compartment syndrome that may result in ischaemic contrature. Neurovascular injury Due to trauma or surgical approach. Infections Neuromas Flatfoot deformity with instability with weight bearing. Painful hardware, hardware failure, or breakage. Complex regional pain syndrome.
- 54. THANK YOU