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LISFRANC
INJURY
Dr.Subodh Pathak
“Surgery is bright when operating but it
is still brighter when there is no blood
and mutilation and yet leads to the
pati...
Injuries to the foot can have a dramatic impact on the
overall health, activity, and emotional status of
patients.
A recen...
Jacques Lisfranc de St. Martin
(April 2, 1790 – May 13, 1847)
Pioneering French surgeon and gynecolo
gist.
Pioneered ……………...
Lisfranc described an amputation involving
the tarsometatarsal joint due to a severe
gangrene that developed when a soldie...
Foot Anatomy
Lisfranc joint complex
consists of three
articulations including
◦ Tarsometatarsal articulatio
n.
◦ Intermetatarsal articu...
The Lisfranc complex is made up of bony
and ligamentous elements that combine to
add structural support to the transverse
...
Stability of TMT joint
The trapezoidal shape of
the middle three MT
bases and their
associated cuneiforms
produce a stable...
Peicha et al showed that persons
with Lisfranc injury had a shallower
medial mortise depth compared with
control subjects....
Ligaments
Transverse Ligament
Oblique Ligaments
Dorsal
Planter
Interosseu
s
Lisfranc Ligament
2bands
In a biomechanical evaluation, Solan
et al assessed the strength of each
ligamentous set—dorsal,
interosseous, and plantar...
Structural stability to the transverse
arch is enhanced by the short plantar
muscles as well as by the muscular
and tendin...
Foot Muscles – Plantar Surface
First layer
◦ Abductor
Hallucis
◦ Abductor Digiti
Minimi
◦ Flexor
Digitorum
Brevis
Foot Muscles – Plantar
Surface
Second
Layer.
Tendons of
FHL, FDL.
Lumbricals.
Foot Muscles – Plantar Surface
Third Layer
◦ Flexor Hallucis
Brevis
◦ Adductor Hallucis
Transverse and
Oblique Heads
◦ Fle...
Foot Muscles – Plantar Surface
Fourth or
Interosseus
Layer
2 muscles-
Plantar Interossei.
Dorsal Interossei.
2 tendons-
- ...
Incidence
Injuries to the Lisfranc joint occur in 1 per
55,000 individuals each year in the United
States and are 2 to 3 t...
Mechanism of Injury
Direct Injury
Indirect Injury
Orthopedics
June 2012 - Volume 35 · Issue 6: e868-e873
DOI: 10.3928/01477447-20120525-26
Arthrodesis Versus ORIF for Lisfr...
Two different plantar flexion
mechanisms lead to dorsal
joint failure.
The first occurs in ankle
equinus and
metatarsophal...
Urgent Braking
Indirect Injury
Indirect injury
Twisting injuries
lead to forceful
abduction of the
forefoot, often
resulting in a 2nd
metatarsal base
fra...
Fracture-dislocations
are often associated
with significant soft-
tissue trauma, vascular
compromise, and
compartment synd...
Classification
Classification systems are inherently
effective in allowing for the description
of both high- and low-impac...
Quenu and Kuss (1909):
Homolateral
Isolated
Divergent
1. Modified by Hardcastle in 1982
2. Further modified by Myerson in ...
Quenu and Kuss (1909)
Homolateral Divergent
Hardcastle (1982)
Homolateral or Total
Incongruity:
• All 5 metatarsals
displace in common
direction
•Fracture base of 2nd...
Isolated Partial
Incongruities:
• Displacement of 1 or
more metatarsals
away from the others
Divergent:
• Lateral displacement
of lesser metatarsals
with medial
displacement of the 1st
metatarsal
• May have extensio...
TOTAL INCONGRUITY
PARTIAL INCONGRUITY
DIVERGENT
Chiodo& Myerson(2001)COLUMNAR
THEORY
Nunley and Vertullo Athletic
Injuries(2002)
3-stage diagnostic classification.
Stage I - A tear of dorsal ligaments and sp...
Clinical Findings
Midfoot pain with
difficulty in weight
bearing
Swelling across the
dorsum of the foot
Deformity variable...
Clinical Findings
Check neurovascular
status for compromise
of dorsalis pedis artery
and/or deep peroneal
nerve injury
COM...
Planter Ecchymosis Sign
The passive pronation-abduction test
described by is performed by eliciting
pain on abduction and pronation of the
forefoo...
Trevino and Kodros described a
“rotation test,” in which stressing the
second tarsometatarsal joint by
elevating and depre...
DIAGNOSIS
Requires a high degree of clinical
suspicion
20% misdiagnosed
40% no treatment in the 1st week
??? MIDFOOT SPRAI...
RADIOGRAPHIC
EVALUATION
Xrays
Computed tomography (CT) scan.
MRI
Bone Scans
UltraSound scan
Radiographic Evaluation
AP, Lateral, and 30°
Oblique X-Rays are
mandatory
AP: The medial
margin of the 2nd
metatarsal base...
Radiographic Evaluation
Oblique: Medial
base of the 4th
metatarsal and
medial margin of the
cuboid should be
alligned
AP View Xrays
Oblique View Xrays
3
4
5
Oblique View Xrays
Radiographic Evaluation
Lateral: The dorsal
surface of the 1st
and 2nd metatarsals
should be level to
the corresponding
cu...
Lisfranc
Injury
A “fleck sign” should
be sought in the
medial cuneiform–
second metatarsal
space. This
represents an
avulsion of the
Lisfr...
Lisfranc injuries BIG challenge
20% of injuries go unrecognized, likely
secondary to the difficulty encountered
with stand...
50% of athletes with midfoot injuries
had normal non–weight-bearing
radiographs
Nunley JA, Vertullo CJ: Classification, in...
Stress Radiographs
Radiographs must be obtained with
the patient bearing weight in case of
subtle injuries.
If the radiogr...
AP Full Wt bearing Xray
Taking Lateral Views
NWB Xray FWB Xray
MRI
MRI has an advantage in identifying
partial ligament injuries and subtle
ligament injuries.
Especially useful in low v...
Magnetic Resonance Imaging
In a recent study evaluating the predictive
value of MRI for midfoot instability, Raikin et
al ...
MRI
3D CT SCAN
Stress Fluroscopy under
Anaesthesia
The foot is stressed in a medial/lateral plane. The forefoot is forced laterally with ...
Management
CONSERVATIVE
SURGICA
L
Check Stability………..
The definition of instability presently is
defined as a greater than 2-mm shift in
normal joint posit...
Goals of Treatment
Painless,
Plantigrade
Stable foot.
Maintenance of anatomic alignment
seems to be the critical factor in...
Non operative Management
Indications
◦ <2-mm displacement of the
tarsometatarsal joint in any plane
◦ No evidence of joint...
Treatment
◦ Short leg non-weight-bearing
cast for 6 weeks
◦ Weight bearing cast for an
additional 4 to 6 weeks
◦ Recheck s...
Surgical Intervention
Best results are obtained through
anatomic reduction and stable fixation.
The timing of surgery is p...
Closed manipulation under anesthesia
with casting as a definitive treatment
has been shown to be a poor choice
because mai...
Operative Treatment
Surgical
emergencies:
1. Open fractures
2. Vascular
compromise
(dorsalis pedis)
3. Compartment
syndrome
Dorsal incisions
centered over
the involved
joints are used
to approach the
midfoot.
Operative Treatment
Technique
1 – 3 dorsal
incisions:
1. 1st incision
centered at TMT
joint and along axis
of 2nd ray, lat...
Operative Treatment
Technique
Reduce and
provisionally stabilize
2nd TMT joint
Reduce and
provisionally stabilize
1st TMT ...
Operative Treatment
Technique
If reductions are
anatomic proceed
with permanent
fixation:
1. Screw fixation is
preferable ...
Operative Treatment
Technique
3. Screws are
positional not lag
4. To aid reduction
or if still unstable
use a screw from
m...
Operative Treatment
Technique
5. If intercuneiform
instability exists use
an intercuneiform
screw
6.The lateral
metatarsal...
Preop AP
Postop AP
Postop Lateral
Lisfranc Fracture fixed with
screws and K wires
Dorsal plating for bridging fixation of
comminuted fractures can be used.
Painful hardware has not been a concern, and rem...
Screw fixation remains the traditional
fixation technique, although there is
evidence to suggest that primary
arthrodesis ...
Postoperative Management
Splint 10 –14 days, nonweight bearing
Short leg cast, nonweight bearing 4 –
6 weeks
Short leg wei...
Hardware Removal
Lateral column stabilization can be
removed at 6 to 12 weeks
Medial fixation should not be removed
for 4 ...
COMPLICATIONS
EARL
Y
LAT
E
EARLY COMPLICATIONS
Vascular injuries.
Foot compartment syndrome.
Infections and wound
complications
LATE COMPLICATIONS
Post traumatic arthritis
1. Present in most, but may not be
symptomatic
2. Related to initial injury an...
Good or excellent results have been
accomplished in 50% to 95% of patients
with anatomic alignment, compared with
17% to 3...
Neuromas.
Flatfoot deformity with instability with
weight bearing.
Painful hardware, hardware failure, or
breakage.
Comple...
Prognosis
Long rehabilitation (> 1 year)
Incomplete reduction leads to
increased incidence of deformity and
chronic foot p...
Lisfranc injury
Lisfranc injury
Lisfranc injury
Lisfranc injury
Lisfranc injury
Lisfranc injury
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Lisfranc injury

Lisfranc Injury,Trauma

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Lisfranc injury

  1. 1. LISFRANC INJURY Dr.Subodh Pathak
  2. 2. “Surgery is bright when operating but it is still brighter when there is no blood and mutilation and yet leads to the patient's recovery” Jacques Lisfranc de Saint-Martin (1787-1847)
  3. 3. Injuries to the foot can have a dramatic impact on the overall health, activity, and emotional status of patients. A recent study looking at the outcomes of multiple trauma patients with and without foot involvement found a significant worsening of the outcome in the presence of a foot injury. Their conclusion is that more attention and aggressive management need to be given to foot injuries to improve the outcome of multiply injured patients.
  4. 4. Jacques Lisfranc de St. Martin (April 2, 1790 – May 13, 1847) Pioneering French surgeon and gynecolo gist. Pioneered ……………. Lithotomy Amputation of Cervix Uteri Removal of Rectum The Lisfranc joint and the Lisfranc fracture are named after him.
  5. 5. 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.
  6. 6. Foot Anatomy
  7. 7. Lisfranc joint complex consists of three articulations including ◦ Tarsometatarsal articulatio n. ◦ Intermetatarsal articulation . ◦ Intertarsal articulations.
  8. 8. The Lisfranc complex is made up of bony and ligamentous elements that combine to add structural support to the transverse arch. 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
  9. 9. Stability of TMT joint The trapezoidal shape of the middle three MT bases and their associated cuneiforms produce a stable arch referred to as the “transverse” or “Roman” arch. The keystone to the transverse arch is the second TMT joint, a product of the recessed middle cuneiform
  10. 10. Peicha et al showed that persons with Lisfranc injury had a shallower medial mortise depth compared with control subjects. They suggested that adequate mortise depth provides for greater stability by allowing for a stronger Lisfranc ligament. Peicha G, Labovitz J, Seibert FJ, et al.: The anatomy of the joint as a risk factor for Lisfranc dislocation and fracture-dislocation: An anatomical and radiological case control study. J Bone Joint Surg Br2002;84(7):981-985
  11. 11. Ligaments
  12. 12. Transverse Ligament Oblique Ligaments Dorsal Planter Interosseu s
  13. 13. Lisfranc Ligament
  14. 14. 2bands
  15. 15. In a biomechanical evaluation, Solan et al assessed the strength of each ligamentous set—dorsal, interosseous, and plantar—by stressing it to failure. They concluded that the Lisfranc ligament was strongest, followed by the plantar ligaments and the dorsal ligaments.
  16. 16. Structural stability to the transverse arch is enhanced by the short plantar muscles as well as by the muscular and tendinous support of the peroneus longus and the tibialis anterior and tibialis posterior.
  17. 17. Foot Muscles – Plantar Surface First layer ◦ Abductor Hallucis ◦ Abductor Digiti Minimi ◦ Flexor Digitorum Brevis
  18. 18. Foot Muscles – Plantar Surface Second Layer. Tendons of FHL, FDL. Lumbricals.
  19. 19. Foot Muscles – Plantar Surface Third Layer ◦ Flexor Hallucis Brevis ◦ Adductor Hallucis Transverse and Oblique Heads ◦ Flexor Digiti Minimi brevis.
  20. 20. Foot Muscles – Plantar Surface Fourth or Interosseus Layer 2 muscles- Plantar Interossei. Dorsal Interossei. 2 tendons- - peroneus longus . - Tibialis posterior.
  21. 21. Incidence Injuries to the Lisfranc joint occur in 1 per 55,000 individuals each year in the United States and are 2 to 3 times more common in men. Approximately 4% of professional football players sustain Lisfranc injuries each year As index of suspicion increases, so does incidence Approximately 20% of Lisfranc’s injuries may be overlooked. Mantas JP, Burks RT. Lisfranc injuries in the athlete. Clin Sports Med. 1994; 13(4):719–730. Thompson MC, Mormino MA. Injury to the tarsometatarsal joint complex. J Am Acad Orthop Surg. 2003; 11(4):260–267.
  22. 22. Mechanism of Injury Direct Injury Indirect Injury
  23. 23. Orthopedics June 2012 - Volume 35 · Issue 6: e868-e873 DOI: 10.3928/01477447-20120525-26 Arthrodesis Versus ORIF for Lisfranc Fractures Shahin Sheibani-Rad, MD, MS; J. Christiaan Coetzee, MD; M. Russell Giveans, PhD; Christopher DiGiovanni, MD
  24. 24. 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
  25. 25. Urgent Braking
  26. 26. Indirect Injury
  27. 27. Indirect injury Twisting injuries lead to forceful abduction of the forefoot, often resulting in a 2nd metatarsal base fracture and/or compression fracture of the cuboid (“ nut cracker”)
  28. 28. Fracture-dislocations are often associated with significant soft- tissue trauma, vascular compromise, and compartment syndrome.
  29. 29. Classification Classification systems are inherently effective in allowing for the description of both high- and low-impact injuries. Many Classifications developed and updated. None of them useful in Deciding the treatment and overall prognosis and Clinical Outcome.
  30. 30. Quenu and Kuss (1909): Homolateral Isolated Divergent 1. Modified by Hardcastle in 1982 2. Further modified by Myerson in 1986
  31. 31. Quenu and Kuss (1909)
  32. 32. Homolateral Divergent
  33. 33. Hardcastle (1982) Homolateral or Total Incongruity: • All 5 metatarsals displace in common direction •Fracture base of 2nd common
  34. 34. Isolated Partial Incongruities: • Displacement of 1 or more metatarsals away from the others
  35. 35. Divergent: • Lateral displacement of lesser metatarsals with medial displacement of the 1st metatarsal • May have extension of injury into cuneiforms or
  36. 36. TOTAL INCONGRUITY PARTIAL INCONGRUITY DIVERGENT
  37. 37. Chiodo& Myerson(2001)COLUMNAR THEORY
  38. 38. 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
  39. 39. Clinical Findings Midfoot pain with difficulty in weight bearing Swelling across the dorsum of the foot Deformity variable due to possible spontaneous reduction
  40. 40. Clinical Findings Check neurovascular status for compromise of dorsalis pedis artery and/or deep peroneal nerve injury COMPARTMENT SYNDROME
  41. 41. Planter Ecchymosis Sign
  42. 42. The passive pronation-abduction test described by is performed by eliciting pain on abduction and pronation of the forefoot with the hindfoot fixed. Curtis MJ, Myerson M, Szura B: Tarsometatarsal joint injuries in the athlete. Am J Sports Med 1993;21(4):497-502.
  43. 43. Trevino and Kodros described a “rotation test,” in which 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. PIANO KEY SIGN
  44. 44. DIAGNOSIS Requires a high degree of clinical suspicion 20% misdiagnosed 40% no treatment in the 1st week ??? MIDFOOT SPRAIN???
  45. 45. RADIOGRAPHIC EVALUATION Xrays Computed tomography (CT) scan. MRI Bone Scans UltraSound scan
  46. 46. Radiographic Evaluation AP, Lateral, and 30° Oblique X-Rays are mandatory AP: The medial margin of the 2nd metatarsal base and medial margin of the medial cuneifrom should be alligned
  47. 47. Radiographic Evaluation Oblique: Medial base of the 4th metatarsal and medial margin of the cuboid should be alligned
  48. 48. AP View Xrays
  49. 49. Oblique View Xrays 3 4 5
  50. 50. Oblique View Xrays
  51. 51. Radiographic Evaluation Lateral: The dorsal surface of the 1st and 2nd metatarsals should be level to the corresponding cuneiforms
  52. 52. Lisfranc Injury
  53. 53. 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
  54. 54. Lisfranc injuries BIG challenge 20% of injuries go unrecognized, likely secondary to the difficulty encountered with standard Xray Many so-called sprains present with non–weight-bearing radiographs that are difficult to interpret.
  55. 55. 50% of athletes with midfoot injuries had normal non–weight-bearing radiographs Nunley JA, Vertullo CJ: Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med2002;30(6):871-878.
  56. 56. Stress Radiographs Radiographs must be obtained with the patient bearing weight in case of subtle injuries. If the radiograph reveals no displacement, and the patient cannot bear weight, a short leg cast should be used for 2 weeks, and the radiographs should be repeated with weight bearing
  57. 57. AP Full Wt bearing Xray
  58. 58. Taking Lateral Views
  59. 59. NWB Xray FWB Xray
  60. 60. 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.
  61. 61. Magnetic Resonance Imaging In a recent study evaluating the predictive value of MRI for midfoot instability, Raikin et al found that MRI demonstrating a rupture or grade 2 sprain of the plantar ligament between the first cuneiform and the bases of the second and third MTs is highly predictive of midfoot instability, and these patients should be treated with surgical stabilization
  62. 62. MRI
  63. 63. 3D CT SCAN
  64. 64. Stress Fluroscopy under Anaesthesia The foot is stressed in a medial/lateral plane. The forefoot is forced laterally with the hindfoot brought medially….Pronation Abduction Stress
  65. 65. Management CONSERVATIVE SURGICA L
  66. 66. Check Stability……….. The definition of instability presently is defined as a greater than 2-mm shift in normal joint position. Diastasis between the first and second MT in the injured midfoot is considered normal provided that it measures <2.7 mm.
  67. 67. Goals of Treatment Painless, Plantigrade Stable foot. Maintenance of anatomic alignment seems to be the critical factor in achieving a satisfactory result.
  68. 68. Non operative Management Indications ◦ <2-mm displacement of the tarsometatarsal joint in any plane ◦ No evidence of joint line instability with weight-bearing or stress radiographs
  69. 69. Treatment ◦ Short leg non-weight-bearing cast for 6 weeks ◦ Weight bearing cast for an additional 4 to 6 weeks ◦ Recheck stability with stress views at 10 days from injury
  70. 70. Surgical Intervention Best results are obtained through anatomic reduction and stable fixation. The timing of surgery is predicated on resolution of swelling, when the skin begins to wrinkle. Lisfranc injuries are best managed within the first 2 weeks following the inciting event.
  71. 71. Closed manipulation under anesthesia with casting as a definitive treatment has been shown to be a poor choice because maintenance of the reduction is too difficult and residual deformity can lead to significant morbidity.
  72. 72. Operative Treatment Surgical emergencies: 1. Open fractures 2. Vascular compromise (dorsalis pedis) 3. Compartment syndrome
  73. 73. Dorsal incisions centered over the involved joints are used to approach the midfoot.
  74. 74. Operative Treatment Technique 1 – 3 dorsal incisions: 1. 1st incision centered at TMT joint and along axis of 2nd ray, lateral to EHL tendon 2. Identify and protect NV bundle
  75. 75. Operative Treatment Technique Reduce and provisionally stabilize 2nd TMT joint Reduce and provisionally stabilize 1st TMT joint If lateral TMT joints remain displaced use 2nd or 3rd incision 2nd met. Base unreduced reduced
  76. 76. Operative Treatment Technique If reductions are anatomic proceed with permanent fixation: 1. Screw fixation is preferable for the medial column 2. “Pocket hole” to prevent dorsal cortex fracture
  77. 77. Operative Treatment Technique 3. Screws are positional not lag 4. To aid reduction or if still unstable use a screw from medial cuneiform to base of 2nd metatarsal
  78. 78. Operative Treatment Technique 5. If intercuneiform instability exists use an intercuneiform screw 6.The lateral metatarsals frequently reduce with the medial column and pin fixation for mobility is acceptable
  79. 79. Preop AP Postop AP Postop Lateral
  80. 80. Lisfranc Fracture fixed with screws and K wires
  81. 81. Dorsal plating for bridging fixation of comminuted fractures can be used. Painful hardware has not been a concern, and removal is not common with properly placed low-profile plating systems. Weight bearing is advanced rapidly.
  82. 82. Screw fixation remains the traditional fixation technique, although there is evidence to suggest that primary arthrodesis may be superior for the purely ligamentous midfoot injury.
  83. 83. Postoperative Management Splint 10 –14 days, nonweight bearing Short leg cast, nonweight bearing 4 – 6 weeks Short leg weight bearing cast or brace for an additional 4 – 6 weeks Arch support for 3 – 6 months
  84. 84. Hardware Removal Lateral column stabilization can be removed at 6 to 12 weeks Medial fixation should not be removed for 4 to 6 months Some advocate leaving screws indefinitely unless symptomatic
  85. 85. COMPLICATIONS EARL Y LAT E
  86. 86. EARLY COMPLICATIONS Vascular injuries. Foot compartment syndrome. Infections and wound complications
  87. 87. LATE COMPLICATIONS Post traumatic arthritis 1. Present in most, but may not be symptomatic 2. Related to initial injury and adequacy of reduction 3. Treated with arthrodesis for medial column 4. Interpositional arthroplasty may be considered for lateral column
  88. 88. Good or excellent results have been accomplished in 50% to 95% of patients with anatomic alignment, compared with 17% to 30% of patients with nonanatomic alignment following injury Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle. 1986; 6(5):225–242.
  89. 89. Neuromas. Flatfoot deformity with instability with weight bearing. Painful hardware, hardware failure, or breakage. Complex regional pain syndrome.
  90. 90. Prognosis Long rehabilitation (> 1 year) Incomplete reduction leads to increased incidence of deformity and chronic foot pain Incidence of traumatic arthritis (0 – 58%) and related to intraarticular surface damage and comminution.

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