Lisfranc joint injury
Basic Anatomy
Forefoot
14 phalanges
5 metatarsal bones
Midfoot
Bones
Navicula, Cuboid
3 cuneiforms
Joints
Tarsometatarsal
Intermetatarsal
Intertarsal
Midtarsal(Chopart)
Hindfoot
Talus /Calcaneus
Subtalar joint
Lisfranc ?
Jacques L. Lisfranc
French gynecologist and Napoleonic surgeon
First to describe and amputation technique through the TMT joint
Quénu und Küss
First descriptions of acute injury of TMT joint complex
Lisfranc ligaments
interosseous ligament from MC to 2nd MT base
Lisfranc joint complex
Bones and ligaments connecting midfoot and forefoot
Biomechanic of Lisfranc joint complex
Inherently stable
Stable Osseous Structure
Ligamentous Strains
Osseous – Unique transeverse stability
Relatively short intermediate cuneiform
Sandwiched between
medial and lateral cuneiforms
2nd MT base : Keystone on Roman arch
Biomechanic of Lisfranc joint complex
Inherently stable
Stable Osseous Structure
Ligamentous Strains
2) Ligamentous
plantar Lisfranc ligament (Green)
dorsal Lisfranc ligament (Red)
Weaker
interosseous Lisfranc ligament (Blue)
between 2nd-5th metatarsal bases
NO direct attachment between 1st and 2nd
Injury mechanism
Direct injury
Direct force to TMT joint area (ex. crushing injuries)
Soft tissue damage
Indirect injury
Axial loading, rotational, bending and compressive force
More common
Clinical Importance
Missed or overlooked injuries are common (up to 20%)
Loss of transverse arch of foot
Secondary arthritis and deformity
Severe pain & Functional impairment
Signs & Symptoms
Painful swelling
Inability to pain-free weight bearing or tip-toe standing
Plantar ecchymosis
Radiology
Medial shaft of 2nd MT be aligned with medial aspect of middle cuneiform on AP view
Medial shaft of 4th MT be aligned with medial aspect of cuboid on Oblique view
1st MT-cuneiform articulation should have no incongruency
Fleck sign
Space between 2nd MT base and medial cuneiform
Avulsion of Lisfranc ligament
5) Weight bearing with comparison view
Malalignment > 1mm
Articular incongruency > 2mm
Radiology
Medial shaft of 2nd MT be aligned with medial aspect of middle cuneiform on AP view
Medial shaft of 4th MT be aligned with medial aspect of cuboid on Oblique view
1st MT-cuneiform articulation should have no incongruency
Fleck sign
Space between 2nd MT base and medial cuneiform
Avulsion of Lisfranc ligament
5) Weight bearing with comparison view
Malalignment > 1mm
Articular incongruency > 2mm
Radiology
Medial shaft of 2nd MT be aligned with medial aspect of middle cuneiform on AP view
Medial shaft of 4th MT be aligned with medial aspect of cuboid on Oblique view
1st MT-cuneiform articulation should have no incongruency
Fleck sign
Space between 2nd MT base and medial cuneiform
Avulsion of Lisfranc ligament
5) Weight bearing with comparison view
Malalignment > 1mm
Articular incongruency > 2mm
Radiology
Medial shaft of 2nd MT be aligned with medial aspect of middle cuneiform on AP view
Medial shaft of 4th MT be aligned with medial aspect of cuboid on Oblique view
1st MT-cuneiform articulation should have no incongruency
Fleck sign
Space between 2nd MT base and medial cuneiform
Avulsion of Lisfranc ligament
5) Weight bearing with comparison view
Malalignment > 1mm
Articular incongruency > 2mm
Radiology
Medial shaft of 2nd MT be aligned with medial aspect of middle cuneiform on AP view
Medial shaft of 4th MT be aligned with medial aspect of cuboid on Oblique view
1st MT-cuneiform articulation should have no incongruency
Fleck sign
Space between 2nd MT base and medial cuneiform
Avulsion of Lisfranc ligament
5) Weight bearing with comparison view
Malalignment > 1mm
Articular incongruency > 2mm
Radiology
Medial shaft of 2nd MT be aligned with medial aspect of middle cuneiform on AP view
Medial shaft of 4th MT be aligned with medial aspect of cuboid on Oblique view
1st MT-cuneiform articulation should have no incongruency
Fleck sign
Space between 2nd MT base and medial cuneiform
Avulsion of Lisfranc ligament
5) Weight bearing with comparison view
Malalignment > 1mm
Articular incongruency > 2mm
Management
Nonoperative
Cast immobilization for 8 weeks
But,
Secondary displacement
Inferior functional outcome
Primary OR & IF has become the preferred method of treatment
Normal gait biomechanics
Prevent 2ndary arthritis
Fixation technique
Smooth K-wires
Early removal (at 6wks) : Lack of rigidity, reduction loss
High energy trauma : Initial treatment
Cortical screws
Rigid fixation and gentle compression
Medial cuneiform - 2nd MT base
Articular damage and unstable fixation in osteoporotic bone
Plate fixation
More stable than screws
Do not damage tarsometatarsal joint
Fracture that extends through disphysis of metatarsal bones
Take Home Message
Lisfranc joint complex injury
Inherently stable
Osseous
Ligamentous
Maintaining suspicion!!
Careful radiographic review is important
