Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Lisfranc Fracture-Dislocation

Basics
Description
  • Dislocation of the TMT joints of the foot.
    • Can occur at any age
    • Often accompanied by fractures around the TMT joints
  • Classification:
    • Type A: Total incongruity of TMT joint
    • Type B: Partial incongruity of TMT joint complex, either medial or lateral
    • Type C: Divergent (1st metatarsal medial, 2nd-5th lateral)
Epidemiology
Incidence
Lisfranc injuries account for ~1/3 of midfoot injuries.
 
Risk Factors
  • Car accidents
  • Motorcycle accidents
Etiology
  • The mechanism of injury includes a wide spectrum of causes from low-energy compression and twisting to high-energy crush injuries.
  • Common cause: Car and motorcycle accidents:
    • Pressure on a brake pedal with a plantar flexed foot leads to the Lisfranc pattern of injury.
  • Sporting events
Associated Conditions
  • Comminuted fractures of the metatarsal bases or cuneiforms
  • Severe soft-tissue injury
  • Compartment syndrome
  • Open fractures
Diagnosis
Signs and Symptoms
  • Pain
  • Swelling
  • Deformity
  • Ecchymosis
  • Difficulty bearing weight
  • Tenderness over midfoot
  • Possible spontaneous reduction
Physical Exam
  • Rotational stress on the forefoot causes pain at Lisfranc joint.
  • Palpation over the 2nd metatarsal base also can cause pain.
Tests
Imaging
  • Radiography:
    • Plain films usually are diagnostic.
    • AP, lateral, and oblique projections are mandatory.
      • On the AP view, the medial margin of the 2nd metatarsal base should be aligned with the middle cuneiform.
      • On the oblique view, the medial base of the 4th metatarsal should be aligned with the medial margin of the cuboid.
      • On the lateral view, an unbroken line should run from the dorsum of the 1st and 2nd metatarsals to the corresponding cuneiform.
    • Avulsion fracture of the 2nd metatarsal base (fleck fracture) and compression fracture of the cuboid are pathognomonic of this condition.
    • If the diagnosis is uncertain on plain film, especially if the Lisfranc joint has reduced spontaneously, stress radiography with fluoroscopy may be helpful in further defining the instability pattern.
  • CT is an important adjunct to plain radiographs.
    • Shows small fractures and displacements that are not visible on plain films
    • In 1 study, radiographs missed the Lisfranc injury in 24% of cases and CT scan revealed the injury.
Differential Diagnosis
  • Soft-tissue contusion
  • Ligament sprain
  • Isolated metatarsal or midfoot fractures
Treatment
General Measures
  • Before the patient is taken to the operating room:
    • Compartment syndrome and neurovascular injury should be assessed.
    • The foot is splinted and kept elevated until surgery.
  • The goal of treatment is to achieve and maintain anatomic reduction of the joints while the ligaments heal.
    • Usually requires surgical intervention
  • Before and after surgery: Ice, elevation, and a compression dressing
  • Foot pumps may help reduce foot swelling.
Special Therapy
Physical Therapy
  • Patients should be referred for gait training on a nonweightbearing basis postoperatively.
  • Edema control and ROM of the toes and ankle are important to decrease late stiffness.
Surgery
  • Open reduction and internal fixation of joints:
    • Through 2-3 dorsal longitudinal incisions
    • Fixation may consist of Kirschner wires or 3.5-mm cortical screws.
      • If Kirschner wires are used as fixation, they can be removed in the office at 6 weeks, and the patient may begin protected weightbearing.
      • If screws are used as fixation, unprotected weightbearing is not permitted until the screws have been removed, at 10-12 weeks after surgery.
  • Fusion of the joints with 3.5-mm cortical screws has been advocated by some as primary treatment or as a salvage procedure for later arthritis of the midfoot.
Follow-up
Prognosis
  • Patients with anatomic reduction generally have good results.
    • In 1 study, 11 of 24 patients had a good to excellent result.
  • Outcomes are worse with nonanatomic reduction and extensive joint injury.
  • Patients with worker compensation claims have poorer outcomes.
  • The role of joint fusion is controversial.
    • Recently, a randomized study showed that joint fusion gave better results than did reduction and fixation.
  • Patients with posttraumatic arthritis can undergo salvage procedures with arthrodesis.
Complications
  • Traumatic arthritis
  • Fixed deformity
  • For injuries diagnosed late (7-8 weeks):
    • Poor prognosis
    • Patients may be candidates for primary arthrodesis .
Patient Monitoring
Follow-up radiographs (at 1-month intervals) should be taken to check for maintained alignment of the Lisfranc complex.
Miscellaneous
Codes
ICD9-CM
825.25 Metatarsal fracture
 
Patient Teaching
Patients must be warned about the risks of traumatic arthritis and fixed deformity, which may require later arthrodesis.
FAQ
Q: How long will it take to recover from a Lisfranc injury?
A: Lisfranc injuries are severe injuries to the midfoot and commonly require surgery. Recovery takes at least a year. Patients may require hardware removal. ~25% develop arthritis and may require later fusion.

Comments are closed.