Fractures and Dislocations of the Mid-foot Including Lisfranc Injuries Arthur K. Walling, MD Clinical Professor of Orthopaedics Director Foot and Ankle Fellowship Florida Orthopaedic Institute, Tampa, Florida Created March 2004; Revised August 2006

Lisfranc’s Joint Injuries Any bony or ligamentous injury involving the tarsometatarsal joint complex Named after the Napoleonic-era surgeon who described amputations at this level without ever defining a specific injury

Anatomy Lisfranc’s joint: articulation between the 3 cuneifoms and cuboid (tarsus) and the bases of the 5 metatarsals Osseous stability is provided by the Roman arch of the metatarsals and the recessed keystone of the second metatarsal base

Anatomy Lisfranc’s ligament: large oblique ligament that extends from the plantar aspect of the medial cuneiform to the base of the second metatarsal (there is no transverse metatarsal ligament from 1 to 2)

Anatomy Interosseous ligaments: connect the 2 thru 5 metatarsal bases both dorsal and plantar (stronger and larger) Secondary stabilizers: plantar fascia, peroneus longus, and intrinsincs

Anatomy Four Major Units 1. 1st MT – Medial Cuneiform: 6 degrees of Mobility 2. 2nd MT – Middle Cuneiform > Firmly Fixed 3. 3rd MT – Lateral Cuneiform > Firmly Fixed 4. 4th – 5th MT – Cuboid: Mobile

Anatomy Associated Structures: 1. Dorsalis pedis artery – courses between 1st and 2nd metatarsal bases 2. Deep peroneal nerve: runs alongside the artery

Incidence Generally considered rare ( 1 per 55,000 people per year or 15/5500 fractures ) As index of suspicion increases, so does incidence Approximately 20% of Lisfranc’s injuries may be overlooked ( especially in polytraumatized patients )

Mechanisms of Injury Trauma: motor vehicle accidents account for one third to two thirds of all cases (incidence of lower extremity foot trauma has increased with the use of air bags) Crush injuries Sports-related injuries are also occurring with increasing frequency

Mechanisms of Injury - Direct Direct Injuries: force is applied directly to the Lisfranc’s articulation. The applied force is to the dorsum of the foot.

Mechanisms of Injury - Direct Direct Injuries: plantar displacement is more common, but dorsal displacement can also occur. Open fracture/compartment syndrome/soft tissue injury greater

Mechanisms of Injury - Indirect Indirect injuries: more common than direct and result from axial loading or twisting. Metatarsal bases dislocate dorsally more often than plantarly.

Mechanism of Injury - Indirect Typical of athletic injury Axial loading to plantar flexed foot results in hyper-plantar flexion and ligament rupture Rarely associated with open injury or vascular compromise

Mechanism of Injury - Indirect 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”)

Associated Fractures Base of 2nd metatarsal Avulsion of navicular Isolated medial cuneiform Cuboid

Classification Quenu and Kuss (1909): Homolateral, Isolated, and Divergent 1. Modified by Hardcastle in 1982 2. Further modified by Myerson in 1986 Fail to encompass all injury patterns especially crush injuries Guide treatment but do not establish prognosis

Classification Quenu and Kuss (1909) HOMOLATERAL: most common

Classification Quenu and Kuss (1909) ISOLATED

Classification Quenu and Kuss (1909) DIVERGENT: least commom

Classification Hardcastle (1982) Homolateral or Total Incongruity: All 5 metatarsals displace in common direction Fracture base of 2nd common

Classification Hardcastle (1982) Isolated Partial Incongruities: Displacement of 1 or more metatarsals away from the others

Classification Hardcastle (1982) Divergent: Lateral displacement of lesser metatarsals with medial displacement of the 1st metatarsal May have extension of injury into cuneiforms or talonavicular joint

Classification Myerson (1986)

Classification Myerson (1986)

Classification Myerson (1986)

Diagnosis Requires a high degree of clinical suspicion 1. 20% misdiagnosed 2. 40% no treatment in the 1st week Be wary of the diagnosis of “midfoot sprain”

Clinical Findings Midfoot pain with difficulty in weight bearing Swelling across the dorsum of the foot Deformity variable due to possible spontaneous reduction

Clinical Findings Ecchymosis may appear late Local tenderness at tarsometatarsal joints Gentle stressing plantar/dorsiflexion and rotation will reveal instability

Clinical Findings Check neurovascular status for compromise of dorsalis pedis artery and/or deep peroneal nerve injury Asses for possible COMPARTMENT SYNDROME

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

Radiographic Evaluation Oblique: Medial base of the 4th metatarsal and medial margin of the cuboid should be alligned

Radiographic Evaluation Lateral: The dorsal surface of the 1st and 2nd metatarsals should be level to the corresponding cuneiforms

Radiographic Evaluation Standing views provide “stress” and may demonstrate subtle diastasis Comparison views are very helpful Associated fractures: Base of 2nd metatarsal Avulsion navicular Isolated medial cuneiform Cuboid

Radiographic Evaluation Additional imaging: 1. True stress views or fluroscopy 2. CT Scans 3. Bone scan – for persistent pain with no radiographic findings 4. If suspicious: repeat x-rays and keep looking

Treatment Early recognition is the key to preventing long term disability Anatomic reduction is necessary for best results: displacement of >1mm. or gross instability of tarsometatarsal, intercuneiform, or naviculocuneiform joints is unacceptable Goal: obtain or maintain anatomic reduction

Treatment Nonoperative: for nondisplaced injuries with normal weightbearing or stress x-rays Short leg cast 4 to 6 weeks nonweight bearing Repeat x-rays to rule out displacement as swelling decreases Total treatment 2-3 months

Operative Treatment Surgical emergencies: 1. Open fractures 2. Vascular compromise (dorsalis pedis) 3. Compartment syndrome

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

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(s) 2nd met. Base unreduced reduced

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

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

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

Case Example Preop AP Postop AP Postop Lateral

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

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

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

Complications Compartment syndrome Infection Complex mediated pain syndrome Neurovascular injury Hardware failure

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

Navicular Fractures Anatomy: a horseshoe shaped disc sitting between the talus and cuneiforms Numerous short ligaments attach dorsally, plantarly, and laterally Deltoid attaches medially

Navicular Fractures Blood supply: because of the large articular surfaces, vessels can only enter dorsally, plantarly, and thru tuberosity Medial and lateral thirds have good blood supply, the central third is largely avascular # of vessels decreases with age

Navicular Fractures Avulsion fractures: usually dorsal lip (essentially severe sprain) Treatment: 1. Immobilization & progressive weight bearing 2. Excision of fragment if painful

Navicular Fractures Tuberosity fractures: avulsion by p. tibial tendon and spring lig. Usually minimally displaced May have associated calcaneocuboid impaction ORIF depending on degree of displacement ( > 5mm.)

Navicular Fractures Body Fractures High energy trauma with axial foot loading Frequently associated with talonavicular subluxation CT scans helpful for preop planning Anatomic reduction essential

Navicular Fractures Body Fractures Classification Sangeorzan Type 1: coronal fracture plane

Navicular Fractures Body Fractures Classification Sangeorzan Type 2: primary fracture dorsolateral to plantar medial with medial displacement of major fragment and forefoot

Navicular Fractures Body Fractures Classification Sangeorzan Type 3: comminution of the body in the sagittal plane with forefoot laterally displaced

Navicular Fractures Body Fractures Treatment: ORIF if any displacement Anteromedial incision along medial aspect Tib. Ant. Second anterolateral incission to help reduce lateral fragment

Navicular Fractures Body Fractures Treatment cont.: 4. May require stabilization or fusion to cuneiforms 5. Avoid fusion of essential talonavicular joint if at all possible Missed navicular fx required orif and primary fusion secondary to arthritis

Navicular Fractures Body Fractures Prognosis: With adequate reduction most have good result, but few are “normal” Type 3 worst prognosis: 1. Only ½ adequately reduced in Sangeorzan series (60% of joint surface) 2. 6 of 21 developed ostonecrosis with one collapse

Navicular Stress Fractures Incidence: Uncommon Etiology: repetitive stress and poor blood supply Running most common, but can occur in all patients active in sports Diagnosis:Vague arch pain with midfoot tenderness Delay in diagnosis common X-Rays: AP, Lat., and Oblique CT and Bone scans if uncertain

Navicular Stress Fractures Treatment Incomplete Fracture: Nonweight bearing cast until healed (variable time) Complete fracture or nonunion: ORIF with screws perpendicular to fracture plane with or without bone graft Complications: nonunion or persistent pain

Cuboid Fractures Isolated fractures are rare Most often associated with other fractures &/or dislocations Two types of fractures usually seen

Cuboid Fractures Avulsion fractures: most common Compression fractures: mechanism of injury “nutcracker” axial loading with plantar flexion and forefoot abduction

Cuboid Fractures Treatment Isolated and nondisplaced: immobilization 6 to 8 weeks Displaced: ORIF 1. Often requires bone graft and small plate 2. Can use small external fixateur for distraction

Indications for Surgery: Cuboid Fractures > or = 2 mm displacement of articular surface Cuboid subluxation with weight bearing or stress x-rays (May require transarticular pin fixation or external fixator) Loss of bony length

Cuneiform Fractures Isolated fractures quite rare Displacement of these fractures is unusual Healing with few complications is likely Mechanisms of injury: 1. Direct trauma – most common and heal rapidly with nonoperative treatment 2. Indirect trauma (Lisfranc variants): ORIF

Cuneiform Instability May occur in any direction including axial shortening Requires ORIF Usually seen in conjunction with Lisfranc injuries If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to ota@aaos.org E-mail OTA about Questions/Comments Return to Lower Extremity Index