1. 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

2. 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

3. 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

4. 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)

5. 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

6. 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

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

8. 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 )

9. 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

10. 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.

11. 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

12. 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.

13. 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

14. 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”)

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

16. 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

17. Classification Quenu and Kuss (1909)
HOMOLATERAL: most common

18. Classification Quenu and Kuss (1909)
ISOLATED

19. Classification Quenu and Kuss (1909)
DIVERGENT: least commom

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

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

22. 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

23. Classification Myerson (1986)

24. Classification Myerson (1986)

25. Classification Myerson (1986)

26. 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”

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

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

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

30. 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

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

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

33. 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

34. 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

35. 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

36. 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

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

38. 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

39. 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

40. 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

41. 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

42. 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

43. Case Example
Preop AP
Postop AP
Postop Lateral

44. 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

45. 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

46. 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

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

48. 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

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

50. 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

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

52. 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.)

53. 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

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

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

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

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

58. 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

59. 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

60. 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

61. 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

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

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

64. 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

65. 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

66. 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

67. Cuneiform Instability
May occur in any direction including axial shortening
Requires ORIF
Usually seen in conjunction with Lisfranc injuries
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