Lisfranc Injury is defined as the fracture dislocation of the tarsometatarsal articulation. Lisfranc ligament runs from medial cuneiform to second metatarsal.
Clinical Features of Lisfranc Injury
Swelling over the dorsum of the foot
Plantar ecchymosis sign
Piano Key test is positive
Stress examination of midfoot
Inability to bear weight
Elevating and depressing 2nd TMT Joint develops PAIN
X-ray features of Lisfranc Injury
In Normal foot:
In anteroposterior view: The medial shaft of the 2nd Metatarsal aligns with the medial aspect of the 2nd cuneiform [normal]
In Oblique view: The medial shaft of the 4th Metatarsal aligns with the medial aspect of cuboid
1st Tarsometatarsal Joint should be congruent
‘Fleck Sign’ Avulsion of Lisfranc ligament should be seen at medial cuneiform and 2nd metatarsal space
Navicular cuneiform articulation should be evaluated for subluxation
Loss of the arch and/or loss of alignment between the plantar aspect of 5th MT and medial cuneiform on the lateral view
Classification of Lisfranc (Midfoot) Injuries
Myerson’s classification
References: Dr. Jeffrey Hocking / This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License
Type A
Totally incongruity
Displacement of all metatarsals with /without fracture of base of 2nd MT
Lateral/ Dorsolateral
Type B
Partial incongruity
One or more articulation remains intact
- B1: Medially displaced (sometimes involving intercuneiform/ navicular-cuneiform )
- B2: Laterally displaced may involve 1st MT-cuneiform also
Type C
Diversant Injuries
More prone to compartment syndrome
- C1: Partial
- C2: Complete
Treatment of Lisfranc (Midfoot) Injuries
Indication for Non-operative management
Non-displaced / Purely ligamentous injury i.e. Malalignment < 1mm, Articular displacement < 2 mm
Intact medial column of the foot (length/ stability)
No major associated midfoot injuries
No vascular or soft tissue compromise
Surgical contraindications
Options:
RICE
- Rest
- Immobilization
- Compression
- Elevation
Lisfranc foot braces
Lisfranc foot support or Lisfranc shoes
Lisfranc socks or compression socks
Below knee cast
NSAIDs
Enzymes to reduce swellings
Indication for Surgery
Malalignment ≥ 1mm
Articular incongruity ≥ 2mm
Soft tissue or bone fragment prevents the reduction
- Avulsion fracture
- Tibialis anterior tendon
- Dorsal/ Plantar ligaments
Medial column instability or shortening
Associated multiple midfoot injuries
Associated compartment syndrome
Open fracture
Contraindication to surgery
Compromise soft tissue
General Health condition of the patient
Peripheral vascular disease
Neuropathy
Non-compliance to treatment
Surgical Steps for Management of Lisfranc Injury
- Under Anesthesia
- Dorsal incision lateral to EHL tendon over the interval of 1st and 2nd MT
- Slightly lateral if access to 3rd MT joint is necessary
- If 4th and 5th MT joint reduction is necessary 2nd incision is given more lateral
- Locate and incise Inferior extensor retinaculum
- Dorsalis pedis artery and the deep peroneal nerve is isolated and retracted
- Lisfranc Joint is visible
- Remove soft tissue interposition
- Reduce 1st TMT joint and fix with guide wires
- Insert a cannulated screw from dorsally 1st metatarsal to medial cuneiform
- 2nd screw may be kept proximal to distal along 1st TMT joint
- Another guide wire from medial cuneiform to the base of 2nd MT after reduction
- Keep 4mm cannulated screw
- Similarly, intercuneiform screws can be kept from medial –>middle cuneiform
- Lateral MT cuboid disruption is reduced and fixed with K wires
- Close skin with interrupted nylon suture
Postoperatively
- Posterior splint and a bulky dressing
- Convert lateral into a non-weight-bearing cast after 6-8 weeks
- Screw removed after 4-5 months
- Lateral K wire removed after 6-8 weeks
See also: Fifth Metatarsal Fracture
See also: Hammer toe and claw toe
