LisFranc Injury

History

  • Named after Jacques Lisfranc de Saint-Martin, a French field surgeon during the Napoleonic wars

Definition

  • Involving the tarso-metatarsal joint (TMTJ)
  • Broad spectrum of injuries
    • Sprain or subluxation
    • Fracture
    • Fracture-dislocation

Epidemiology

  • Approximately 0.2% of all fractures
  • Accounts for more than 15% of all athletic injuries
  • Second most common athletic injury
  • Occurs most frequently in third decade of life

Anatomy

Bony Stability

  • Midfoot made up of 5 bones
    • navicular, cuboid, 3 cuneiforms
  • Lisfranc joint comprised of 3 cuneiforms, cuboid and 5 metatarsals (MT)
  • 1st to 3rd MT articulate with cuneiforms
  • 4th and 5th MT articulate with cuboid
  • Bases of MT wider dorsally
    • Form half of Roman arch
    • 2nd MT is keystone of transverse arch
  • 3 columns
    • Medial
      • medial cuneiform and 1st MT
    • Middle
      • intermediate and lateral cuneiforms and 2nd and 3rd MT
    • Lateral
      • Cuboid and 4th and 5th MT

Ligamentous Stability

  • Dorsal, plantar and interosseous ligaments
  • Longitudinal, oblique and transverse fibres
  • LisFranc ligament
    • 1cm x 0.5cm
    • Base of 2nd MT to medial cuneiform
    • Isolated injury to this ligament results in instability
  • Note: no intermetatarsal ligament from 1st MT to 2nd MT
Lisfranc Ligament complex (radiopaedia.org)

Mechanism of Injury

High energy

  • Twisting/abduction injury to forefoot
    • Fall from horse with foot in stirrups
    • MVA (most common)
  • Axial loading
    • Fall from height
    • Ankle equinus with body weight loading
  • Crush injury
    • To dorsum of midfoot
    • Greatest risk of compartment syndrome and open fracture

Low energy

  • Professional athletic trauma
  • Misstep (contributes to late diagnosis)

Classification

1. Myerson (most commonly used today)

  • A: Total incongruity (lateral or dorsoplantar)
  • B: Partial incongruity
    • B1: medial displacement of 1st MT
    • B2: lateral displacement of other MT
  • C: Divergent displacement
    • C1: partial
    • C2: complete

2. Originally developed by Quenu and Kuss, modified by Hardcastle (less common)

  1. Homolateral
    • All MT displaced in same direction
  2. Isolated
    • Only 1st MT injured/displaced
  3. Divergent
    • 1st MT displaced medially
    • Other 4 MT displaced laterally

History and Examination

  • Mechanism of injury
  • High incidence of failure to diagnose
  • Swelling and pain out of proportion
  • Bruising plantar aspect of foot can indicate LisFranc ligament rupture
  • Signs of compartment syndrome

Imaging

Radiographs

Non-weighbearing (NWB)

  • AP
    • Fleck sign
      • Avulsion of LisFranc ligament from base of 2nd MT
    • Assess medial column
Fleck sign (radiopaedia.org)
  • 30 degrees internal oblique
    • Assess lateral column
  • Lateral

Weightbearing (WB)/ stress radiographs

  • If normal or equivocal findings on NWB but high clinical suspicion
  • Diastasis between 1st and 2nd MT

CT

  • Confirms displacement
  • Identifies and assesses fracture pattern

MRI

  • Primarily important for the diagnosis and management of low-energy Lisfranc injuries
  • Can detect subtle marrow oedema
  • Can potentially misdiagnose small avulsion fractures as bone bruise

Management

Non-operative

  • For stable injuries with no displacement
    • Non-displaced
    • stable under radiographic stress exam
    • Unusual to treat non-op
  • Treatment
    • NWM in cast
    • Protected WB in controlled ankle motion walking boot
    • Close serial follow up

Operative

  • Indicated for any displacement

Closed technique

  • For isolated LisFranc with diastasis
  • Longitudinal traction
  • Reduction 1st intermetatarsal joint
  • Percutaneous fixation screws
  • From medial cuneiform to 2nd MT

Open technique

  • Several methods
    • Open reduction internal fixation (ORIF)
    • Open reduction with hybrid internal and external fixation (rare)
    • Open arthrodesis (rare)
    • One such technique described here
  • ORIF
    • 1st dorsal incision between 1st and 2nd MT, lateral to EHL
    • Protect branches of superficial peroneal nerve (SPN)
    • Reduce 1st and 2nd MT to cuneiforms
    • Check AP reduction
    • K wire provisional fixation
      • 1st MT to medial cuneiform
      • 2nd MT to intermediate cuneiform
      • medial cuneiform to base 2nd MT
      • +/- medial to intermediate cuneiform if unstable
    • Cannulated screws over K wire
    • 2nd incision between 3rd and 4th MT if required
    • Reduce 3rd and 4th TMTJ
    • K wire/screw 3rd MT to lateral cuneiform
    • Fix 4th and 5th MT to cuboid with K wires
    • 5th K wire usually inserted percutaneously
    • Check oblique view
  • Postop
    • Strick NWB in early stages of healing
    • Minimum 4 months before considering removal of hardware

Prognosis

  • Residual pain and stiffness with non-anatomical reduction
    • Secondary osteoarthritis
    • Progressive planovalgus

References

Mulcahy, H. (2018). Lisfranc Injury. Radiologic Clinics Of North America, 56(6), 859-876. doi: 10.1016/j.rcl.2018.06.003

Richter, M., Wippermann, B., Krettek, C., Schratt, H., Hufner, T., & Thermann, H. (2001). Fractures and Fracture Dislocations of the Midfoot: Occurrence, Causes and Long-term Results. Foot & Ankle International, 22(5), 392-398. doi: 10.1177/107110070102200506

Author Contributions

Matthew Sun, medical student, Western Health Intern 2021