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British Medical Books Health Issues Computerized Tomography

Lisfranc Injury

Importance

  • commonly missed - often in polytrauma
  • difficult to assess on X-rays
  • severe complications

Anatomy

Lisfranc joint = tarso - metatarsal joint

  • bony configuration & ligaments -> stability
  • strong transverse metatarsal ligaments hold all MT heads together
  • Lisfranc ligament from medial cuneiform to base of 2nd MT
  • weak link between 1st & 2nd MT heads - no ligament ties
  • weak dorsal ligaments

Mechanism of injury

  • compression or twisting of the plantarflexed foot
    • horse-riding accidents
    • sports injuries
    • MVA

Signs & Symptoms

  • suspicion of injury

Sprain

  • pain & swelling in midfoot
  • tenderness at Lisfranc joint
  • passive pronation/abduction of forefoot painful
  • no X-ray changes

Dislocation / Fracture-dislocation

  • more pain & tenderness
  • deformity - forefoot shortened & wide
  • dorsalis pedis pulse may be diminished
  • X-ray changes

X-Ray Diagnosis

AP

  • base of 2nd MT & 2nd cuneiform must line up.
  • notch on base of 5th MT must line up with lateral aspect of cuboid.
  • lateral aspect of base of 1st MT must line up w/ lateral aspect of medial cuneiform

Lateral

  • usually dorsal displacement of MT

30° Oblique

  • medial aspects of base of 4th MT lines up with medial aspect of cuboid.
  • base of 3rd MT and medial aspect of lateral cuneiform
  • compare to other side
  • stress views may be required

Classification

Hardcastle modification of Quenu & Kuss

Type A - total incongruity

  • all MTs move laterally or medially

Type B - partial incongruity

  • some MTs displace
    • medial
    • lateral

Type C - divergent

  • MTs diverge into different direction

Management

Non operative

Sprain

  • 6 weeks immobilisation in B/K POP
  • allows ligaments to heal

Dislocations / fracture dislocations

  • closed reduction & POP
  • confirm with x-rays

Problems

    • difficulty obtaining adequate reduction
    • re-displacement

Operative Methods

  • if closed reduction unsuccessful or displaces

Closed reduction & percutaneous K-wiring

  • under image
  • stabilise MT to tarsus in reduced position
  • B/K POP for 6 weeks - NWB

Problems

    • difficult to obtain adequate reduction
    • K - wires frequently migrate & displace
    • pin - tract sepsis

Open reduction & internal fixation using K - wires or screws

  • Incision - 1st intermetatarsal space, 2nd incision between 3rd & 4th MT’s
  • fixation using K - wires or 3,5mm cortical screws

Advantages

  • accurate reduction possible
  • joints can be washed out and ligaments removed from joints & sutured
  • rigid fixation possible with early mobilisation (PWB in 1st 6/52, then FWB in POP)

Complications

Immediate

Vascular

    • dorsalis pedis occlusion with gangrene.
    • compartment syndromes in muscular compartments of foot

Long Term

Displacements of #’s

OA of joints - related to:

    • accuracy of reduction
    • extent of injury
    • loss of articular surface
    • open #’s
    • associated injury to surrounding bones