This document provides an overview of Lisfranc fracture-dislocations, which involve dislocation of the metatarsals from their normal articulation with the mid-tarsal bones. It describes the typical clinical presentation as swelling, pain and tenderness in the midfoot. Plain film x-rays are important for diagnosis but may miss injuries, so weight-bearing views and CT can help evaluate the injury. Treatment involves casting or surgery depending on the severity; complications can include long recovery times and need for further surgery.
This document provides an overview of Lisfranc fracture-dislocations, which involve dislocation of the metatarsals from their normal articulation with the mid-tarsal bones. It describes the typical clinical presentation as swelling, pain and tenderness in the midfoot. Plain film x-rays are important for diagnosis but may miss injuries, so weight-bearing views and CT can help evaluate the injury. Treatment involves casting or surgery depending on the severity; complications can include long recovery times and need for further surgery.
This document provides an overview of Lisfranc fracture-dislocations, which involve dislocation of the metatarsals from their normal articulation with the mid-tarsal bones. It describes the typical clinical presentation as swelling, pain and tenderness in the midfoot. Plain film x-rays are important for diagnosis but may miss injuries, so weight-bearing views and CT can help evaluate the injury. Treatment involves casting or surgery depending on the severity; complications can include long recovery times and need for further surgery.
Trainee Advanced Practitioner Plain Film Reporting
May 2011 Lisfranc Fracture-Dislocation
History
Definition Clinical presentation Mechanism of Injury Classifications Imaging Treatment Conclusion History
Jacques Lisfranc Definition
Where the metatarsals dislocate from their normal
articulation with the mid-tarsal bones 1 st
2 nd Most commonly involves the
and the medial cuneiform and
metatarsals
Incidence is 1 in 55,000 people
each
year
Easily missed on initial x- rays Can be difficult to diagnose Clinical
Presentation
Swelling
midfoot and large lump in the
Unable to weight bear
Tenderness along the tarso-metatarsal joints Tenderness with passive abduction and pronation of the forefoot withthe hindfoot held f lexed Clinical Presentation
Instability of the Lisfranc Joint
Plantar midfoot ecchymosis
Mechanism Of Injury
Hyper-extending the forefoot
Catching the forefoot in a hole in the ground Horseback rider falling and hanging the forefootin the stirrup Commonly seen as a Charcots Joint in diabetic Patients RTAs especially when foot is trapped in dorsi- f lexion under the foot pedal Crush injuries
Mechanism Of Injury
Placing the foot into
extreme plantar f lexion with an axial load Classification
Sprains are the most common injury to the tarso- metatarsal ligament, it is graded I, II and III (Burroughs et al 1998) Grade I - Pain at the joint, minimal swelling and no instability of the joint Grade II Increased pain and swelling of the joint, with mild laxity but no instability Grade III Complete ligamentous disruption and may represent a fracture-dislocation Classification
Classification
Adam and Dixon 2008, say there are 2 basic types of Lisfranc injuries, homolateral and divergent: Homolateral Where the metatarsals are shifted laterally Divergent The first metatarsal shifts medially and the remainder of the forefoot shifts laterally Classification
Classification
Myerson 1986, identifies 3 classifications of Lisfranc Injuries: Total incongruity
displaced Can be either medially or laterally
Medial Lateral Classification
Partial incongruity Either medial (Type B1)or lateral (Type B2),
the
most common
type
Type B2 (complete) Type B1 Type B2 (partial) Classification
Divergent displacement Either partial (type C1) or
total
(type C2)
Type C1 Type C2 Imaging
First investigation is a plain film x-ray AP and Oblique Imaging
Plain film plays a very important role in diagnosing Lisfranc fracture-dislocations To look for alignment On the AP, the lateral border of the 1 st metatarsal is aligned with the Lateral border of the medial cuneiform Imaging
On the AP the
medial border of
2 nd the
metatarsal is in line with
the medial border of the
intermediate
cuneiform
Imaging
On the oblique view Medial and lateral borders of
the lateral cuneiform should align with the medial and lateral 3 rd borders of the
metatarsal
Imaging
Also on the oblique Medial border of the cuboid should
align with the medial border of the 4 th
metatarsal
Imaging
Radiology.com 2006 Imaging
Radiology.com 2006 Imaging
Patients still may need further plain film
views Weight-bearing AP Weight-bearing lateral Stress views done under anaesthetics Imaging
CT plays an important role in looking at the widening of the joint spaces CT also can detect associated fractures Help with confirming the diagnosis Help to formulate the surgical treatment plan Imaging
MRI can
damage be
useful to evaluate the
soft
tissue
Looks at
the Lisfranc ligament
Not routinely used
Imaging
Doppler ultrasound may be used to look at the
dorsalis pedis artery if it can not
be felt by hand
Nuclear medicine could be used
distinguish any fractures but you could not
Fractures Associated
Dislocations
with
Lisfranc
2 nd
Base of
Cuboid metatarsal
Fractures of the shafts
of the metatarsals
1 st
2 nd
Dislocations of the
(medial) and
(middle) and cuneonavicular joints
Navicular Treatment
For a Lisfranc sprain:
Non-weight bearing In a cast or removable 4-6 weeks recovery Physiotherapy boot
Gradual return to activity
Treatment
For a Lisfranc fracture-dislocation,
surgery ORIF K-Wires Arthrodesis it
is
usually
Complications
Can take up to with surgery
1 year to recover Examples of Lisfranc Injuries 1
Examples of Lisfranc Injuries 1
Examples of Lisfranc Injuries 2
Examples of Lisfranc Injuries 3
Example of Lisfranc Injuries 3
Conclusion
Serious injury Difficult to diagnose Can lead to compartment syndrome Can have vascular compromise if not treated quickly A quick and accurate diagnosis can allow the appropriate treatment to take place efficiently Can take a long time to recover Complications that may lead to further surgery Advance practice plays an important role References
ADAM, A and DIXON, A.K. (2008) Grainger and Allisons Diagnostic
5 th
Radiology. A textbook of Medical Imaging. Edition, volume 2 in GRAINGER, R.G. and ALLISON, D.J. (eds.). London:Churchill Livingstone AMERICAN COLLEDGE OF FOOT AND ANKLE SURGEONS (2009) Lisfranc Injuries.
22 nd
Accessed April 2010) BURROUGHS, K.E. and REIMER, C.D. and FIELDS, K.B. (1998). Lisfranc injury of the foot: A commonly Missed diagnosis. Published by the American Academy of Family Physicians 2 nd
CHAN, O. (2007) ABC of Emergency Radiology. Oxford:Blackwell Publishing Edition. BMJ Books. FOOT EDUCATION (2009) Lisfranc Fracture ORIF. www.footeducation.com/lisfranc-fracture-orif (Accessed 14th May 2010) 2 nd HELMS, C.A. (1995) Fundamentals of Skeletal Radiology. London:W.B. Saunders Company Edition. References
HOWELL, G.A. (2009) Lisfranc Ligament Tear. www.radsource.us/clinic/0908 (Accessed 14th May 2010) LARSEN, D. And MORRIS, P. (2006) Limb X-Ray Interpretation. London:Whurr Publishers LEARNING RADIOLOGY.COM (2006) Lisfranc Fracture-Dislocation.
22 nd www.learningradiology.com (Accessed April 2010) Edition. 3 rd LISLE, D.A. (2007) Imaging for students: London: Hodder Arnold McCONNELL, J. AND EYRES, R. AND NIGHTINGALE, J. (2005) Interpreting Trauma Radiographs. Oxford:Blackwell Publishing MYERSON (1986) cited in East Lancashire Foot and Ankle Hyperbook, Lisfranc Injuries
23 rd
www.foothyperbook.com (Accessed May 2010) RABY, N. And BERMAN, L. And DE LACY, G. (2009) Accident and 2 nd
Emergency Radiology. A survival Guide. London:Elsevier Saunders Edition. References
THE CENTRE FOR ORTHOPAEDICS AND SPORTS MEDICINE (2000) Lisfranc Fracture-Dislocation 22 nd (Accessed April 2010) TREVINO, S.G. (2009) Lisfranc Fracture Dislocation 23 rd www.emedicine.medscape.com (Accessed VANDERHEIDEN, T. (2008) Lisfranc Injury. May 2010) 15 th www.about.com (Accessed May 2010) WATURA ET AL. BJR 77 (Supplement 1):S46 Figure 10. 22 nd www.BJR.com (Accessed April 2010) WHEELESS, C.R. (2009) Lisfrancs Fracture/Tarso- metatarsal Injuries. Duke Orthopaedics presents Wheeless Textbook of Orthopaedics. 14 th www.wheelessonline.com (Accessed May 2010)