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Flashcards in 9 - Lisfranc's Injury Deck (43):

Key learning points

- Define the key tarsal-metatarsal joint anatomic landmarks used to assess injury
- Describe the radiographic features of TMTJ injury
- Compare the evidence based treatment recommendations and the evolution of treatment recommendations



- Lis franc’s joint (3 Cuneiforms, Cuboid, Bases of metatarsals 1-5)
- Intrinsic Osseous Stability is provided by the Roman arch of the metatarsals and the recessed keystone of the second metatarsal base
- Further stability is provided by ligaments


Ligament anatomy

- Inter-osseous ligaments connect metatarsals 2 - 5 at the bases (Both dorsal and plantar)
- ***No transverse metatarsal ligament from the first to the second***
- Plantar ligaments are stronger and larger


Lis franc's ligament

- Strong oblique ligament from the plantar aspect of the medial cuneiform to the base of the second metatarsal


Associated structures

- Dorsalis pedis artery courses between 1st and 2nd metatarsal bases
- Deep peroneal nerve runs alongside the artery


Lis franc's injury

- Fracture and dislocation of the tarso-metatarsal joint complex
- May be a pure dislocation due to ligament rupture only (Primarily Ligamentous)
- May involve fractures of the metatarsals and the cuneiforms (Intra articular and/or Extra articular)
- Lots of variability


Classifications of lis franc's injuries

- Quenu and Kuss (1909) – Homolateral, Isolated, and Divergent
- Modified by Hardcastle in 1982
- Further modified by Myerson in 1986
- Fail to encompass all injury patterns especially crush injuries and do not establish prognosis


Reality of classifications

o Lots of them
o Do they really help? No


What MUST you evaluate in a Lis Franc's injury?


o Angulation & Translocation
o Transverse & Sagittal displacement


What may hide a true deformity?


Spontaneous reduction
o ***Does it match the other side?
o ***Careful attention to the “key-stone”


Subtle Lis Franc's deformity

The subtle ones are the toughest
- Often missed in the ED
- History and physical exam is key
- Alignment of the second metatarsal base medially is an important radiographic finding


Mechanism of injury

- Trauma
o Motor vehicle accidents account for one third to two thirds of all cases
o Incidence of lower extremity foot trauma has increased with the use of air bags
- Direct or Crush injuries
- Sports-related injuries are also occurring with increasing frequency


Mechanism of injury - indirect force

- More common than direct
- Result from axial loading or twisting
- Metatarsal bases dislocate dorsally more often than plantar


Advanced imaging

- CT and MRI are unlikely to be helpful with either diagnosis or treatment
- Must be suspicious due to the possibility of spontaneous reduction
- ***Stability is key*** Do a Stress test***
- Comparison to the other foot


Clinical questions for treatment of TMTJ dislocation

- Reduction vs. No Reduction?
- Closed Reduction with Pin vs. Open Reduction?
- Wires vs. Screws?
- ORIF vs. Fusion?



- Positional changes from unstable Lis franc’s causes severe progressive functional abnormalities
- Angular and Translational

Notes on x-ray
o “Skinny” joint on the lateral view – no normal joint space
o Sign of degenerative joint disease
o Subchondral sclerosis
o This is a sign of DJD
o 2nd metatarsal is set back behind joint of 1st metatarsal
o 1st metatarsal should be parallel to talar neck line on the lateral view (“Meary’s line”)


*** KEY POINTS ***

- TMTJ stability and alignment is important for function
- Arthrodesis is the most stable option for repair with the lowest revision rate
- There is no good argument from a surgical or functional standpoint for “Joint Preservation” in the TMTJ
- Locking plates provide a stable, load bearing construct that tolerates external stresses better than traditional AO techniques
- Must prioritize deformity correction in both acute and late reconstructions


Case study - alignment on x-ray

- Base of second metatarsal is not lined up with the intermediate cuneiform
- This is how you know that there is a dislocation
- On an AP x-ray this is the most reliable clue to why there is an injury and this is not just normal anatomy


Case study - fracture

- Fracture of base of 2nd metatarsal
- Evulsion of Lis Franc’s ligament which goes from base of 2nd metatarsal to medial cuneiform
- All the cortices of the joint line up,
- If you have the evulsion, you have a severe instability and it needs to be addressed


Case study - dislocation, no fracture

- Base of the 1st metatarsal and medial cuneiform
- No fracture, so this is a purely ligamentous
- Much worse than a fracture
- Worse prognosis



Classifications = not important, not clinically relevant


Case study - 3rd metatarsal fracture

- Base of the 3rd metatarsal is fractured
- Do a contralateral x-ray to be able to compare
- To get a lateral film will tell you if there is any sagittal plane deviation
- Stress test shows you that there is a severe injury
- Substantial dislocation is present
- Advanced imaging is not necessary
- The key to a Lis Franc’s injury is restoring stability – do not worry about restoring “function”
- CT and MRI are unlikely to be helpful with either diagnosis or treatment
- Must be suspicious due to the possibility of spontaneous reduction



- Do you need to reduce it?
- Open or closed? Closed reduction should always be tried first according to literature
- Joint NEEDs to be stabilized, one way or another


Elevated first ray

- 1st ray elevation leads to forefoot supination, leading to compensation via hind foot pronation
- Hallux limitus will occur
- Additional stress on the lateral metatarsal heads
- Reduces weight bearing on the medial foot
- Hind foot pronation leads to medial rotation of the knee
- Midfoot abduction leads to a rotational equilibrium leading to pronation of the foot


Small shift equals big deformity

- Even when it is just a “little bit off” it is a big problem because it will get worse 100% of the time


Reduction vs no reduction

- Instability is well known to result in progressive collapse biomechanical dysfunction and painful arthrosis
- All studies that compare accurate reduction to mal position show better outcome for accurate reduction


Percutaneous fixation

- Instability remains
- Imperfect reduction – there’s no way to get it perfect
- Intraarticular fractures need to be perfect
- Studies do not support the use of percutaneous fixation
- Highly variable
- Inadequate reduction leads to continued instability and further damage
- Almost everyone recommends ORIF
- 100% of patients had DJD of TMTJ regardless soft reduction


Screws or pins

- Incomplete stability after ORIF
- Loss of reduction after pin removal
- High incidence of DJD
- High rate of revision surgery
- ORIF needs revision because they will fail, even with the best options we have
- 3 operations is not uncommon


Arthrodesis vs ORIF

- Even though the evidence is compelling that you need stability and arthrodesis, some still say you need to try ORIF first
- Arthrodesis has much better results


ORIF stats

- 15 of 20 had loss of correction, arthrosis and or pain
- 16 out of 220 needed hardware removal and secondary surgery


Ligamentous injury ******

o Dorsal instability
o Medial second metatarsal base fracture
o Much more stable
o This is because the dorsal ligaments are the only ones that are torn, but they don ‘t even matter
o Plantar ligaments are still intact and they are strong

o Plantar instability
o Pure ligamentous instability with dislocation
o Less reliable

o Better outcome than if it is purely ligamentous


ORIF - Henning 2009

Prospective randomized study of patients presenting with Lis franc’s fracture dislocation
o ORIF vs primary arthrodesis of 1-2-3
o Follow up for 1 year
o 94% fusion rate in the arthrodesis group
o ***Found similar short term stability …


ORIF vs complete TMTJ - Muiler 2002

- ORIF did better functionally than complete TMTJ arthrodesis 1-4
- Only fuse 1-2-3


Late or revision arthrodesis - Rammelt 2008

- We can always fuse it later, but no one actually wants 2-3 operations
- We can talk people into it, but we should not be doing this
- Primary arthrodesis had better functional results, less complicated recovery than secondary arth
- Medial column fusion gave better result than fusion of all 5 joints
- It is a much harder operation



- 2nd and 3rd surgeries common
- High DJD in first 5 years
- No post op advantage


Case study

- Evulsion fracture off of the medial cuneiform (or 2nd metatarsal), but looks more like medial cuneiform
- Lateral deviation of base of 2nd metatarsal (possibly – very subtle)
- Implication of the evulsion fracture is that it is an intraarticular and involves
- Lis Franc’s is more plantar than dorsal, so it is the most important
- If it is truly unstable with a stress test, arthrodesis of 1-2-3 is the best treatment option
- Alignment is key for arthrodesis
- Align the 2nd with intermediate cuneiform and


Case study

- Joint space is diminished 2-5, joint space is irregular in 1
- Treatment is arthrodesis



- Closed pinning and ORIF – high failure rates and high revision rates
- Consider adjacent joint degeneration



- 1st ray is elevated
- Leads to hallux limitus
- It causes degenerative changes of the first MPJ with arthritic changes


Surgical technique

- 2 incisions
- Only make incision over 4 and 5
- Fuse 1-2-3
- Lateral incision is much more lateral than you would think
- Need to know the anatomy “associated anatomy slide on DP
- Not fusing 4 and 5, just debriding it



- Hard to diagnose
- Just as bad as leaving it, is fusing it in an abnormal position
- The key is that they come in and they are subtle, they don’t do a stress test
- Stress test – thumb pressure on cuboid, hand pressure on 1st metatarsal



- Type II= slip of the physis and fracture of the shaft
- Non-articular and has robust
- Relax the patient and reduce it closed


Steps for reduction of fracture

- Anesthesia
- Increase deformity
- Traction
- Reduce deformity
- Maintain reduction (screws, immobilization, cast, etc.)