Lisfranc Injuries

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Definition/Description

Dislocation of the tarsometatarsal articulations.

Clinically Relevant Anatomy

The foot can be subdivided into three parts : the forefoot area which contains the toes, the midfoot area consisting the small bones called navicular, cuneiform and cuboid. The third part is the hindfoot consisting of the talus (lower ankle) and the calcaneus (heel).

The Lisfranc joints are tarsometaral articulations. In the normal Lisfranc joint complex, first 3 metatarsal bases articulate with their respective cuneiforms, and the lateral 2 metatarsals articulate with the cuboid. The second metatarsal base is tightly recessed in a mortise formed by the 3 cuneiform bones. The intertarsal ligaments, dorsal and plantar tarsalmetatarsal (TMT) ligaments, and transverse ligaments provide soft tissue stability.

The Lisfranc ligament is a large band of plantar collagenous tissue that spans the articulation of the medial cuneiform and the second metatarsal base.

While transverse ligaments connect the bases of the lateral four metatarsals, no transverse ligament exists between the first and the second metatarsal bases. The joint capsule and dorsal ligaments form the only minimal support on the dorsal surface of the Lisfranc joint.

The basy architecture of this joint, specifically the ‘keystone’ wedging of the second metatarsal of the cuneiform forms the focal point that supports the entire tarsometatarsal articulation.

Epidemiology /Etiology

Injuries to the Lisfranc joint are usually the result of combined external rotation and compression force. Injuries can be caused by either direct or indirect trauma. Injuries to the joint are often missed due to anatomical complexity and rarity.

Characteristics/Clinical Presentation

Clinically, with the calcaneus held stable, abduction or pronation of the forefoot will produce pain over the midfoot. Typically, there is difficulty weight bearing, minimal swelling over the midfoot, and palpable tenderness along the tarsometatarsal joints. Athletes may have pain with running on the toes and with push-off phase of running.

Lisfranc injuries can include sprains, dislocations, fractures of all three at the same time. An injury can be caused by an indirect or direct trauma. A direct trauma is can be caused when an external force works on the foot, for example when you drop something heavy on it. An indirect trauma is caused when a twisting of the foot happens after it gets caught on something. An injury at the Lisfranc joint is mostly the result of the combined external rotation and compression force.

Like in most cases of injury, an injury to the Lisfranc joint can have some complications. The most common complication is post-traumatic arthritis of the joint. Post-traumatic arthritis mimics degenerative arthritis, but it’s course is accelerated because of severe injury. This can cause chronic pain in the injured joint.

Another complication is called the compartment syndrome. It occurs when traumatic injury causes swelling and bleeding to raise the pressure within the tissues of the body.

The incidence of the Lisfranc joint fracture dislocations is one case per 55,000 persons each year.

As many as 20 percent of the Lisfranc joint injuries are missed on initial anteroposterior and oblique radiographs.

Image:Lisfranc_injury.jpg

Differential Diagnosis

The injury was first noticed in the early 1800s by the French surgeon Jacques Lisfranc. The injury was caused when soldiers were thrown of their horses and their foot was stuck into the stirrup. Now automobile accidents, falls and sport injuries can also lead to an injury on the Lisfranc joint. This kind of injury is more and more seen by football players, gymnasts and ballet dancers. The injury can be potentially career ending.  

The Lisfranc joint injury isn’t easy to be diagnosed, apart from when there is a marked swelling and radiographic changes noticeable. The most common symptoms are :

• swelling of the foot and/or ankle
• bruising of the foot and/or ankle
• pain usually in the middle part of the foot
• widening of the midfoot area
• large bump on the top mid-foot area
• not being able to put any weight on the injured foot

Differential Diagnosis to Lisfranc injury includes: midfoot sprain, metatarsal fracture, cuboid fracture, posterior tibialis tendon dysfunction, and compression injuries to the navicular.

Diagnostic Procedures

Currently, there are no specific clinical tests to confirm the extent of an injury. Therefore, diagnosis of ligmentous injuries may be based on a high level of suspicion. In suspected Lisfranc injuries, use of imaging modalities is warrented. Recommended radiographs include anteroposterior, lateral, and 30 degree internal oblique projections in weightbearing. 

The injury can be seen on x-ray. Sometimes there is a x-ray needed of the uninjured foot to see if there is an injury or not. A weight-bearing radiograph is necessary, because a non-bearing x-ray may not reveal any injury.
On x-ray, dislocation of the tarsometatarsal joint is indicated by :

• loss of in-line arrangement of the lateral margin of the first metatarsal base with the lateral edge of the medial cuneiform.
• loss of in-line arrangement of the medial margin of the second metatarsal base with the medial edge of the middle cuneiform in the weight-bearing anteroposterior view.
• the presence of small avulsed fragments, which are further indications of ligamentous injury and probable joint disruption.

The Lisfranc injury can also be physical examined. When Lisfranc joint complex injury is suspected, palpation of the foot should begin distally and continue proximally to each tarsometatarsal articulation. Tenderness along the metatarsal joints supports the diagnosis of midfoot sprain with potential for segmental instability.

Pain can localize to the medial or lateral aspect of the foot at the tarsometatarsal region on direct palpation, or it can be produced by abduction and pronation of the forefoot while the hindfoot is held fixed.

The dorsalis pedis pulse and capillary refill should also be evaluated. It can be disrupted in a severe dislocation.

Computed tomography should be reserved for questionable cases such as the severely injured foot where adequate positioning cannot be obtained or cases where the multiplicity of fractures and dislocations makes complete evaluation difficult. Computed tomography should also be used when adequate reduction cannot be achieved to determine the presence of bony fragments or entrapped soft tissues that may be hindering reduction.

Medical Management

Medical Management to Lisfranc injuries may be operative or non-operative depending on severity. In mild to moderate sprains, the lower extremity may be immobilized for approximately six weeks. More severe injuries may be treated with open reduction and internal fixation. Following ORIF, the foot is usually immpbilized for 8-12 weeks.

Physical Therapy Management

If a mild sprain is the case and the radiograph shows no diastosis immobilization is suggested. If there is a minimal displacement of the bones, a stiff walking cast applied for approximately eight weeks is an appropriate alternative. However, the most common treatment is to secure the fractured and dislocated bones with either internal (screws) or external (pins) fixation. 

Physical therapy intervention begins shortly following immobilization in both operatvie and conservative treatment. Interventions include: edema reduction, strengthing to address post immobilization atrophy, flexibility exercises, gait training, and manufacturing of foot orthoses to help support the tarsometatarsal articulations. 

Other therapeutic exercises are doing stairs, swimming, walking in the pool, standing on toes, jump rope, squats. 

Recent Related Research (from Pubmed)

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