Lisfranc Injuries
Original Editor - Adam West, Dieter Schuddinck
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Search Strategy[edit | edit source]
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Definition/Description[edit | edit source]
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Clinically Relevant Anatomy[edit | edit source]
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. [1]
The Lisfranc ligament is a large band of plantar collagenous tissue that spans the articulation of the medial cuneiform and the second metatarsal base. [2][3]
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. [3]
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[edit | edit source]
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.[4]
Characteristics/Clinical Presentation[edit | edit source]
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.[5] Athletes may have pain with running on the toes and with push-off phase of running. [6]
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.[7]
Differential Diagnosis
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Differential Diagnosis to Lisfranc injury includes: midfoot sprain, metatarsal fracture, cuboid fracture, posterior tibialis tendon dysfunction, and compression injuries to the navicular.[8]
Diagnostic Procedures[edit | edit source]
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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. [9]
Outcome Measures[edit | edit source]
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Examination[edit | edit source]
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Medical Management
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Treatment 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.[6]
Physical Therapy Management
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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.[10]
Key Research[edit | edit source]
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Resources
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Clinical Bottom Line[edit | edit source]
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Recent Related Research (from Pubmed)[edit | edit source]
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References[edit | edit source]
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- ↑ Wadsworth DJ, Eadie NT. Conservative Management of Subtle Lisfranc Joint Injury: A Case Report. JOSPT 35(3):154-164,2005.
- ↑ Trevino SG, Kodros S. Controversies in tarsometatarsal injuries. Orthop Clin North Am 1995;26:229-38.
- ↑ 3.0 3.1 Englanoff G, Anglin D, Hutson HR. Lisfranc fracture-dislocation: a frequently missed diagnosis in the emergency department. Ann Emerg Med 1995;26:229-33.
- ↑ Nunley JA, Vertullo CJ. Classification, investigation, and management of midfoot sprains. Am J Sports Med. 2002;30:871-878.
- ↑ Reischl SF, Noceti-DeWit LM. Current concepts of orthopaedic physical therapy. 2nd edition: The Foot and Ankle: Physical Therapy Patient Management Utilizing Current Evidence. 2006.
- ↑ 6.0 6.1 Burroughs KE, Reimer CD. Fields KB. Lisfranc injury of the foot: a commonly missed diagnosis. Am Fam Physician. 1998;58:118-124.
- ↑ Englanoff G, Anglin D, Hutson HR. Lisfranc fracture-dislocation: a frequently missed diagnosis in the emergency department. Ann Emerg Med 1995;26:229-33.
- ↑ Reischl SF, Noceti-DeWit LM. Current concepts of orthopaedic physical therapy. 2nd edition: The Foot and Ankle: Physical Therapy Patient Management Utilizing Current Evidence. 2006.
- ↑ Wadsworth DJ, Eadie NT. Conservative Management of Subtle Lisfranc Joint Injury: A Case Report. JOSPT 35(3):154-164,2005.
- ↑ Reischl SF, Noceti-DeWit LM. Current concepts of orthopaedic physical therapy. 2nd edition: The Foot and Ankle: Physical Therapy Patient Management Utilizing Current Evidence. 2006.
