L16 lisfranc & midfoot inj

orthopaedics and trauma

1. Fractures and Dislocations
of the Mid-foot Including
Lisfranc Injuries
Arthur K. Walling, MD
Clinical Professor Of Orthopaedics
Director Foot and Ankle Fellowship
Florida Orthopaedic Institute
Tampa, Florida

2. Lisfranc’s Joint Injuries
•Any bony or ligamentous injury involving
the tarsometatarsal joint complex
•Named after the Napoleonic-era surgeon
who described amputations at this level
without ever defining a specific injury

3. Anatomy
•Lisfranc’s joint:
articulation between the 3
cuneifoms and cuboid
(tarsus) and the bases of
the 5 metatarsals
•Osseous stability is
provided by the Roman
arch of the metatarsals and
the recessed keystone of
the second metatarsal base

4. Anatomy
•Lisfranc’s ligament:
large oblique ligament
that extends from the
planter aspect of the
medial cuneiform to
the base of the second
metatarsal (there is no
transverse metatarsal
ligament from 1 to 2)

5. Anatomy
•Interosseous
ligaments: connect the
2 thru 5 metatarsal
bases both dorsal and
plantar (stronger and
larger)
•Secondary stabilizers:
plantar fascia,
peroneus longus, and
intrinsincs

6. Anatomy
•Four Major Units
1. 1
st
MT – Medial Cuneiform: 6 degrees of
Mobility
2. 2
nd
MT – Middle Cuneiform > Firmly Fixed
3. 3
rd
MT – Lateral Cuneiform > Firmly Fixed
4. 4
th
– 5
th
MT – Cuboid: Mobile

7. Anatomy
•Associated Structures:
1. Dorsalis pedis
artery – courses
between 1
st
and 2
nd

metatarsal bases
2. Deep peroneal
nerve: runs alongside
the artery

8. Incidence
•Generally considered rare ( 1 per 55,000
people per year or 15/5500 fractures )
•As index of suspicion increases, so does
incidence
•Approximately 20% of Lisfranc’s injuries
may be overlooked ( especially in
polytraumatized patients )

9. Mechanisms of Injury
•Trauma: motor vehicle accidents account
for one third to two thirds of all cases
( incidence of lower extremity foot trauma
has increased with the use of air bags )
•Crush injuries
•Sports-related injuries are also occurring
with increasing frequency

10. Mechanisms of Injury - Direct
Direct Injuries:
force is applied
directly to the
Lisfranc’s
articulation. The
applied force is
to the dorsum of
the foot.

11. Mechanisms of Injury - Direct
Direct Injuries:
plantar
displacement is
more common,
but dorsal
displacement
can also occur.
Open fracture/compartment syndrome/soft tissue injury greater

12. Mechanisms of Injury - Indirect
Indirect injuries:
more common
than direct and
result from axial
loading or
twisting.
Metatarsal bases
dislocate dorsally
more often than
plantarly.

13. Mechanism of Injury - Indirect
•Typical of athletic
injury
•Axial loading to
plantar flexed foot
results in hyper-
plantar flexion and
ligament rupture
•Rarely associated with
open injury or
vascular compromise

14. Mechanism of Injury - Indirect
•Twisting injuries lead
to forceful abduction
of the forefoot, often
resulting in a 2
nd

metatarsal base
fracture and/or
compression fracture
of the cuboid (“ nut
cracker”)

15. Associated Fractures
•Base of 2
nd
metatarsal
•Avulsion of navicular
•Isolated medial
cuneiform
•Cuboid

16. Classification
•Quenu and Kuss (1909): Homolateral,
Isolated, and Divergent
1. Modified by Hardcastle in 1982
2. Further modified by Myerson in 1986
•Fail to encompass all injury patterns
especially crush injuries
•Guide treatment but do not establish
prognosis

17. Classification
Quenu and Kuss (1909)
HOMOLATERAL:
most common

18. Classification
Quenu and Kuss (1909)
ISOLATED

19. Classification
Quenu and Kuss (1909)
DIVERGENT:
least commom

20. Classification
Hardcastle (1982)
Homolateral or Total
Incongruity:
• All 5 metatarsals
displace in common
direction
•Fracture base of 2
nd

common

21. Classification
Hardcastle (1982)
Isolated Partial
Incongruities:
• Displacement of 1 or
more metatarsals away
from the others

22. Classification
Hardcastle (1982)
Divergent:
• Lateral displacement of
lesser metatarsals with
medial displacement of
the 1
st
metatarsal
• May have extension of
injury into cuneiforms or
talonavicular joint

23. Classification
Myerson (1986)

24. Classification
Myerson (1986)

25. Classification
Myerson (1986)

26. Diagnosis
•Requires a high degree of clinical suspicion
1. 20% misdiagnosed
2. 40% no treatment in the 1
st
week
•Be wary of the diagnosis of “midfoot
sprain”

27. Clinical Findings
•Midfoot pain with
difficulty in weight
bearing
•Swelling across the
dorsum of the foot
•Deformity variable
due to possible
spontaneous reduction

28. Clinical Findings
•Ecchymosis may
appear late
•Local tenderness at
tarsometatarsal joints
•Gentle stressing
plantar/dorsiflexion
and rotation will
reveal instability

29. Clinical Findings
•Check neurovascular
status for compromise
of dorsalis pedis artery
and/or deep peroneal
nerve injury
•Asses for possible
COMPARTMENT
SYNDROME

30. Radiographic Evaluation
•AP, Lateral, and 30°
Oblique X-Rays are
mandatory
•AP: The medial
margin of the 2
nd

metatarsal base and
medial margin of the
medial cuneifrom
should be alligned

31. Radiographic Evaluation
•Oblique: Medial base
of the 4
th
metatarsal
and medial margin of
the cuboid should be
alligned

32. Radiographic Evaluation
•Lateral: The dorsal
surface of the 1
st
and 2
nd

metatarsals should be
level to the
corresponding
cuneiforms

33. Radiographic Evaluation
•Standing views provide “stress” and may
demonstrate subtle diastasis
•Comparison views are very helpful
•Associated fractures:
1.Base of 2
nd
metatarsal
2.Avulsion navicular
3.Isolated medial cuneiform
4.Cuboid

34. Radiographic Evaluation
•Additional imaging:
1. True stress views or
fluroscopy
2. CT Scans
3. Bone scan – for
persistent pain with no
radiographic findings
4. If suspicious: repeat x-
rays and keep looking

35. Treatment
•Early recognition is the key to preventing long
term disability
•Anatomic reduction is necessary for best results:
displacement of >1mm. or gross instability of
tarsometatarsal, intercuneiform, or
naviculocuneiform joints is unacceptable
•Goal: obtain or maintain anatomic reduction

36. Treatment
•Nonoperative: for
nondisplaced injuries
with normal
weightbearing or
stress x-rays
•Short leg cast
•4 to 6 weeks
nonweight bearing
•Repeat x-rays to rule
out displacement as
swelling decreases
•Total treatment 2-3
months

37. Operative Treatment
•Surgical emergencies:
1. Open fractures
2. Vascular
compromise (dorsalis
pedis)
3. Compartment
syndrome

38. Operative Treatment
Technique
•1 – 3 dorsal incisions:
1. 1
st
incision centered
at TMT joint and
along axis of 2
nd
ray,
lateral to EHL tendon
2. Identify and protect
NV bundle

39. Operative Treatment
Technique
•Reduce and
provisionally stabilize
2
nd
TMT joint
•Reduce and
provisionally stabilize
1
st
TMT joint
•If lateral TMT joints
remain displaced use
2
nd
or 3
rd
incision(s)
2
nd
met. Base
unreduced
reduced

40. Operative Treatment
Technique
•If reductions are
anatomic proceed with
permanent fixation:
1. Screw fixation is
preferable for the
medial column
2. “Pocket hole” to
prevent dorsal cortex
fracture

41. Operative Treatment
Technique
3. Screws are
positional not lag
4. To aid reduction or
if still unstable use a
screw from medial
cuneiform to base of
2
nd
metatarsal

42. Operative Treatment
Technique
5. If intercuneiform
instability exists use
an intercuneiform
screw
6.The lateral
metatarsals frequently
reduce with the medial
column and pin
fixation for mobility is
acceptable

43. Case Example
Preop AP
Postop AP
Postop Lateral

44. Postoperative Management
•Splint 10 –14 days, nonweight bearing
•Short leg cast, nonweight bearing 4 – 6
weeks
•Short leg weight bearing cast or brace for an
additional 4 – 6 weeks
•Arch support for 3 – 6 months

45. Hardware Removal
•Lateral column stabilization can be
removed at 6 to 12 weeks
•Medial fixation should not be removed for 4
to 6 months
•Some advocate leaving screws indefinitely
unless symptomatic

46. Complications
•Post traumatic arthritis
1. Present in most, but may not be symptomatic
2. Related to initial injury and adequacy of
reduction
3. Treated with arthrodesis for medial column
4. Interpositional arthroplasty may be considered
for lateral column

47. Complications
•Compartment syndrome
•Infection
•Complex mediated pain syndrome
•Neurovascular injury
•Hardware failure

48. Prognosis
•Long rehabilitation (> 1 year)
•Incomplete reduction leads to increased
incidence of deformity and chronic foot
pain
•Incidence of traumatic arthritis (0 – 58%)
and related to intraarticular surface damage
and comminution

49. Navicular Fractures
•Anatomy: a horseshoe
shaped disc sitting
between the talus and
cuneiforms
•Numerous short
ligaments attach
dorsally, plantarly, and
laterally
•Deltoid attaches
medially

50. Navicular Fractures
•Blood supply: because of
the large articular
surfaces, vessels can only
enter dorsally, plantarly,
and thru tuberosity
•Medial and lateral thirds
have good blood supply,
the central third is largely
avascular
•# of vessels decreases
with age

51. Navicular Fractures
•Avulsion fractures:
usually dorsal lip
(essentially severe sprain)
•Treatment:
1. Immobilization &
progressive weight
bearing
2. Excision of fragment if
painful

52. Navicular Fractures
•Tuberosity fractures:
avulsion by p. tibial
tendon and spring lig.
•Usually minimally
displaced
•May have associated
calcaneocuboid impaction
•ORIF depending on
degree of displacement ( >
5mm.)

53. Navicular Fractures
Body Fractures
•High energy trauma with axial foot loading
•Frequently associated with talonavicular
subluxation
•CT scans helpful for preop planning
•Anatomic reduction essential

54. Navicular Fractures
Body Fractures Classification
•Sangeorzan Type 1:
coronal fracture plane

55. Navicular Fractures
Body Fractures Classification
•Sangeorzan Type 2:
primary fracture
dorsolateral to plantar
medial with medial
displacement of major
fragment and forefoot

56. Navicular Fractures
Body Fractures Classification
•Sangeorzan Type 3:
comminution of the
body in the sagittal
plane with forefoot
laterally displaced

57. Navicular Fractures
Body Fractures
•Treatment:
1.ORIF if any
displacement
2.Anteromedial
incision along medial
aspect Tib. Ant.
3.Second anterolateral
incission to help
reduce lateral
fragment

58. Navicular Fractures
Body Fractures
•Treatment cont.:
4. May require
stabilization or fusion
to cuneiforms
5. Avoid fusion of
essential talonavicular
joint if at all possible
Missed navicular fx required
orif and primary fusion
secondary to arthritis

59. Navicular Fractures
Body Fractures
•Prognosis: With adequate reduction most
have good result, but few are “normal”
•Type 3 worst prognosis:
1. Only ½ adequately reduced in
Sangeorzan series (60% of joint surface)
2. 6 of 21 developed ostonecrosis with one
collapse

60. Navicular Stress Fractures
•Incidence: Uncommon
•Etiology: repetitive
stress and poor blood
supply
•Running most
common, but can
occur in all patients
active in sports
•Diagnosis:Vague arch
pain with midfoot
tenderness
•Delay in diagnosis
common
•X-Rays: AP, Lat., and
Oblique
•CT and Bone scans if
uncertain

61. Navicular Stress Fractures
Treatment
•Incomplete Fracture: Nonweight bearing
cast until healed (variable time)
•Complete fracture or nonunion: ORIF with
screws perpendicular to fracture plane with
or without bone graft
•Complications: nonunion or persistent pain

62. Cuboid Fractures
•Isolated fractures are
rare
•Most often associated
with other fractures
&/or dislocations
•Two types of
fractures usually seen

63. Cuboid Fractures
•Avulsion fractures:
most common
•Compression
fractures: mechanism
of injury “nutcracker”
axial loading with
plantar flexion and
forefoot abduction

64. Cuboid Fractures
Treatment
•Isolated and nondisplaced: immobilization 6
to 8 weeks
•Displaced: ORIF
1. Often requires bone graft and small plate
2. Can use small external fixateur for
distraction

65. Cuneiform Fractures
•Isolated fractures quite
rare
•Displacement of these
fractures is unusual
•Healing with few
complications is likely
•Mechanisms of injury:
1. Direct trauma –
most common and
heal rapidly with
nonoperative treatment
2. Indirect trauma
(Lisfranc variants):
ORIF
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