Lisfranc fracture dislocation

Lisfranc fracture dislocation

1. LISFRANC
FRACTURE
DISLOCATION
Dr.Ponnilavan

2. ANATOMY
•In the AP plane, the base of the second
metatarsal is recessed between the medial
and lateral cuneiforms. This limits
translation of the metatarsals in the frontal
plane.
•In the coronal plane, the middle three
metatarsal bases are trapezoidal, forminga
transverse arch that prevents plantar
displacement of the metatarsalbases.

3. •The second metatarsal base is the keystone
in the transverse arch of thefoot.
•There is only slight motion across thetarso-
metatarsal joints, with 10 to 20 degrees of
dorsoplantar motion at the fifth metatarso-
cuboid joint and 20 degrees plantar flexion
at the first metatarso-cuneiform joint

4. •Theligamentoussupportbeginswiththe
strongligamentslinkingthebasesofthe
secondthroughfifthmetatarsals.
•The most important ligament isLisfranc
ligament, which attaches the medial
cuneiform to the base of the second
metatarsal.

6. MECHANISM
•Twisting
•Axialloading
•Crushing

7. •Twisting: Forceful abduction of the forefoot
on the tarsus results in fracture of the base
of the second metatarsal and shear or crush
fracture of thecuboid.
•Most commonmechanism

8. •Axial loading of a fixed foot may be seen
with extreme ankle equinus with axial
loading of the body weight, such as a missed
step off a curb or landing from a jumpduring
a dancemaneuver.
•Crushing mechanisms are common in
industrial injuries to Lisfranc joint, often
with soft tissue compromise, and
compartmentsyndrome

9. AXIALLOADING

10. CLINICALEVALUATION
•Patients present with variable foot
deformity, pain, swelling, and tenderness on
the dorsum of thefoot.
•Diagnosis requires a high degree of clinical
suspicion.
•Often missed or misdisgnosed as a simple
sprain

11. •Careful neurovascular examination is
essential
•Maybe assosiated with laceration of the
dorsalis pedisartery.
•Severe swelling of the foot is common and
compartment syndrome of the foot must be
ruledout

12. RADIOGRAPHICEVALUATION
•Themedialborderofthesecondmetatarsal
shouldbecolinearwiththemedialborderof
themiddlecuneiformontheAPview
•The medial border of the fourth metatarsal
should be colinear with the medial border of
the cuboid on the obliqueview

15. •Dorsal displacement of the metatarsals on
the lateral view is indicative of ligamentous
compromise.
•Fleckfractures around the base of the
second metatarsal are indicative of
disruption of Lisfrancjoint.

16. •Weight-bearing radiographs provide a stress
film of the jointcomplex.
•Stress views can beobtained.
•CT scan to assess intraarticularcomminution.

17. CLASSIFICATION

18. OUENU ANDKUSS
CLASSIFICATION
•Homolateral: All five metatarsals displaced
in the samedirection
•Isolated: One or two metatarsals displaced
from theothers
•Divergent: Displacement of the metatarsals
in 2planes

20. MYERSONCLASSIFICATION
•Total incongruity: Lateral anddorsoplantar
•Partial incongruity: Medial andlateral
•Divergent: Partial and total

22. TREATMENT

23. NONOPERATIVE
•Injuries that present with painful weight
bearing, and tenderness but fail to exhibit
any signs of instability should be considereda
sprain.
•<2mm displacement of tarsometatarsaljoint
•Patients with nondisplaced/ ligamentous
injuries should be placed in a short legcast

24. •Initially, the patient is kept non weight
bearing with crutches and is permittedto
bear weight as comfortallows.
•Repeat x-rays are necessary once swelling
decreases, to detect osseousdisplacement.

25. OPERATIVEMANAGEMENT
•This should be considered when
displacement of the tarsometatarsal jointis
>2mm.
•The best results are obtained through
anatomic reduction and stablefixation.
•The most common approach is usingtwo
longitudinalincisions.

27. •The first is centered over the first/second
intermetatarsal space allowing identification
of the neurovascular bundle and access to
the medial two tarsometatarsaljoints.
•A second longitudinal incision is madeover
the fourthmetatarsal

28. •The key to reduction is correction of the
fracture-dislocation of the second metatarsal
base.
•Once reduction is accomplished, fixationis
maintained by kirschner wires or screw
fixation

29. •The lateral metatarsals frequently reduce
with reduction of the medialcolumn
•If intercuneiform instability exists, an
intercuneiform screw / k wire can beused.
•StiffnessfromORIFisnotofsignificant
concernbecauseofthealreadylimited
motionofthetarsometatarsaljoints.

34. COMPLICATIONS
•Posttraumaticarthritis
•Compartmentsyndrome
•Infection
•CRPS/RSD
•Neurovascularinjury
•Hardwarefailure

35. THANKYOU