Lisfranc Fracture-Dislocations

Bala Katyal
Trainee Advanced Practitioner – Plain Film Reporting
May 2011
Lisfranc Fracture-Dislocation
 History
 Definition
 Clinical presentation
 Mechanism of Injury
 Classifications
 Imaging
 Treatment
 Conclusion
History
Jacques Lisfranc
Definition
 Where the metatarsals dislocate from their normal
articulation with the mid-tarsal bones
 Most commonly involves the 1st and 2nd metatarsals
and the medial cuneiform
 Incidence is 1 in 55,000 people each
year
 Easily missed on initial x-rays
 Can be difficult to diagnose
Clinical Presentation
 Swelling and large lump in the
midfoot
 Unable to weight bear
 Tenderness along the tarso-metatarsal joints
 Tenderness with passive abduction
and pronation of the forefoot with
the hindfoot held flexed
Clinical Presentation
 Instability of the Lisfranc Joint
 Plantar midfoot ecchymosis
Mechanism Of Injury
 Hyper-extending the forefoot
 Catching the forefoot in a hole in the ground
 Horseback rider falling and hanging the forefoot
in the stirrup
 Commonly seen as a Charcot’s Joint in diabetic
patients
 RTA’s – especially when foot is trapped in dorsiflexion under the foot pedal
 Crush injuries
Mechanism Of Injury
 Placing the foot into
extreme plantar flexion
with an axial load
Classification
 Sprains are the most common injury to the tarso-
metatarsal ligament, it is graded I, II and III
(Burroughs et al 1998)
 Grade I - Pain at the joint, minimal swelling and no
instability of the joint
 Grade II – Increased pain and swelling of the joint,
with mild laxity but no instability
 Grade III – Complete ligamentous disruption and may
represent a fracture-dislocation
Classification
Classification
 Adam and Dixon 2008, say there are 2 basic types of
Lisfranc injuries, homolateral and divergent:
 Homolateral – Where the metatarsals are shifted laterally
 Divergent – The first metatarsal shifts medially and the
remainder of the forefoot shifts laterally
Classification
Classification
 Myerson 1986, identifies 3 classifications of Lisfranc
Injuries:
 Total incongruity – Can be either medially or laterally
displaced
Medial
Lateral
Classification
 Partial incongruity – Either medial (Type B1)or lateral
(Type B2), the most common type
Type B1
Type B2 (partial)
Type B2 (complete)
Classification
 Divergent displacement – Either partial (type C1) or
total (type C2)
Type C1
Type C2
Imaging
 First investigation is a plain film x-ray AP and Oblique
Imaging
 Plain film plays a very important role in diagnosing
Lisfranc fracture-dislocations
 To look for alignment
 On the AP, the lateral border of the
1st metatarsal is aligned with the
Lateral border of the medial
cuneiform
Imaging
 On the AP the medial border of
the 2nd metatarsal is in line with
the medial border of the
intermediate cuneiform
Imaging
 On the oblique view
 Medial and lateral borders of
the lateral cuneiform should
align with the medial and lateral
borders of the 3rd metatarsal
Imaging
 Also on the oblique
 Medial border of the cuboid should
align with the medial border of the
4th metatarsal
Imaging
Radiology.com 2006
Imaging
Radiology.com 2006
Imaging
 Patients still may need further plain film
views
 Weight-bearing AP
 Weight-bearing lateral
 Stress views done under anaesthetics
Imaging
 CT plays an important role in looking at the widening
of the joint spaces
 CT also can detect associated
fractures
 Help with confirming the
diagnosis
 Help to formulate the surgical
treatment plan
Imaging
 MRI can be useful to evaluate the soft tissue
damage
 Looks at the Lisfranc ligament
 Not routinely used
Imaging
 Doppler ultrasound may be used to look at the
dorsalis pedis artery if it can not be felt by hand
 Nuclear medicine could be used but you could not
distinguish any fractures
Fractures Associated with Lisfranc
Dislocations
 Base of 2nd metatarsal
 Cuboid
 Fractures of the shafts of the metatarsals
 Dislocations of the 1st (medial) and 2nd
(middle) and cuneonavicular joints
 Navicular
Treatment
 For a Lisfranc sprain:
 Non-weight bearing
 In a cast or removable boot
 4-6 weeks recovery
 Physiotherapy
 Gradual return to activity
Treatment
 For a Lisfranc fracture-dislocation, it is usually
surgery
 ORIF
 K-Wires
 Arthrodesis
 Complications with surgery
 Can take up to 1 year to recover
Examples of Lisfranc Injuries 1
Examples of Lisfranc Injuries 1
Examples of Lisfranc Injuries 2
Examples of Lisfranc Injuries 3
Example of Lisfranc Injuries 3
Conclusion
 Serious injury
 Difficult to diagnose
 Can lead to compartment syndrome
 Can have vascular compromise if not treated quickly
 A quick and accurate diagnosis can allow the
appropriate treatment to take place efficiently
 Can take a long time to recover
 Complications that may lead to further surgery
 Advance practice plays an important role
References
 ADAM, A and DIXON, A.K. (2008) Grainger and Allison’s Diagnostic
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Radiology. A textbook of Medical Imaging. 5th Edition, volume 2 in
GRAINGER, R.G. and ALLISON, D.J. (eds.).
London:Churchill Livingstone
AMERICAN COLLEDGE OF FOOT AND ANKLE SURGEONS (2009)
Lisfranc Injuries.
Accessed 22nd April 2010)
BURROUGHS, K.E. and REIMER, C.D. and FIELDS, K.B. (1998). ‘Lisfranc
injury of the foot: A commonly Missed diagnosis’. Published by the American
Academy of Family Physicians
CHAN, O. (2007) ABC of Emergency Radiology. 2nd Edition. BMJ Books.
Oxford:Blackwell Publishing
FOOT EDUCATION (2009) Lisfranc Fracture ORIF.
www.footeducation.com/lisfranc-fracture-orif (Accessed 14th May 2010)
 HELMS, C.A. (1995) Fundamentals of Skeletal Radiology. 2nd Edition.
London:W.B. Saunders Company
References
 HOWELL, G.A. (2009) Lisfranc Ligament Tear.
www.radsource.us/clinic/0908 (Accessed 14th May 2010)
 LARSEN, D. And MORRIS, P. (2006) Limb X-Ray Interpretation.
London:Whurr Publishers
 LEARNING RADIOLOGY.COM (2006) Lisfranc Fracture-Dislocation.
www.learningradiology.com (Accessed 22nd April 2010)
 LISLE, D.A. (2007) Imaging for students: 3rd Edition.
London: Hodder Arnold
 McCONNELL, J. AND EYRES, R. AND NIGHTINGALE, J. (2005)
Interpreting Trauma Radiographs.
Oxford:Blackwell Publishing
 MYERSON (1986) cited in East Lancashire Foot and Ankle Hyperbook,
Lisfranc Injuries
www.foothyperbook.com (Accessed 23rd May 2010)
 RABY, N. And BERMAN, L. And DE LACY, G. (2009) Accident and
Emergency Radiology. A survival Guide. 2nd Edition.
London:Elsevier Saunders
References
 THE CENTRE FOR ORTHOPAEDICS AND SPORTS MEDICINE
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(2000) Lisfranc Fracture-Dislocation
(Accessed 22nd April 2010)
TREVINO, S.G. (2009) Lisfranc Fracture Dislocation
www.emedicine.medscape.com (Accessed 23rd May 2010)
VANDERHEIDEN, T. (2008) Lisfranc Injury.
www.about.com (Accessed 15th May 2010)
WATURA ET AL. BJR 77 (Supplement 1):S46 Figure 10.
www.BJR.com (Accessed 22nd April 2010)
WHEELESS, C.R. (2009) Lisfranc’s Fracture/Tarso-metatarsal
Injuries. Duke Orthopaedics presents Wheeless’ Textbook of
Orthopaedics.
www.wheelessonline.com (Accessed 14th May 2010)
Any Questions