LisFranc`s Fracture Dislocation in Athletes

LisFranc’s Fracture Dislocation
in Athletes
Southwest General Sports Medicine Symposium
June 6, 2015
Dr. Joseph R. Bartal, DPM
Board Certified, Foot and Ankle Surgery
Fellow, American College of Foot and Ankle Surgery
Section Chief: Division of Podiatry, Southwest General
Private Practice: Southwest Foot and Ankle Associates, Inc. Middleburg Heights, OH
Attending Physician: University Hospitals Podiatric Surgical Residency
Adjunct Professor: Lower Extremity Anatomy, Kent State University College of Podiatric
Medicine
LisFranc Fracture/Dislocation: History
Jacques LisFranc de St. Martin
• 1790 – 1847 Paris, France
• Field Surgeon during Napoleonic Wars
• First described in 1813 as an amputation technique
through the midfoot after a cavalry officer developed
gangrene when thrown from his horse while the foot
remained in the stirrup.
• Technique was later perfected following the Russian Invasion
LisFranc Fracture / Dislocation: Anatomy
The Tarsometatarsal Joint:
a.k.a. LisFranc’s Joint
• Complex of arthroidial (gliding) joints
• Medial, intermediate, lateral cuneiforms
• Cuboid, Metatarsal bases 1-5
• Form the Transverse arch of the foot
LisFranc Fracture / Dislocation: Anatomy
LisFranc’s Ligament
•Strong dorsal and interosseous ligament
connecting the distal lateral 1st cunieform
to the proximal medial base of the 2nd
metatarsal
•Integrity of the ligament is paramount to
the stability of the TMT complex!!
The 2nd Metatarsal is the KEYSTONE of
the transverse arch
LisFranc Fracture / Dislocation: Injury
Mechanism of injury: Indirect
•Axial load is applied to the hindfoot while the
forefoot is forcibly plantar flexed
•2nd metatarsal is unlocked (LisFranc ligament disrupted)
•Severity of injury then is dependent upon the force
applied
•Variable mechanism if injury
•Plantarflexed forefoot fixated while forcibly abducted
Santonio Holmes, WR LisFranc Injury Week 4, 2012
LisFranc Fracture / Dislocation: Injury
Mechanism of injury: Indirect
LisFranc Fracture / Dislocation: Injury
Mechanism of injury: Direct
•Higher Velocity, more severe trauma
•Usually associated with crush injuries or MVA
•Mountain biking, snow / kite boarding
•May compromise neurovascular status
Surgical emergency!!
6 “P’s” of Compartment Syndrome:
• Pain
• Pallor
• Paresthesia
• Pulselessness
• Paralysis
• Poikilothermia
Direct LisFranc injury leading to compartment syndrome
•Any LisFranc Injury, direct or indirect, can have associated compartment syndrome!!
•Incidence is estimated at around 5%, likely lower
•Treatment is Emergency Fasciotomy
Post op day 10
Return to OR for repair of
LisFranc Fracture and primary
closure of faciotomy wounds
Post op 10 days
ORIF with primary
closure, 3 weeks
post injury
LisFranc Fracture / Dislocation: Diagnosis
Physical Exam:
• Pain,
swelling along the dorsal midfoot
• May or may not be able to weightbear
• Gross deformity is usually not evident!!
•Often a spontaneous relocation
• Bruising / eccymosis along plantar medial arch
•In cases of a mild sprain, athletes
will describe a weakness or
hesitation when pushing off
•Apply an abductory force to the
forefoot while everting against a
stabilized hindfoot and ankle
LisFranc Fracture / Dislocation: Diagnosis
Imaging:
•X-rays, 3 foot views
•Partial / Full WB if possible
•20% of LisFranc injuries misdiagnosed
on XR alone!!!
•Contralateral X-rays if diastasis is questionable
•MRI if LisFranc injury is suspected
CT scan if significant
comminution of
fractures
LisFranc Fracture / Dislocation: Classification
Quenu and Kuess (1909), Modified by Hardcastle et al (1979)
Relabelled by Myerson, 1986
LisFranc Fracture / Dislocation: Classification
•Total Incongruity
•Homolateral dislocation
•Type A
•Divergent
•Total Displacement
•Type C2
LisFranc Fracture / Dislocation: Classification
•Nunley and Vertullo 2002
•Designed for athletic midfoot
sprains that were often delayed or
misdiagnosed
•Average time to diagnosis was 4 mo.
•Achieved 93% excellent results
Stressed the need for FULL WB x-rays to
allow reproducible, comparable images
LisFranc Fracture / Dislocation: Treatment
Treatment options are dependent upon the severity of the injury
Conservative vs surgical:
Conservative Treatment:
No appreciable diastasis noted on WB
MRI shows mild to moderate sprain of
LisFranc’s ligament
Anatomic alignment of the ENTIRE
Tarsometatarsal joint
No gross instability on PE
NWB
WB
4-6 weeks NWB in cast
Progress to protected WB in walking boot / aircast for 4 weeks thereafter
Progressive return to normal activities, PT over next 6-8 weeks
AVERAGE return to competition level activities is 3-4 months, up to 6 months
LisFranc Fracture / Dislocation: Treatment
Surgical Treatment:
• Diastasis greater than 2mm
• Fracture of the base of the 2nd met
“Fleck fracture”
• Anatomical incongruity of TMT
• Unstable jointEversion / abduction test
• Recurrent Injury: “stepped funny”
• Conservative treatment fails
Surgical Treatment:
1. Identify the FULL extent of the
injury using intra-operative
stress radiographs
Don’t be fooled by
pre-op x-rays!!!!
Surgical Treatment Goals:
2. Reduce the deformity
Anatomic
alignment is
CRITICAL!!!
Surgical Treatment:
3. Fixation
Many options………
Dependent upon:
•Number of bones/
joints involved
• Severity of injury
• Soft tissue quality
• Pt. size / physique
•Patient demands
3. Fixation options continued
External Fixation
3. Fixation options continued
Suture Button / Tightrope
3. Fixation options continued
Primary arthrodesis:
“Surgical immobilization of a joint by fusion of the adjacent bones”
Indicated for severely comminuted fractures
Post Operative management:
Strict NWB in below knee cast for 6-8 weeks
Progression to walking cast / aircast for the next 4-6 weeks
Begin active and passive ROM exercises
WB as tolerated with protection
Hardware removal at ~12-16 weeks post op
Stress radiographs intra-operatively
Begin active PT following week
Full, protected WB for additional 4 weeks
Progressive transition into regular shoes ~4 months
Begin light conditioning ~5 months
•Full Return to competitive athletics can significantly vary:
-Severity of the injury
-Surgical vs non surgical
-Physical demands of particular sport / specific position
LisFranc Prognosis: The Good, the Bad, and the Ugly
The Good:
•Most NFL players (90%) return to competition
•No statistical difference in offensive / defensive production
•Nearly half of NFL players who returned produced at least one
season that exceeded their pre-injury performance
Matt Schaub QB, Houstan Texans
LisFranc injury 11/11
Andrew Miller P, Boston Red Sox
Injured 7/6/13
Udonsi Haslem C, Miami Heat
Injured 11/12
LisFranc Prognosis: The Good, the Bad, and the Ugly
The Bad:
•Average Return to NFL : 11.1 months
•85% were season ending injuries
•Even non surgical injuries required 6
months for full return
•Stigma associated with LisFranc Injury
Cedric Benson, RB Green Bay
•LisFranc Injuries are on the rise!!!
Injured 10/2012
•“Scourge of the NFL”
•NFL Foot and Ankle Subcommittee:
1. More accurate Diagnosis
2. Playing surfaces- High ankle sprains, turf toe
3. Shoe Gear- lighter, more flexible
4. Players are more physical: Bigger, faster, stronger
LisFranc Prognosis: The Good, the Bad, and the Ugly
The Ugly:
•Approximately 10% Never return to the NFL
•Statistics are unknown for NCAA athletics, though likely higher
•Untreated or neglected injuries can lead to debilitating pain,
deformity, and loss of function
•Severe injuries may require additional surgery even with
appropriate treatment
Conclusion:
• Timely and accurate diagnosis is paramount to successful treatment
• High index of suspicion with any midfoot injury
• Beware of possible compartment syndrome
• Early and aggressive treatment, whether conservative vs surgical, is
absolutely critical
• Patients need to be aware that returning to competition level athletics
is highly probable……. Just not any time soon.
QUESTIONS???