LISFRANC FRACTURE - DISLOCATIONUPDATE 1988

D. Richard DiNapoli, D.P.M.Thomas D. Cain, D.P.M.

lntroduction

The tarsometatarsal joints form a bony arc f rom medialto lateral across the foot similar to a stone arch. This os-seousconf iguration combined with an extensive Iigamen-tous support networkand "key-stone" natu reof the recess-ed second metatarsal base provide a signif icantamou ntofstab i I ity to the m idfoot jo i nt com plex (Fi g. 1). The reportedincidenceof dislocation and f ractureof the Lisf ranc's jointis less than 1% of all f ractu res. The severity may range f roman occult subluxation to a grossly malaligned fracture-d islocation.

Fracture dislocation of the Lisf ranc joint complex is re-

po rted Iy m i sd i ag n osed ap p roxi m ately 20 % of theti m e. Th e

morbidityassociated with this in ju ry is great. Severe edemaand hematomaformation followingthe inju ry isaf requentoccu rrence and necessitates the useof Doppler u ltrasou ndfor identification of pedal arteries. Damage to the perfor-ating vessels and arterial spans lead ing to circu Iatory com-prom ise and am putation have been reported. Other com-pl ications i ncl u de severe post-trau matic degene rative ar-thritis, reflex sympathetic dystrophy and painful osseousp rom i nences. Preve ntio n of these com p I icatio n s req u i res

accurate diagnosis and prompt treatment.

Anatomic Consideration

Full knowledge of the regional anatomy is essential forappreciation of the osseous and soft tissue damage that

Fig. 1. Tarsometatarsal joints conf iguration is similarto stonearch. Recessed position of second metatarsal confers addedstabilityto this joint

occurs. The mechanism of this injury, the injury patterns,and technique for reduction are fully dependent on theosseous and Iigamentous relationships.

The metatarsals are bou nd to one another by a series oftransverse dorsal and plantar ligaments as well as inter-metatarsal ligaments. The one exception is the lack of Iiga-mentous attachment between the first and second meta-tarsals. This anatomic fact is responsible for the inju ry pat-tern where the fou r lesser metatarsals d islocated laterallyas a unit leavingthe first metatarsl unaffected. It has beenproposed that the pattern of dislocation of the f irst meta-tarsal is dependent upon the lesser four metatarsals.

The ligaments that tether the metatarsus to the lessertarsus are disrupted during this injury. The ligaments arestronger plantarlythan dorsally. The dorsal med ial ligamentattaching the medial cuneiform to the first metatarsal is

the largest ligament at this level. During open repairs ofthis injury, it is often possible to primarily repair this liga-ment. Probably the most sign if icant Iigament of the tarso-metatarsal joi nt i s the i nterosseou s I igament that attachesthe med ial cu neiform to the second metatarsal base. Thisstructu re is commonly designated the Lisf ranc's Iigamentand is responsible for the production of an avulsion f rac-

ture off the medial aspect of the second metatarsal (Figs.

2, 3). The remaining ligaments are either disrupted oravulsed from their attachments creating multiple smallflake fractures.

Th e i n he re nt o sseou s stab i I ity of th e tarso m etatarsal j o i ntwas previously mentioned. The convex shape formed bythe metatarsal-lesser tarsus articulations from medial tolateralcombined with the dorsalto plantarwedged shapeof the articulations creates added stability both in thetransverse and sagittal planes.

Classification of lniury

Numerous classifications of this injury have been pro-posed in the literature based upon mechanics of injury,direction of force and resultant injury pattern. No partic-u Iar study specif ically add ressed the in ju ry pattern in lightof surgical repair and end results. Hardcastle and asso-ciates describe a comprehensive classification that wasbased upon injury pattern of metatarsal displacement(Fig. a). They report that the amount of displacement willinf luence the degree of f ixation and prognosis. The classi-fication system is simpletoapplyand based upon the radi-ograph ical appearance.

198

Fig.2. Lisf ranc's ligament attaches medial cuneiform andmedial aspect of second metatarsal base

Type A - Total: Total incongruity of the entire tarsometa-tarsaljoint. The displacement mayoccur in the sagittalortransverse planes.

Type B - Partial:Partial incongruityof the jointcomplex ineither sagittal, transverse planes, or both. Partial in ju riesmay exist and are of two types.

Med i al d i s p I ac e m e nt atf ects the f i rst m etata rsal e ith e rin isolation or combined with displacement of oneor more of the second, third, or fourth metatarsals.

Late ral d i s p I ace m e nt involves o n e o r mo re of the fo u rlesser metatarsals while the first is unaffected.

Type C - D ivergent:fheremay be partial ortotal i ncongru ityof the joint. The first metatarsal is displaced medially andany combination of the lateral four metatarsals is dis-placed laterally in either the sagittal or transverse planesor both.

Mechanics of lnjury

Two mechanisms of tarsometatarsal joint injury havebeen postulated: direct and indirect.

Thedirect mechanism involves acrush ing force concen-trated at the dorsu m of the foot with a variable pattern ofload, direction, and velocity resulting in a variety of f rac-tu re-d islocation patterns.

Ihe indirect mechanism is the least understood andmost variable. Wiley in 1W1 performed cadaver studiesand proposed that there were two main forces associatedwith the indirect mechanism; forefoot abduction andforced forefoot plantar f lexion. The foot is u sually in ju redwhile in a plantarflexed or equinus-type position. A trau-matic abd uctoryforce is applied to the forefootwh ich pro-duces an excessive amount of shear stress at the secondmetatarsal base. This results in either a transverse basefracture of the second metatarsal or an avulsion f racture

Fig.3. Avulsion f racture of medial aspect of base of secondmetatarsal is generated by Lisf ranc's ligament. Also shown isf ractu re of med ial cu neiform

of the medial aspect of the second metatarsal base. Theavulsion f ragment is usually attached to the Lisfranc Iiga-ment. lf the abduction force continues the lesser meta-tarsal s may s h ift Iateral ly as the late ral tarso metatarsal I iga-ments fail and ru ptu re. Occasionallythe severe add u ctoryforce will result in a distal cuboid compression fracture.

Diagnosis

The diagnosis of tarsometatarsalf ractu re dislocation re-qu ires Iittle insightwith obvious cli nical and radiographicevidence. This is contrasted to the diagnosis of an occult,reduced f racture-dislocation which requires a high indexof clinical suspicion because of the long term sequellaeof a missed diagnosis.

Often the patient recalls an audible snap or pop afterexperiencingaforced plantarf lexion ordirect inju ry mech-anism. The patient may relate stepping off of a curb, slip-ping on the stairs, or stepping in a hole. The indirect mech-an ism more often occu rs in a motorveh icle accidentwherethe plantarf Iexed foot sustains a Iongitudinalforce againstthe floor board.

ln both, physical exam will reveal gross edema over theentire forefoot and midfoot region. There will be markedpal pato ry te nd e rn ess over th e tarsometatarsal joi nts. I den-tif ication of pedal pulses must be performed. If the dor-sal i s ped is and posterior ti bial artery can not be pal pated,a Doppler ultrasound must be used. Excessive range ofmotion at the tarsometatarsal joint may be present.

Standard diagnostic roentgenograms should be per-formed on the foot and ankle and comparison views mayalso be warrented. lf in itial rad iographs appear su perf iciallynormal, careful scrutiny maydiscern the pathognomonicsign of a relocated tarsometatarsal .ioint fracture disloca-tion. Attention should be directed to the first metatarsalbase which may reveal a slight diastasis between the f irst

199

PARTIALINCONGRUITY

TYPE 81

TOTALINCONGRUITY

TYPE A

Lateral Dislocation

DIVERGENT

PartialDisplacement

TYPE C1

Wt/?Y

Dorsoplantar

WMLateral

TYPE 82

%#V

Fig.4. Artist's interpretation of Hardcastle and associates classif ication of Lisf ranc's joint iniuries

and second metatarsals. Carefu Iexamination of the secondmetatarsal base may highlight a small avulsion fragmentdiagnostic of dislocation at this level. One shou ld also fol-low the cortical margins of the metatarsals and their ad-jacent tarsal bones. The most consistant relationship ap-pears to be the med ial cortical margi n of the second meta-tarsal and medial edge of the second cuneiform (Fig. 5).

A com pression f ractu re of the cu boid may also be d iag-nostic of the lateral d isplacement type of tarsometatarsalfracture dislocation.

lf standard radiographs prove negative butclinicalsymp-toms persist, stress radiographs should be performed.Stress rad iog raph s, i n the tran sverse o r sagittal plane, m aybe performed u nder local anesthesiaor general anesthesiafor a more accurate diagnosis (Fig.6).

Treatment

The literature concerning appropriate treatment com-bines all inju ries u nderthe heading of Lisf ranc dislocationregardless of the in ju ry pattern. Some authors have noteddifferences amongthe inju ry patterns and thetypeof treat-ment that was rendered. The best functional results areprovided through accurate anatomic alignment whetheropen orclosed. Wire f ixation has proven to maintain align-mentfollowing reduction. Closed reduction with castingof the u nstable joints has not proven effective. Factors thatwill influence the outcome of the injury are delay in diag-nosis, amount of displacement, Iocal soft tissue injury,and finally quality and maintenance of initial reduction.

At Doctors Hospital the staff approahces treatment ofth is in ju ry in itiallywith closed reduction. Anesthesia com-bined with muscle relaxation is usually required. Distalforefoot traction i s appl ied agai nst cou ntertraction of theheel. The forefoot is suspended f rom the operating roomtable by Chinese finger traps and tape with countertrac-tion weights applied to the heel(Fig.7). Manipulation maythen be attem pted to reposition the second metatarsocu ne-iform articu lation. Once relocation isverif ied radiographic-ally, percutaneous wire stabilization may be employed.

Soft tissue interposition between osseous segments oreven f racture comminution may prevent anatomic reduc-tion. Tibialis anterior.and peroneus longus have been de-scribed in the literature as interposing between osseousarticu lation s and preventi ng anatom ic real ign ment.

Should closed reduction methods fail, open reductionis indicated. Open reduction is also indicated for inspec-tion of pedal blood vessels if circulatory compromise is

present.

The ope rative app roach em ploys long itu d i nal cu rvi I i nearincisions to help prevent further compromise (Fig. B). Thef irst incision is usually placed medially over the f irst meta-tarsocuneiform joint with adequate distal exposure. Re-

cent experiences have demon strated that the dorsal med-

Fig.5. A. & B. Dorsoplantar and lateral oblique radiographs oftype C inju ry. Caref u I scruti ny of medial cortical margi n of se-

cond metatarsal and cuneiform will reveal a diastasis and avul-sion f racture

ial ligament of this joint can be separated from the iointcapsule during the dissection process. A second dorsalincision is commonly placed just over the articulation ofthe second and third metatarsal bases and articulatingcuneiforms. lnspection of the second metatarsocunei-form joint must be performed and any osseous f ragmentsfound to be within the joint excised. A similar approachis utilized for the f ifth metatarsocuboid joint.

Onceanatom ic al ignment has been accomplished,wi re

stabi I ization is em ployed u nder d i rect visual ization (Fig. 9).

The technique for wire stabilization depends primarilyupon the injury pattern. It has been noted in several cases

that instability exists at the intercuneiform articulations.Cases with cu neiform instability req u irewire stabilizationof the cuneiforms f rom medial to lateral prior to stabiliz-ing the metatarsus on the tarsus.

ln type A injuries, stabilization using two wires is com-mon but depends on the stability of the second metatar-socuneiform joint. lf severe dislocation is present at this

201

Fig.7. Closed manipulative reduction of Lisf ranc's injury usingf inger traps and heel weights

Fig.6. A. & B. Clinical and radiographic demonstration ofLisf ranc injuryType C with marked edema and pathognomonicdiastasis of f irst and second metatarsal. C. & D. Excessive mo-tion is present clinically at the tarsometatarsal articu lation. Ab-duction stress radiograph reveals gross dislocation

level the su rgeon may encou nter d iff icu lty stabilizing thefirst metatarsocuneiform joint. Initial stabilization of thesecond metatarsocu neiform ioint has been fou nd to create

a sign if icant amou nt of stabilityto the entire joint com plex/

perm itting greater ease of med ial and lateral stabilizationin those cases. ln general, two wires are used for Type Ainju ries, one mediallyacrossthef irst metatarsocu neiformjoint and one laterally across the fifth metatarsal cuboid

.ioint (Fig. 10).

The medial type B injuries have been noted to be ex-

tremely unstable and usually require two medial fixationwires. The lateraltype B injuries usually require a lateralwire th rough the f ifth metatarsocu boid articu lation. Type

C injuries are extremely unstable and often require threeor more wi res for f ixation. Cu neiform d isru ption seems tooccur more often with this injury.

After radiographic confirmation of alignment, soft tis-sue repair is completed. Recent experience with this in-jury has shown that primary repair of the dorsomedialI igament of the f i rst metatarsocu neiform joi nt and its cap-

su le is qu ite possible (Fig.1'l). The need fordelayed closu re

may exist if severe edema or extensive trauma to the softtissues exists.

Co m p ressive d ressi n gs are app I ied fol lowi ng red uctio nuntil edema and the vascular status has stabilized. This is

D

202

Fig.8. A. & B. Operative technique employs longitudinal cu r-vilinear incisions to decrease vascular compromise andfacilitate su rgical exposu re

Fig. 10. A. Radiographic demonstration of occult Lisf rancd islocation. B. Abd uctory stress exam reveals total laterald isplacement of metatarsals on lesser tarsus. C. Postoperative

Fig.9. A. & B. Anatomic alignment is directly visualized whilepercutaneous pinningwith Kirschnerwires is performed

c

203

radiograph demonstrating stabilization of f irst metatar-socuneiform joint and f ifth metatarsocuboid joint

Fig. 11. A. & B. ldentif ication o{ dorsomedial Iigament of f irstmetatarsocuneiform joint. C. Primary repair of Iigament andcapsu Ie. Note percutaneou s wi re stabi I ization.

dependenton the extent and severityof the injury, usually5 to 14 days" Below the knee casting is then employed for6to 12 wec(s. Wire removal is possible between 6 and 8

weeks. Weightbearing may begin after cast removalwithsu pportive shoegear. Carefu I monitoring for red islocationis extremely i mportant.

A number of complications have been previously men-tioned. ln old in ju ries where there are severe destructivechanges and pain, or deform ity, arth rodesis of the involvedtarsometatarsal joints is indicated and may be performedin a variety ways.

Summary

Fracture-dislocation of the Lisfranc joint complex is arelatively uncommon injury. Diagnosis of the grosslyedematous and painful footwith radiographic changes isnot difficult. The occult disruption of this joint complexrequires a high index of suspicion. Accurate anatomic re-duction at initial presentation has produced the most satis-factory results. Surgical intervention in acute and chroniccases may be warranted.

References

Aitkon AP, Pou lson D: Dislocations of the tarsometatarsaljoint./ Bone Joint Surg 454:246-260,1963.

B lai r WF: I rred u ci b Ie tarsometatarsal f ractu re-d i s locatio n.Tra u m a 21:988-990, 1981.

B ru net JA, Wi lcox JJ : The Iate resu lts of tarsom etatarsal joi ntinjuries. J Bone Joint Surg 698:437-440,1987.

Cain TD: Lisfranc f ractu re-d islocation. ln McClamry ED (ed):

D octo rs H os p ita I S u rgi cal S e m i n ar Syl I ab u s, 1985. Tucker,GA, Doctors Hospital Podiatry lnstitute,1985, pp 200-203.

Cassebaum WH: Lisfranc fracture-dislocations. C/inO rt h o p 30 116-128, 19 63.

Engber WD, Roberts JM: lrreducible tarsometatarsalf ractu re-d i s I ocat i o n. C I i n O rt h o p 168:102404, 1982.

C i ssane W: A d an gerou s type of f ractu re of the foot . J B o n e

Joint Surg 338:535-53& 1951.

Coossens M, DeStoop N: Lisf ranc's f racture-dislocations:etiology, radiology and results of treatment. Clin Orthop176:154462, 1983.

Hardcastle PH, Reschauer R, Kutscha-Lissberg E, Schoff-man n W: I nj u ries to the tarsometatarsal joint. J Bo ne Joi ntS u rg 648 :349 -356, 1982.

Jeff reys TE: Lisf ranc's f ractu re-d isloc ation. J Bone J oi nt S u rg458:546-551,1963.

Johnson GF: Pediatric Lisfranc injury: "BunkBed"f racture.AJ R 137 :1041:1044, 1981.

Myerson MS, Fisher R1l Burgess AR, Kenzora JE: Fracturedislocations of the tarsometatarsal joints. End results cor-related with pathology and treatment. Foot Ankle6:225-242,1986.

204

Norpray JE, Geline RA, Stewberg Rl, Galinski AW Gilula pp 843-847.

LA: Subtleties of Lisfranc f racture-dislocation. A/R137:1151:1156,19g1. WileyJJ:The mechanism of tarso-metatarsaljoint injuries.

sarraf ian sK: Anatomy of the Foot and Ankte: Descriptive, J Bone Joint surg 538:474-482' 19v'

Topographic, Functional. Philadelphia, Lippincott, 1983, Wilson DW: Injuries to the tarso_metatarsal joints./ Bonepp 185-191.

Joint Surg 548:677-686,1972.

SmithTF: Dislocations.ln McGlamryED (ed): Textbookof Wilppula E: Tarsometatarsal fracture-dislocation. ActaFoot Surgery, vol 2. Baltimore, Williams & Wilkins, 1987, Orthop Scand M:335-345,1973-

205