1. LISFRANC INJURY Dr.Subodh Pathak

2. Surgery is bright when operating but it is still brighter when there is no blood and mutilation and yet leads to the patient's recovery Jacques Lisfranc de Saint-Martin (1787-1847) 3. Injuries to the foot can have a dramatic impact on the overall health, activity, and emotional status of patients. A recent study looking at the outcomes of multiple trauma patients with and without foot involvement found a significant worsening of the outcome in the presence of a foot injury. Their conclusion is that more attention and aggressive management need to be given to foot injuries to improve the outcome of multiply injured patients. 4. Jacques Lisfranc de St. Martin (April 2, 1790 May 13, 1847) Pioneering French surgeon and gynecolo gist. Pioneered . Lithotomy Amputation of Cervix Uteri Removal of Rectum The Lisfranc joint and the Lisfranc fracture are named after him. 5. Lisfranc described an amputation involving the tarsometatarsal joint due to a severe gangrene that developed when a soldier fell from a horse with his foot caught in a stirrup. 6. Foot Anatomy 7. Lisfranc joint complex consists of three articulations including Tarsometatarsal articulatio n. Intermetatarsal articulation . Intertarsal articulations. 8. The Lisfranc complex is made up of bony and ligamentous elements that combine to add structural support to the transverse arch. The bony architecture is composed of 5 MTs and their respective articulations with the cuneiforms medially and the cuboid laterally. The TMT joint complex represents the dividing line between the midfoot and the forefoot 9. Stability of TMT joint The trapezoidal shape of the middle three MT bases and their associated cuneiforms produce a stable arch referred to as the transverse or Roman arch. The keystone to the transverse arch is the second TMT joint, a product of the recessed middle cuneiform 10. Peicha et al showed that persons with Lisfranc injury had a shallower medial mortise depth compared with control subjects. They suggested that adequate mortise depth provides for greater stability by allowing for a stronger Lisfranc ligament. Peicha G, Labovitz J, Seibert FJ, et al.: The anatomy of the joint as a risk factor for Lisfranc dislocation and fracture-dislocation: An anatomical and radiological case control study. J Bone Joint Surg Br2002;84(7):981-985 11. Ligaments 12. Transverse Ligament Oblique Ligaments Dorsal Planter Interosseu s 13. Lisfranc Ligament 14. 2bands 15. In a biomechanical evaluation, Solan et al assessed the strength of each ligamentous setdorsal, interosseous, and plantarby stressing it to failure. They concluded that the Lisfranc ligament was strongest, followed by the plantar ligaments and the dorsal ligaments. 16. Structural stability to the transverse arch is enhanced by the short plantar muscles as well as by the muscular and tendinous support of the peroneus longus and the tibialis anterior and tibialis posterior. 17. Foot Muscles Plantar Surface First layer Abductor Hallucis Abductor Digiti Minimi Flexor Digitorum Brevis 18. Foot Muscles Plantar Surface Second Layer. Tendons of FHL, FDL. Lumbricals. 19. Foot Muscles Plantar Surface Third Layer Flexor Hallucis Brevis Adductor Hallucis Transverse and Oblique Heads Flexor Digiti Minimi brevis. 20. Foot Muscles Plantar Surface Fourth or Interosseus Layer 2 muscles- Plantar Interossei. Dorsal Interossei. 2 tendons- - peroneus longus . - Tibialis posterior. 21. Incidence Injuries to the Lisfranc joint occur in 1 per 55,000 individuals each year in the United States and are 2 to 3 times more common in men. Approximately 4% of professional football players sustain Lisfranc injuries each year As index of suspicion increases, so does incidence Approximately 20% of Lisfrancs injuries may be overlooked. Mantas JP, Burks RT. Lisfranc injuries in the athlete. Clin Sports Med. 1994; 13(4):719730. Thompson MC, Mormino MA. Injury to the tarsometatarsal joint complex. J Am Acad Orthop Surg. 2003; 11(4):260267. 22. Mechanism of Injury Direct Injury Indirect Injury 23. Orthopedics June 2012 - Volume 35 Issue 6: e868-e873 DOI: 10.3928/01477447-20120525-26 Arthrodesis Versus ORIF for Lisfranc Fractures Shahin Sheibani-Rad, MD, MS; J. Christiaan Coetzee, MD; M. Russell Giveans, PhD; Christopher DiGiovanni, MD 24. Two different plantar flexion mechanisms lead to dorsal joint failure. The first occurs in ankle equinus and metatarsophalangeal joint plantar flexion, with the Lisfranc joint engaged along an elongated lever arm. The joint is rolled over by the body 25. Urgent Braking 26. Indirect Injury 27. Indirect injury Twisting injuries lead to forceful abduction of the forefoot, often resulting in a 2nd metatarsal base fracture and/or compression fracture of the cuboid ( nut cracker) 28. Fracture-dislocations are often associated with significant soft- tissue trauma, vascular compromise, and compartment syndrome. 29. Classification Classification systems are inherently effective in allowing for the description of both high- and low-impact injuries. Many Classifications developed and updated. None of them useful in Deciding the treatment and overall prognosis and Clinical Outcome. 30. Quenu and Kuss (1909): Homolateral Isolated Divergent 1. Modified by Hardcastle in 1982 2. Further modified by Myerson in 1986 31. Quenu and Kuss (1909) 32. Homolateral Divergent 33. Hardcastle (1982) Homolateral or Total Incongruity: All 5 metatarsals displace in common direction Fracture base of 2nd common 34. Isolated Partial Incongruities: Displacement of 1 or more metatarsals away from the others 35. Divergent: Lateral displacement of lesser metatarsals with medial displacement of the 1st metatarsal May have extension of injury into cuneiforms or 36. TOTAL INCONGRUITY PARTIAL INCONGRUITY DIVERGENT 37. Chiodo& Myerson(2001)COLUMNAR THEORY 38. Nunley and Vertullo Athletic Injuries(2002) 3-stage diagnostic classification. Stage I - A tear of dorsal ligaments and sparing of the Lisfranc ligament Stage II - Direct injury to the Lisfranc ligament with elongation or rupture(Radiographic diastasis of 1 to 5 mm greater than the contralateral foot ) Stage III - A progression of the above, with damage to the plantar TMT ligaments and 39. Clinical Findings Midfoot pain with difficulty in weight bearing Swelling across the dorsum of the foot Deformity variable due to possible spontaneous reduction 40. Clinical Findings Check neurovascular status for compromise of dorsalis pedis artery and/or deep peroneal nerve injury COMPARTMENT SYNDROME 41. Planter Ecchymosis Sign 42. The passive pronation-abduction test described by is performed by eliciting pain on abduction and pronation of the forefoot with the hindfoot fixed. Curtis MJ, Myerson M, Szura B: Tarsometatarsal joint injuries in the athlete. Am J Sports Med 1993;21(4):497-502. 43. Trevino and Kodros described a rotation test, in which stressing the second tarsometatarsal joint by elevating and depressing the second metatarsal head relative to the first metatarsal head elicits pain at the Lisfranc joint. PIANO KEY SIGN 44. DIAGNOSIS Requires a high degree of clinical suspicion 20% misdiagnosed 40% no treatment in the 1st week ??? MIDFOOT SPRAIN??? 45. RADIOGRAPHIC EVALUATION Xrays Computed tomography (CT) scan. MRI Bone Scans UltraSound scan 46. Radiographic Evaluation AP, Lateral, and 30 Oblique X-Rays are mandatory AP: The medial margin of the 2nd metatarsal base and medial margin of the medial cuneifrom should be alligned 47. Radiographic Evaluation Oblique: Medial base of the 4th metatarsal and medial margin of the cuboid should be alligned 48. AP View Xrays 49. Oblique View Xrays 3 4 5 50. Oblique View Xrays 51. Radiographic Evaluation Lateral: The dorsal surface of the 1st and 2nd metatarsals should be level to the corresponding cuneiforms 52. Lisfranc Injury 53. A fleck sign should be sought in the medial cuneiform second metatarsal space. This represents an avulsion of the Lisfranc ligament. Myerson et al 1986 54. Lisfranc injuries BIG challenge 20% of injuries go unrecognized, likely secondary to the difficulty encountered with standard Xray Many so-called sprains present with nonweight-bearing radiographs that are difficult to interpret. 55. 50% of athletes with midfoot injuries had normal nonweight-bearing radiographs Nunley JA, Vertullo CJ: Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med2002;30(6):871-878. 56. Stress Radiographs Radiographs must be obtained with the patient bearing weight in case of subtle injuries. If the radiograph reveals no displacement, and the patient cannot bear weight, a short leg cast should be used for 2 weeks, and the radiographs should be repeated with weight bearing 57. AP Full Wt bearing Xray 58. Taking Lateral Views 59. NWB Xray FWB Xray 60. MRI MRI has an advantage in identifying partial ligament injuries and subtle ligament injuries. Especially useful in low velocity injuries and in settings of Normal radiographs. 61. Magnetic Resonance Imaging In a recent study evaluating the predictive value of MRI for midfoot instability, Raikin et al found that MRI demonstrating a rupture or grade 2 sprain of the plantar ligament between the first cuneiform and the bases of the second and third MTs is highly predictive of midfoot instability, and these patients should be treated with surgical stabilization 62. MRI 63. 3D CT SCAN 64. Stress Fluroscopy under Anaesthesia The foot is stressed in a medial/lateral plane. The forefoot is forced laterally with the hindfoot brought medially.Pronation Abduction Stress 65. Management CONSERVATIVE SURGICA L 66. Check Stability.. The definition of instability presently is defined as a greater than 2-mm shift in normal joint position. Diastasis between the first and second MT in the injured midfoot is considered normal provided that it measures