The Lisfranc injury is an injury of the foot in which one or more of the metatarsal bones
are displaced from the tarsus. The injury is named after Jacques Lisfranc de St. Martin,
a French surgeon and gynecologist who described the injury in 1815, after the War of the Sixth
Coalition.
Causes In humans, the midfoot consists of five bones
that form the arches of the foot and their articulations with the bases of the five metatarsal
bones. Lisfranc injuries are caused when excessive kinetic energy is applied either directly
or indirectly to the midfoot and are often seen in traffic collisions or industrial accidents.
Direct Lisfranc injuries are usually caused by a crush injury, such as a heavy object
falling onto the midfoot, or the foot being run over by a car or truck, or someone landing
on the foot after a fall from a significant height. Indirect Lisfranc injuries are caused
by a sudden rotational force on a plantar flexed forefoot. Examples of this type of
trauma include a rider falling from a horse but the foot remaining trapped in the stirrup,
or a person falling forward after stepping into a storm drain.
In athletic trauma, Lisfranc injuries occur commonly in activities such as windsurfing,
kitesurfing, wakeboarding, or snowboarding. American football players occasionally acquire
this injury, and it most often occurs when the athlete's foot is plantar flexed and another
player lands on the heel. This can also be seen in pivoting athletic positions such as
a baseball catcher or a ballerina spinning. Diagnosis
In a high energy injury to the midfoot, such as a fall from a height or a motor vehicle
accident, the diagnosis of a Lisfranc injury should, in theory at least, pose less of a
challenge. There will be deformity of the midfoot and X-ray abnormalities should be
obvious. Further, the nature of the injury will create heightened clinical suspicion
and there may even be disruption of the overlying skin and compromise of the blood supply. Typical
X-ray findings would include a gap between the base of the first and second toes. The
diagnosis becomes more challenging in the case of low energy incidents, such as might
occur with a twisting injury on the racquetball court, or when an American Football lineman
is forced back upon a foot that is already in a fully plantar flexed position. Then,
there may only be complaint of inability to bear weight and some mild swelling of the
forefoot or midfoot. Bruising of the arch has been described as diagnostic in these
circumstances but may well be absent. Typically, conventional radiography of the foot is utilized
with standard non-weight bearing views, supplemented by weight bearing views which may demonstrate
widening of the interval between the first and second toes, if the initial views fail
to show abnormality. Unfortunately, radiographs in such circumstances have a sensitivity of
50% when non-weight bearing and 85% when weight bearing, meaning that they will appear normal
in 15% of cases where a Lisfranc injury actually exists. In the case of apparently normal x-rays,
if clinical suspicion remains, advanced imaging such as magnetic resonance imaging or X-ray
computed tomography is a logical next step. Classification
There are three classifications for the fracture: Homolateral: All five metatarsals are displaced
in the same direction. Lateral displacement may also suggest cuboidal fracture.
Isolated: one or two metatarsals are displaced from the others.
Divergent: metatarsals are displaced in a sagittal or coronal plane and may also involve
the intercuneiform area and include a navicular fracture.
Treatment Options include operative or non-operative
treatment. If the dislocation is less than 2 mm, the fracture can be managed with casting
for six weeks. The patient's injured limb cannot bear weight during this period. For
severe Lisfranc injuries, open reduction with internal fixation and temporary screw or Kirschner
wire fixation is the treatment of choice. The foot cannot be allowed to bear weight
for a minimum of six weeks. Partial weight-bearing may then begin, with full weight bearing after
an additional several weeks, depending on the specific injury. K-wires are typically
removed after six weeks, before weight bearing, while screws are often removed after 12 weeks.
When a Lisfranc injury is characterized by significant displacement of the tarsometatarsal
joint(s), nonoperative treatment often leads to severe loss of function and long-term disability
secondary to chronic pain and sometimes to a planovalgus deformity. In cases with severe
pain, loss of function, or progressive deformity that has failed to respond to nonoperative
treatment, mid-tarsal and tarsometatarsal arthrodesis may be indicated.
History During the Napoleonic Wars, Jacques Lisfranc
de St. Martin encountered a soldier who suffered from vascular compromise and secondary gangrene
of the foot after a fall from a horse. Subsequently, Lisfranc performed an amputation at the level
of the tarsometatarsal joints, and that area of the foot has since been eponymously referred
to as the "Lisfranc joint". Although Lisfranc did not describe a specific mechanism of injury
or classification scheme, a Lisfranc injury has come to mean a dislocation or fracture-dislocation
injury at the tarsometatarsal joints. See also
Bosworth fracture Chopart's fracture-dislocation
Jones fracture Lisfranc ligament
List of eponymous fractures March fracture
References
External links • Lisfranc Fracture Club - Mutual Help and
Support group http:www.footeducation.com/lisfranc-fracture-orif
Diagnosis of joint