However, Nunley and Vertullo (4) recommend obtaining weight-bearing radiographs when possible because they found that 50% of lower-grade midfoot sprains appeared normal on nonweight-bearing images and that this type of imaging is not entirely reliable for detection of subtle injuries. 110 West Rd., Suite 227 Further stabilization of the tarsometatarsal joint is provided by a complex arrangement of ligaments that are divided into dorsal, interosseous, and plantar components that connect the tarsometatarsal, intertarsal, and intermetatarsal articulations. 3, No. Figure 9a Left midfoot low-grade sprain in an 11-year-old boy after a fall. 4, Journal of the American College of Radiology, Vol. 38, No. Figure 12a Radiographs of the left foot in a 26-year-old male parachute jumper who had marked plantar flexion while landing. 4, Journal of the American Podiatric Medical Association, Vol. These chip fractures are virtually pathognomonic of high-impact Lisfranc fracture-displacements and are seen in about 90% of these injuries (7). findings. Typical features of an avulsion fracture at the main insertion of the Lisfranc ligament. Lateral subluxation of the fourth and fifth metatarsal bones was seen before surgery but was reduced without surgical fixation. - lateral radiographs: 1, Seminars in Roentgenology, Vol. - rupture of posteior tib tendon; This orientation allows the Lisfranc joint to be seen on true axial and coronal planes (47). (h) Long-axis three-dimensional (3D) sampling perfection with application optimized contrasts using different flip-angle evolutions (SPACE; Siemens Medical Solutions, Erlangen, Germany) MR image shows the right interosseous Lisfranc ligament (arrows). Currently, bone scintigraphy is rarely used for diagnosis of Lisfranc injuries and has been largely supplanted by CT and MR imaging, which offer better spatial resolution and more direct evaluation of the Lisfranc joint complex. Unable to load your collection due to an error, Unable to load your delegates due to an error. There is no consensus in the literature about the appropriate location to measure the width of the C1 and M2 articulation. One of the major determinants to the development of arthritis is whether postreduction anatomic alignment was achieved (59). C = cuneiform, Cu = cuboid, M = metatarsal. Careers. 59, No. (b) Drawing of the plantar aspect of the left forefoot shows the major ligaments that stabilize the medial and middle columns: the plantar Lisfranc ligament (pC1-M2M3) and the first and second plantar tarsometatarsal ligaments. Two patterns of type B injuries are described: type B1 injuries denote isolated displacement of the first tarsometatarsal joint, and type B2 injuries refer to displacement of one or more of the lesser tarsometatarsal joints. (h) Long-axis three-dimensional (3D) sampling perfection with application optimized contrasts using different flip-angle evolutions (SPACE; Siemens Medical Solutions, Erlangen, Germany) MR image shows the right interosseous Lisfranc ligament (arrows). The peroneus longus (PL) and flexor hallucis longus (FHL) tendons are also shown. 51, No. Signs are often more apparent on the oblique view of the foot. (a) Preoperative anteroposterior radiograph shows a divergent Lisfranc fracture-dislocation. - isolated: one or two metatarsals are displaced from the others; The However, given the superior depiction of soft-tissue supporting structures and the ability to detect soft-tissue injuries in patients with unstable injuries on MR images (51), the American College of Radiology Appropriateness Criteria guidelines slightly favor the use of MR imaging (54). Figure 4b Common indirect forces that result in Lisfranc joint complex injury in the right foot. (b) Short-axis T2-weighted fast SE MR image of the tarsometatarsal joint shows a high-grade tear of the plantar Lisfranc ligament (arrow) with intact dorsal and interosseous Lisfranc ligaments (arrowhead). The lateral (a), middle (b), and medial (c) columns are shown. These injuries have typically been divided into high-impact fracture-displacements, which are often seen after motor vehicle collisions, and low-impact midfoot sprains, which are more commonly seen in athletes. (b) Sagittal reformatted CT image in the same patient shows advanced tarsometatarsal arthropathy and fragmentation (arrow), findings that suggest developing neuropathic arthropathy. Arthrodesis may be preferred in some situations, especially when there are comminuted fractures at the first and second metatarsal bases, because stiffness is preferred to instability to maintain the rigidity of the medial and middle columns during gait (55,58). The fibers are sharply defined, and there is no periligamentous edema. Thus, Nunley and Vertullo (4) hypothesized that Lisfranc ligament complex injuries initially involve the dorsal capsule, with subsequent involvement of the interosseous Lisfranc ligament and then the plantar Lisfranc ligament as greater forces are applied. ray amputation or fusion. 108, No. 11, No. This injury can affect the ligaments soft tissue that connects bone to bone of these bones andor include fractures of the bones themselves. Lisfranc Open Reduction and Internal Fixation Ben Sharareh MD Ventura Orthopedics Orthobullets Team Orthobullets Team TECHNIQUE VIDEO TECHNIQUE STEPS 14 TECHNIQUE STEPS Preoperative Patient Care Operative Techniques Postoperative Patient Care Evidence ( 4 ) evidenceFootprint HIDE EVIDENCE Sort by EF L1\L2 Evidence Date EXPERT COMMENTS ( 4 ) 1, Health Information Management Journal, Vol. (c) Long-axis fat-suppressed proton-densityweighted MR image of the left midfoot demonstrates the oblique course of the interosseous Lisfranc ligament (arrows). Table 1: Quen and Kss Classification of High-Grade Lisfranc Fracture-Displacements. FOIA 39, No. The nerves at this level are very thin and may be difficult to detect or to discriminate from adjacent vessels, even with high-resolution imaging. official website and that any information you provide is encrypted Radiologists must have a thorough understanding of anatomy, mechanisms, and patterns of these injuries to diagnose and help clinicians assess treatment options and prognosis. Comparison of magnetic resonance imaging with intraoperative findings. However, only about 8% of these patients become symptomatic enough to require arthrodesis. The authors believed that this was related to initial misdiagnosis or undertreatment because type B injuries may be the most subtle radiographically and clinically. (d) Short-axis proton-densityweighted MR image through the right tarsometatarsal joint shows the three components of the Lisfranc ligament complex: the dorsal ligament (white arrow), interosseous ligament (arrowhead), and plantar ligament (black arrow). Medial border of 2nd metatarsal is aligned with medial . We will review relevant anatomy and biomechanics, mechanisms of injury, clinical presentation, imaging studies, and diagnostic techniques and treatment. Clipboard, Search History, and several other advanced features are temporarily unavailable. (a) Drawing of the short axis of the midfoot through the metatarsal bases (M1M5) shows the normal transverse midfoot arch (curved red lines).The trapezoidal (keystone) shape of the middle three metatarsal bases helps maintain the alignment. The peroneus longus (PL) and flexor hallucis longus (FHL) tendons are also shown. Fracture dislocations at the tarsometatarsal joints, end results correlated with pathology and treatment. Lisfranc joint injuries are relatively uncommon, and their imaging findings can be subtle. A high index of suspicion is needed to prevent progression of the foot deformity, chronic pain and dysfunction. Although CT can be helpful for assessing ligamentous integrity, it is less useful in the evaluation of low-impact injuries, where ligamentous injuries rather than osseous fractures are suspected. Figure 3h Normal anatomy of the Lisfranc ligament complex. (f) Axial proton-densityweighted MR image of the left midfoot demonstrates the M3 bundle of the plantar Lisfranc ligament (pC1-M2M3; arrow). - longitudinal stress injuries; 1, American Journal of Roentgenology, Vol. Arthrodesis versus ORIF for Lisfranc fractures. Figure 13a Complications after surgical treatment of Lisfranc ligament complex injuries. A review of 20 cases, Anatomical restraints to dislocation of the second metatarsophalangeal joint and assessment of a repair technique, Fracture dislocations at the tarsometatarsal joints, end results correlated with pathology and treatment, Fractures and fracture dislocations of the tarsometatarsal joint, Orthopaedic Specialists of North Carolina. Axial thin-section CT images can be reconstructed along the horizontal long and short axes of the joint, which are often oblique to the normal orthogonal planes of the body. If closed reduction can be achieved with fluoroscopy, fixation with percutaneous screws can be performed. Updated: Jan 5 2021. However, Lisfranc did not describe the injury patterns or mechanisms of injury that occur at this articulation. Used today to describe fractures and dislocations that occur at the junction between the tarsal bones of the midfoot and the . Radiology Masterclass 2007 - now=new Date (g) Axial fat-suppressed proton-densityweighted MR image through the dorsum of the left midfoot shows the dorsal Lisfranc ligament in the long axis (arrow). The medial and middle columns are relatively rigid and allow the midfoot to function as a lever during gait. Although early researchers attempted to categorize injuries according to their mechanism (3234), the systems were often cumbersome and impractical for clinical use (35). In a small study by Macmahon et al (52), seven of 10 cases of complete Lisfranc ligament ruptures (grade 3 sprains) identified at surgery were correctly graded at preoperative MR imaging. Lisfranc sprains classified as Nunley and Vertullo stage I can be treated conservatively. Figure 3e Normal anatomy of the Lisfranc ligament complex. The tarsometatarsal joint is named after Jacques Lisfranc de Saint-Martin (17871847), a French army field surgeon who described a forefoot amputation through the first tarsometatarsal joint (1,2). and will collapse, resulting in dorsal frx dislocation of the metatarsal bases; Nunley and Vertullo (4) have reported that bone scintigraphy has 100% sensitivity for low-grade stage I Lisfranc sprains. This mechanism can result in a cuboid compression fracture (nutcracker injury). The tarsometatarsal, or Lisfranc, joint complex provides stability to the midfoot and forefoot through intricate osseous relationships between the distal tarsal bones and metatarsal bases and their connections with stabilizing ligamentous support structures. (h) Long-axis three-dimensional (3D) sampling perfection with application optimized contrasts using different flip-angle evolutions (SPACE; Siemens Medical Solutions, Erlangen, Germany) MR image shows the right interosseous Lisfranc ligament (arrows). Midfoot swelling in the presence of plantar ecchymosis should be considered to be a Lisfranc injury until proven otherwise. The plantar surface of the M1 base (black line) is superior to the plantar surface of the M5 base (solid white line). 64, No. J Chiropr Med. In a study by Haapamaki et al (45), several patients had either false-positive or false-negative radiographic findings of injury when compared with CT findings, and the injuries of other patients were shown to be either overstaged or understaged at radiography when compared with CT findings. - all 5 metatarsals are displaced in the same direction; 17, No. All courses are CME/CPD accredited in accordance with the CPD scheme of the Royal College of Radiologists - London - UK. Therefore, an understanding of the anatomy, injury mechanisms, classification systems, and imaging features of Lisfranc injuries is necessary to facilitate early and accurate diagnosis and treatment. However, it does not encompass the full spectrum of tarsometatarsal injuries, and newer schemes were formulated to include additional understanding about injury patterns and the impact of certain injuries on patient prognosis. Forced plantar-flexion injuries occur when the forefoot is rigidly planted in the plantar-flexed position and a force is applied through the metatarsals along the longitudinal axis, resulting in a compressive force through the tarsometatarsal joint. (a) Long-axis T2-weighted fast SE MR image of the midfoot shows elongation and thinning of the interosseous Lisfranc ligament, with periligamentous edema (arrow). Mid and Forefoot Trauma. (h) Long-axis three-dimensional (3D) sampling perfection with application optimized contrasts using different flip-angle evolutions (SPACE; Siemens Medical Solutions, Erlangen, Germany) MR image shows the right interosseous Lisfranc ligament (arrows). In basic terms, it is a sprain of the Lisfranc ligament, also known as the oblique interosseous ligament. 18, No. In addition, a nonfat-saturated T1-weighted sequence in at least one plane, either the horizontal long axis or short axis, is helpful to assess for fractures that might otherwise be difficult to perceive. Figure 11a Nunley-Vertullo stage I Lisfranc sprain in a 21-year-old man who hyperextended his right foot while it was stuck in a stool. 4, Contemporary Diagnostic Radiology, Vol. Given the complexity of the Lisfranc joint and the relatively small size of the supporting soft-tissue structures, proper selection of MR imaging sequences and the orientation of imaging planes can help in injury detection. Diagnosis is confirmed by radiographs which may show widening of the interval between the 1st and 2nd ray. The disadvantages of ORIF include the need to remove the screws, potential screw breakage, articular damage to the involved joints, and the risk of subsequent osteoarthritis (11,55). - ref: Outcomes of Lisfranc Injuries in the National Football League. Diabetic Conditions. (b) Drawing of the plantar aspect of the left forefoot shows the major ligaments that stabilize the medial and middle columns: the plantar Lisfranc ligament (pC1-M2M3) and the first and second plantar tarsometatarsal ligaments. talometatarsal angulation require operative treatment; Homolateral injuries are the most common and involve displacement of all five metatarsal bases in the same direction. C = cuneiform, M = metatarsal. 212, No. - Severe Lisfrancs injuries: primary arthrodesis or ORIF? (f) Axial proton-densityweighted MR image of the left midfoot demonstrates the M3 bundle of the plantar Lisfranc ligament (pC1-M2M3; arrow). Stage II injuries demonstrate a 25-mm diastasis between C1 and the base of M2, with no loss in arch height. - Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A competency based surgical skill training & evaluations system that is mobile, user-friendly, and improved technical training. Figure 4a Common indirect forces that result in Lisfranc joint complex injury in the right foot. It is unclear to what degree disruption of these anatomic relationships results in instability of the Lisfranc joint. An estimated 20% of all Lisfranc injuries are initially undiagnosed clinically, which could reflect their subtle initial presentation or the fact that they may occur with polytrauma and may be overlooked while other critical injuries are being addressed (10,11). (d) Short-axis proton-densityweighted MR image through the right tarsometatarsal joint shows the three components of the Lisfranc ligament complex: the dorsal ligament (white arrow), interosseous ligament (arrowhead), and plantar ligament (black arrow). At the midfoot level, the nerve has divided into a sensory medial branch that provides sensation to the first web space and a sensorimotor lateral branch that innervates the extensor hallucis brevis and extensor digitorum brevis muscles. (d) Short-axis proton-densityweighted MR image through the right tarsometatarsal joint shows the three components of the Lisfranc ligament complex: the dorsal ligament (white arrow), interosseous ligament (arrowhead), and plantar ligament (black arrow). The short-axis (coronal) view can be planned from the sagittal sequence and is oriented along the first and second tarsometatarsal joints, and the horizontal long-axis (axial) sequence should be planned from the short-axis sequence and obliquely oriented along the metatarsal bases. Telephone: 410.494.4994, Lisfrancs Fracture / TarsoMetatarsal Injuries. 2013. A nonweight-bearing cast should be used for 6 weeks; if pain continues after cast removal, a removable boot should be used for 4 additional weeks (55). The dorsal structures are highlighted by the ligamentous connections of each cuneiform with the base of M2 (dC1-M2, dC2-M2, and dC3-M2) and C1 with M1 (dC1-M1). Type C injuries have a divergent pattern, with M1 displaced medially and M2M5 displaced laterally (Fig 6). sharing sensitive information, make sure youre on a federal The first cuneometatarsal ligament (pC1-M1) originates near the plantar aspect of the articular surface of C1 and extends distally to attach to the lateral aspect of M1. Radiology Masterclass, Department of Radiology, This image shows a gap between the bases of the first and second metatarsals (MT); the second metatarsal is no longer correctly aligned with the intermediate cuneiform bone, This is a significant finding which indicates disruption of the Lisfranc ligament, Careful assessment of alignment is always required in suspected midfoot injury, If the initial X-ray is normal then repeat images with weight-bearing or CT may be required, Injury to the Lisfranc ligament is often accompanied by subtle fragmentation of the adjacent bones. 2, Journal of Pediatric Orthopaedics, Vol. Osteoarthritis is a well-recognized outcome of Lisfranc injuries, with about 50% of patients showing radiographic signs of Lisfranc osteoarthritis after ORIF. The Myerson system provides a standardized approach for reportable injury patterns and results in a high degree of interobserver reliability for data communication. Additional tarsal injuries, including those to the cuboid, calcaneus, and talus, have been reported in association with Lisfranc injuries, and MR imaging can be helpful in assessing these injuries as well. least 12-16 weeks. The ligament can either be uniformly low in signal intensity or striated with intermediate signal intensity, as shown. Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username. Quenand Kss.The earliest and most basic classification system was published in 1909 by Quen and Kss (36) (Table 1). - homo-lateral: Figure 1a Normal osseous anatomy of the Lisfranc joint complex. check for discontinuity of a line drawn from the medial base of the 2nd metatarsal to the medial side of the middle cuneiform, check for widening of the interval between the 1st and 2nd ray, check for dorsal displacement of the proximal base of the 1st or 2nd metatarsal, check for discontinuity of line drawn from medial side of the base of the 4th metatarsal to the medial side of cuboid, if the injury is subtle, obtain bilateral weight-bearing views, describe complications of surgery including, template the fracture with instrumentation, describe steps of the procedure verbally prior to the start of the case, identify if a dual incision approach needed, patient is placed in the supine position with a bump/bolster beneath the ipsilateral hip, place a sterile bolster/triangle beneath the operative limb at the knee to facilitate access to the midfoot and intraoperative fluoroscopy, identify the EHL and center the dorsomedial incision over the first tarsometatarsal joint between the EHL and EDL tendons, identify the lateral border of the third tarsometatarsal joint for the dorsolateral incision, Make incision centered over the 1st TMT joint between the EHL and EDL tendons, Take care to protect the deep peroneal neurovascular bundle, perform subperiosteal dissection extending to the 1st TMT joint and produce a full thickness flap, use soft tissue flap to protect the neurovascular bundle, identify the intercuneiform joint capsules and test the stability of 1st TMT joint, 2nd TMT joint, lisfranc joint and intercuneiform joint, make skin incision over the lateral border of the third tarsometatarsal joint, expose the EDL tendon and the medial margin of the EDB muscle, perform a subperiosteal dissection directed medially towards the lateral portion of the of the second tarsometatarsal joint and laterally towards the fourth and fifth tarsometatarsal joint when needed, debride the fracture and articular surface of residual scar, callus, and hematoma, if > 50% articular comminution noted, arthrodesis should be considered, for 1st TMT joint, may need to create a unicortical hole in the proximal 1st metatarsal (using a drill bit) to place tine of reduction forceps in, for lisfranc joint, place forceps from the medial cuneiform to the lateral border of the second metatarsal, may use contralateral films to confirm anatomic reduction, place K wire in the intended path of the screw to provide rotational control, this shelf provides an excellent buttress for screw purchase for lisfranc screw, make stab incision directly over the cortical shelf medially, place screw in the cortical shelf medially, angle screw towards the proximal metaphysis of the second metatarsal, confirm placement of screw with fluoroscopy, close the subperiosteal flaps and the floor of the EHL sheath with 0-vicryl, close the EHL tendon sheath with 0-vicryl, close the subcutaneous tissue with 2-0 vicryl, place in bulky jones dressings and weber splint, take xrays of the foot in postop to verify reduction, Wound check and suture removal as necessary, Recognize early complications (wound infection), Transition to convert to venous compression stocking and fracture boot, Check weight-bearing radiographs for alignment, If stable weight-bearing radiographs, allow for weight-bearing as tolerated, Advance to regular shoes and activity as tolerated. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment, Lisfranc's fracture-dislocations: etiology, radiology, and results of treatment. doi: 10.1016/j.fcl.2005.12.005. In a study of 10 patients, Woodward et al (42) reported that nonvisualization of the dorsal Lisfranc ligament and a widening of the C1-M2 space more than 2.5 mm were indirect findings of Lisfranc joint instability at US. (b) Drawing of the plantar aspect of the left forefoot shows the major ligaments that stabilize the medial and middle columns: the plantar Lisfranc ligament (pC1-M2M3) and the first and second plantar tarsometatarsal ligaments. (c) Sagittal reformatted CT image in a 48-year-old woman with progressive left flat-foot deformity who presented with plantar midfoot pain and a palpable abnormality 8 months after ORIF of the first and second tarsometatarsal joints shows the distal tip of one of the screws protruding into the plantar soft tissues (arrow) and causing mass effect on the flexor hallucis longus tendon, with effacement of the medial midfoot arch (arrowhead). The ligament can either be uniformly low in signal intensity or striated with intermediate signal intensity, as shown. Figure 3c Normal anatomy of the Lisfranc ligament complex. The fibers are sharply defined, and there is no periligamentous edema. - ref: Prediction of midfoot instability in the subtle Lisfranc injury. Outcomes of Lisfranc Injuries in the National Football League. Bone scintigraphy of patients with unexplained midfoot pain may show focal increased radiotracer uptake in this region, a finding suggestive of Lisfranc injuries. Figure 10b Nunley-Vertullo stage II left midfoot Lisfranc sprain in a 41-year-old man after a softball twisting injury. J Postgrad Med. The Myerson system subdivides injuries into categories of complete incongruity, in which all of the tarsometatarsal joints are disrupted, and partial incongruity, in which only some of the tarsometatarsal joints are disrupted. Despite a lack of consensus about the workup of suspected midfoot sprains, conventional radiography is usually the initial imaging study performed. Ross G, Cronin R, Hauzenblas J, Juliano P. J Orthop Trauma. - Arthrodesis versus ORIF for Lisfranc fractures. The dorsal Lisfranc ligament provides a rigid connection that maintains stability between the medial and middle columns and supports the base of M2 in its recess between C1 and C3. 19, No. (g) Axial fat-suppressed proton-densityweighted MR image through the dorsum of the left midfoot shows the dorsal Lisfranc ligament in the long axis (arrow). MR imaging is far superior to other imaging modalities for evaluation of soft-tissue and ligamentous injuries and is particularly helpful for assessment of suspected low-grade midfoot sprains. Occasionally, MR findings that suggest injury to the deep peroneal nerve can be seen. The red arrow indicates the major line of compressive force on the midfoot, and the yellow arrows indicate which metatarsals dislocate and in which direction they travel. 6, Operative Techniques in Orthopaedics, Vol. Base of radial styloid. Isolated injuries are the least common and consist of displacement of one or two of the metatarsal bones. (f) Axial proton-densityweighted MR image of the left midfoot demonstrates the M3 bundle of the plantar Lisfranc ligament (pC1-M2M3; arrow). (c) Long-axis fat-suppressed proton-densityweighted MR image of the left midfoot demonstrates the oblique course of the interosseous Lisfranc ligament (arrows). C = cuneiform, Cu = cuboid, M = metatarsal. 2022 Dec;21(4):316-321. doi: 10.1016/j.jcm.2022.02.018. Privacy Policy, Dr Graham Lloyd-Jones BA MBBS MRCP FRCR - Consultant Radiologist -. 56, No. Foot Ankle Surg, Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment, Treatment of Lisfranc joint injury: current concepts, Rupture of Lisfrancs ligament in athletes, Midfoot sprains in collegiate football players, Lisfrancs fracture-dislocation: a clinical and experimental study of tarso-metatarsal dislocations and fracture-dislocations, Injuries of the tarso-metatarsal joints: etiology, classification and results of treatment, Injuries of Lisfrancs joint: severe sprains, dislocations, fractures study of 39 personal cases and biomechanical classification [in French], Injuries to the tarsometatarsal joint: incidence, classification and treatment, An analysis of pathomorphic forms and diagnostic difficulties in tarso-metatarsal joint injuries, Developments and advances in the diagnosis and treatment of injuries to the tarsometatarsal joint, Lisfrancs tarsometatarsal fracture-dislocation, Abduction stress and AP weightbearing radiography of purely ligamentous injury in the tarsometatarsal joint, Bone scintigraphy findings in Lisfranc joint injury, Sonographic evaluation of Lisfranc ligament injuries, CT evaluation of tarsometatarsal fracture-dislocation injuries, Radiographic and computed tomographic evaluation of Lisfranc dislocation: a cadaver study, Lisfranc fracture-dislocation in patients with multiple trauma: diagnosis with multidetector computed tomography, Conventional radiography, CT, and MR imaging in patients with hyperflexion injuries of the foot: diagnostic accuracy in the detection of bony and ligamentous changes, Tarsometatarsal joint: anatomic details on MR images, Ligaments of the Lisfranc joint in MRI: 3D-SPACE (sampling perfection with application optimized contrasts using different flip-angle evolution) sequence compared to three orthogonal proton-density fat-saturated (PD fs) sequences, Magnetic resonance imaging of the Lisfranc ligament of the foot, MR imaging evaluation of subtle Lisfranc injuries: the midfoot sprain, Prediction of midfoot instability in the subtle Lisfranc injury: comparison of magnetic resonance imaging with intraoperative findings, MRI of injuries to the first interosseous cuneometatarsal (Lisfranc) ligament, MR imaging of entrapment neuropathies of the lower extremity. . Open reduction internal fixation versus primary arthrodesis for lisfranc injuries: a prospective randomized study. Pathology Anatomy This mechanism can result in a cuboid compression fracture (nutcracker injury). Many authors recommend a combination of multiplanar high-resolution nonfat-suppressed anatomic (eg, T1-weighted or proton-densityweighted) and fluid-sensitive (eg, fat-suppressed T2-weighted or short inversion time inversion-recovery) sequences. A widening of more than 2 mm between C1 and C2 suggests additional C1-C2 intercuneiform ligament injury. The injury is named after Jacques Lisfranc de St. Martin, a French surgeon and gynecologist who noticed this fracture pattern amongst cavalry men, in 1815, after the War of the Sixth Coalition. C = cuneiform, M = metatarsal. Removal of Plantar-Hindfoot-Midfoot Bony Mass. The second metatarsal dorsally dislocates, with lateral displacement of the lesser metatarsals. Myerson.The most common classification system currently used to describe Lisfranc fracture-displacements was developed by Myerson et al (28) (Table 2). 12, Archives of Orthopaedic and Trauma Surgery, Vol. The medial and middle columns are relatively rigid and allow the midfoot to function as a lever during gait. 41, No. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. Epidemiology Incidence common injury making up 9% of shoulder girdle injuries Demographics 6, Foot & Ankle International, Vol. II. Subtle radiographic changes can represent significant ligamentous Lisfranc injury. Note that there is less than 2 mm between C1 and M2 and between M1 and M2. The fibers are sharply defined, and there is no periligamentous edema. 111, No. However, at bone scintigraphy, increased radiotracer uptake is seen within the joint. - Lisfranc injuries w/o fracture have poor prognosis, with late midfoot collapse a common sequela; Isolated fracture-dislocations of the first tarsometatarsal joint. For stage III injuries with more significant displacement, the Myerson classification system is used to describe the injury pattern. Although there are strong intermetatarsal ligaments between M2 and M5, no substantial intermetatarsal connection is seen between the dorsal M1 and M2 bases (22). Federal government websites often end in .gov or .mil. - divergent: (a) Diagram of the dorsal aspect of the left forefoot in the long axis depicts the two major ligaments between the medial and middle columns: the dorsal Lisfranc ligament (dC1-M2) and the dorsal intercuneiform ligament (dC1-C2). - Salvage of Lisfranc's tarsometatarsal joint by arthrodesis. The tarsometatarsal, or Lisfranc, joint complex is a complicated skeletal and capsuloligamentous structure that provides stability to the midfoot and forefoot. These injuries also can occur in ballerinas, dancers, and gymnasts who forcefully land in a tiptoe plantar-flexed position and in nonathletes after a misstep or a fall from stairs or a curb (3,9,31). C = cuneiform, M = metatarsal. Three separate synovial articulations divide the midfoot into the lateral, middle, and medial columns (Fig 2) (19). 4, Annales franaises de mdecine d'urgence, Vol. A study by Preidler et al (46) showed that 50% more metatarsal and twice as many tarsal fractures were seen at CT than at radiography. (d) Short-axis proton-densityweighted MR image through the right tarsometatarsal joint shows the three components of the Lisfranc ligament complex: the dorsal ligament (white arrow), interosseous ligament (arrowhead), and plantar ligament (black arrow). Basic Postoperative Outpatient Evaluation and Management, Advanced Postoperative Outpatient Evaluation and Managementanagement, 2022 Lineage Medical, Inc. On the basis of their experience with athletes, Nunley and Vertullo (4) developed a three-stage classification system that addresses low-impact injuries and helps direct treatment by evaluating clinical findings, comparative weight-bearing radiographs, and images from bone scintigraphy (Table 3). (d) Short-axis proton-densityweighted MR image through the right tarsometatarsal joint shows the three components of the Lisfranc ligament complex: the dorsal ligament (white arrow), interosseous ligament (arrowhead), and plantar ligament (black arrow). - w/ lateral displacement look for cuboid frx; - disrupted skin and excessive swelling are relative contra-indications for ORIF; Injury. Figure 8c Nunley-Vertullo stage II left midfoot Lisfranc injury in a 58-year-old man who fell while bicycling. 01, Journal of Pediatric Orthopaedics, Vol. 42, No. (b) Sagittal reformatted CT image in the same patient shows advanced tarsometatarsal arthropathy and fragmentation (arrow), findings that suggest developing neuropathic arthropathy. Neurologic Conditions. The radiographic signs of Lisfranc injuries can be subtle, and it is important to understand the patterns of these injuries to aid in diagnosis and help clinicians assess treatment options and prognosis. The degree of malalignment is somewhat subtle but can be typical for these injuries. These structures can be injured, particularly during high-velocity mechanisms, and injury can lead to compartment syndromes and midfoot arthropathy (27). Orthobullets March 8 2019 A Lisfranc injury is characterized by disruption between the articulation of the medial cuneiform and base of the second metatarsal. On the dorsal aspect, no intermetatarsal ligament is seen across M1 and M2. 8, No. Study the course material in the free to access tutorials and galleries sections - then sign up to take your course completion assessment. (e) Short-axis fat-suppressed proton-densityweighted MR image through the left midfoot shows portions of the plantar Lisfranc ligament (pC1-M2M3; arrow). 205, No. From the Department of Radiology, University of Pittsburgh, Pittsburgh, Pa (N.A.S., E.A. These injuries have typically been divided . He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. Enter your email address below and we will send you the reset instructions. 43, No. An official website of the United States government. When findings on weight-bearing or stress radiographs are equivocal, bone scintigraphy, CT, or MR imaging may be performed to better evaluate the joint. A widening of more than 2 mm between C1 and C2 suggests additional C1-C2 intercuneiform ligament injury. Would you like email updates of new search results? As with many other traumatic injuries, men are at least twice as likely as women to present with acute Lisfranc joint complex injuries, and athletes in particular have a greater likelihood of sustaining these injuries (7,8). The second metatarsal dorsally dislocates, with lateral displacement of the lesser metatarsals. Initial radiographic findings were unremarkable. Comparison of primary arthrodesis versus open reduction with internal fixation for Lisfranc injuries: Systematic review and meta-analysis. (e) Short-axis fat-suppressed proton-densityweighted MR image through the left midfoot shows portions of the plantar Lisfranc ligament (pC1-M2M3; arrow). The Lisfranc joint complex consists of the articulation between nine bones of the forefoot and midfoot: the five metatarsals (M1M5), which contribute to the plantar arch; the three cuneiforms (C1C3); and the cuboid. (a) Anteroposterior weight-bearing radiograph of the midfoot shows a small chip fracture (arrow) from the medial margin of the M2 base, a finding called the fleck sign. (b) Lateral weight-bearing radiograph demonstrates continuity of the dorsal surface of the M1 base and C1 (dashed white line). (b) Long-axis reformatted CT image of the midfoot shows the M2 chip fracture and mild C1-M2 widening (arrow) and also depicts proximal C1 and C2 fractures (arrowheads) not identified on the initial radiographs. - Open Reduction Internal Fixation: Professionalism & Rotation Evaluations Accurate ACGME levels AND summative faculty feedback the residents want. Lisfranc fracture-displacements are relatively rare, with a reported incidence of one per 55,000 people in the United States annually (5,6). (b) Long-axis reformatted CT image of the midfoot shows the M2 chip fracture and mild C1-M2 widening (arrow) and also depicts proximal C1 and C2 fractures (arrowheads) not identified on the initial radiographs. 48, No. (b) Sagittal reformatted CT image in the same patient shows advanced tarsometatarsal arthropathy and fragmentation (arrow), findings that suggest developing neuropathic arthropathy. (h) Long-axis three-dimensional (3D) sampling perfection with application optimized contrasts using different flip-angle evolutions (SPACE; Siemens Medical Solutions, Erlangen, Germany) MR image shows the right interosseous Lisfranc ligament (arrows). 11, 9 September 2019 | RadioGraphics, Vol. (b) Anteroposterior weight-bearing radiograph shows a gap of more than 2 mm between C1 and M2 and between M1 and M2 (arrow). In some instances, both modalities may be needed to fully characterize bone and soft-tissue injuries. apex volar angulation due to. Lisfranc's fracture-dislocations: etiology, radiology, and results of treatment. Figure 1b Normal osseous anatomy of the Lisfranc joint complex. Depending on the vector of the force, displacement of the metatarsal bases can be seen in either the plantar or dorsal direction (28). 24, No. Dr. Wheeless enjoys and performs all types of orthopaedic surgery but is renowned for his expertise in total joint arthroplasty (Hip and Knee replacement) as well as complex joint infections. (c) Reformatted 3D CT image of the forefoot better shows the chip fracture (arrow) and osseous malalignment. The interosseous ligament (C1-M2) and plantar Lisfranc ligament (pC1-M2M3) are the strongest ligamentous attachments in the Lisfranc joint (19,24). In patients with clinically suspected Lisfranc injuries and normal or indeterminate radiographic findings, CT or MR imaging may be used. 142, No. - Closed Reduction Percutaneous Pinning Lisfranc joint injuries: trauma mechanisms and associated injuries. Indirect force commonly involves twisting the foot. Given its ability to depict surrounding soft-tissue structures, MR imaging may be helpful in assessing the integrity of the distal peroneus longus and anterior tibialis tendons, which help to support the medial midfoot arch. Fixation of the lateral column is performed to maintain its mobility and thus avoid an overload of the lateral foot (55). Subtle radiographic changes can represent significant ligamentous Lisfranc injury. (c) Long-axis reconstructed computed tomography (CT) image of the midfoot shows the second metatarsal base (M2; arrow) recessed between the medial and lateral cuneiforms (C1 and C3) and forming a mortise-and-tenon joint that helps preserve joint alignment. Figure 11b Nunley-Vertullo stage I Lisfranc sprain in a 21-year-old man who hyperextended his right foot while it was stuck in a stool. On the other hand, MR imaging depicted about 25% more metatarsal fractures and almost twice as many tarsal fractures as did radiography. 28, No. (c) Reformatted 3D CT image of the forefoot better shows the chip fracture (arrow) and osseous malalignment. (a) Initial anteroposterior nonweight-bearing radiograph of the foot shows normal osseous alignment of the medial and middle columns. However, bone scintigraphy may be useful for diagnosis of low-grade injuries when other imaging modalities do not depict abnormalities. Named after Jacques Lisfranc, a field surgeon in Napoleon's army, who described a new technique for an amputation used to treat frostbite of the forefoot in soldiers on the Russian front. Dr Graham Lloyd-Jones BA MBBS MRCP FRCR - Consultant Radiologist - Figure 10c Nunley-Vertullo stage II left midfoot Lisfranc sprain in a 41-year-old man after a softball twisting injury. Pediatric Lisfranc injury: "bunk bed" fracture. Contact us. (c) Long-axis fat-suppressed proton-densityweighted MR image of the left midfoot demonstrates the oblique course of the interosseous Lisfranc ligament (arrows). (b) Lateral weight-bearing radiograph demonstrates continuity of the dorsal surface of the M1 base and C1 (dashed white line). Therefore, if anatomic alignment at closed reduction cannot be achieved, open reduction and internal fixation (ORIF) is indicated. (a) Anteroposterior nonweight-bearing radiograph demonstrates subtle widening between C1 and M2 (arrows). At radiography, injuries are nondisplaced, with no diastasis between C1 and the base of M2 and no loss of the midfoot arch height on lateral weight-bearing radiographs. 2006 Mar;11(1):127-42, ix. Figure 2a Diagrams show the normal three-column anatomy of the Lisfranc ligament complex in the left foot. C = cuneiform, p = plantar. (e) Short-axis fat-suppressed proton-densityweighted MR image through the left midfoot shows portions of the plantar Lisfranc ligament (pC1-M2M3; arrow). Moreover, reformatted 3D CT images can be helpful in assessing osseous alignment for preoperative planning (Fig 8c) (8,12). 32, No. Peroneal Tendon Tears and Instability. Finally, the medial branch of the deep peroneal nerve and the perforating branch of the dorsalis pedis artery travel between M1 and M2 toward the first intermetatarsal space. The ligament can either be uniformly low in signal intensity or striated with intermediate signal intensity, as shown. (a) Diagram of the dorsal aspect of the left forefoot in the long axis depicts the two major ligaments between the medial and middle columns: the dorsal Lisfranc ligament (dC1-M2) and the dorsal intercuneiform ligament (dC1-C2). - Lisfranc joint injuries: trauma mechanisms and associated injuries. Radionuclide bone scans will often show abnormal radiotracer uptake in patients with midfoot injuries and are most helpful for detection of low-grade injuries when the radiographic findings are normal or equivocal (41). Treatment is immobilzation or surgical reconstruction depending on patient activity levels, degree of separation and degree of ligament injury. (e) Short-axis fat-suppressed proton-densityweighted MR image through the left midfoot shows portions of the plantar Lisfranc ligament (pC1-M2M3; arrow). theYear=now.getFullYear() (f) Axial proton-densityweighted MR image of the left midfoot demonstrates the M3 bundle of the plantar Lisfranc ligament (pC1-M2M3; arrow). C = cuneiform, p = plantar. (b) Long-axis reformatted CT image of the midfoot shows the M2 chip fracture and mild C1-M2 widening (arrow) and also depicts proximal C1 and C2 fractures (arrowheads) not identified on the initial radiographs. Magn Reson Imaging Clin N Am. (d) Short-axis proton-densityweighted MR image through the right tarsometatarsal joint shows the three components of the Lisfranc ligament complex: the dorsal ligament (white arrow), interosseous ligament (arrowhead), and plantar ligament (black arrow). proximal fragment pulled into flexion by interossei. (c) Sagittal reformatted CT image in a 48-year-old woman with progressive left flat-foot deformity who presented with plantar midfoot pain and a palpable abnormality 8 months after ORIF of the first and second tarsometatarsal joints shows the distal tip of one of the screws protruding into the plantar soft tissues (arrow) and causing mass effect on the flexor hallucis longus tendon, with effacement of the medial midfoot arch (arrowhead). Although Lisfranc joint complex injuries are relatively uncommon, misdiagnosis or undertreatment of these injuries can lead to significant patient morbidities, such as midfoot pain, planovalgus deformity, and osteoarthritis. government site. This mechanism was first described in individuals who fell from a horse with one foot fixed in a stirrup but can also be seen in sailboarders whose feet are fixed to the board and in athletes with a planted cleated foot and a sudden rotational change in direction (3,29). - Open reduction internal fixation versus primary arthrodesis for lisfranc injuries: a prospective randomized study. A focused history and physical examination must be coupled with a thorough review of imaging studies to identify the correct diagnosis. 5, 6 May 2019 | RadioGraphics, Vol. - always consider compartment syndrome of the foot; - Radiographs: Radiologists must understand the pathophysiology of these injuries and the patterns of imaging findings seen at conventional radiography, computed tomography, and magnetic resonance imaging to improve injury detection and obtain additional information for referring physicians that may affect the selection of the injury classification system, treatment, and prognosis. (b) Lateral nonweight-bearing radiograph shows the typical dorsal subluxation of M1 relative to C1 (arrow). - young competitive atheletes may require anatomic reduction; perform passive range of motion of the metatarsal heads and passive abduction through the forefoot. C = cuneiform, Cu = cuboid, M = metatarsal. Recently, 3D fast spin-echo (SE) volumetric SPACE MR imaging has been used to optimize assessment of the Lisfranc ligamentous complex (Fig 3). The plantar surface of the M1 base (black line) is superior to the plantar surface of the M5 base (solid white line). C = cuneiform, M = metatarsal. - dorsalis pedis may be diminished or absent; [3] Contents 1 Causes 2 Diagnosis 2.1 Classification 3 Treatment 4 History 5 See also 6 References 7 External links Causes [ edit] Lisfranc ligaments: [4] (h) Long-axis three-dimensional (3D) sampling perfection with application optimized contrasts using different flip-angle evolutions (SPACE; Siemens Medical Solutions, Erlangen, Germany) MR image shows the right interosseous Lisfranc ligament (arrows). sampling perfection with application optimized contrasts using different flip-angle evolutions, Indian Journal of Radiology and Imaging, Vol. Every post-traumatic foot X-ray must be checked for loss of alignment at the midfoot-forefoot junction (tarsometatarsal joints). The dorsal ligamentous components have been found to be the weakest, a finding that likely explains the typical dorsal displacement seen with Lisfranc injuries (23). Keywords: Abstract. The left foot shows the advanced stage of an untreated Lisfranc injury with similar first ray instability. 19, Journal of Medical Imaging and Radiation Oncology, Vol. The tibialis poste- rior inserts on the medial aspect of the navic- ular tubercle and extends to the plantar surface of all midfoot bones and the bases of the second and third metatarsals. 24, No. Follow-up radiography should be performed after 2 weeks of cast use to evaluate the injury for increasing diastasis (8). A review of 20 cases. However, the ligament is intact. The ligament can either be uniformly low in signal intensity or striated with intermediate signal intensity, as shown. This mus- cle provides inversion and plantar flexion power to the foot. 24, No. The authors thank David C. Botos for providing the medical illustrations. (a) Drawing demonstrates the forefoot abduction mechanism, with the hindfoot in a fixed position and the forefoot rotated or abducted. 87100 8374 votes High rate. 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