Evolving technique update: how to avoid the subtle lisfranc: 8 tips in 8 minutes. Michael J Coughlin MD Co-chairman, NFL Foot and Ankle Committee
Conflicts • None for this talk • Consultant with Arthrex, Stryker, Integra • Royalties from Arthrex, Stryker, Integra, Erchonia • Textbook royalties- Elsevier
Incidence • Uncommon injury • 1 in 55,000-60,000 per year • 0.2% of fractures • 50% incidence of postraumatic arthritis • Missed/delayed diagnosis can lead to midfoot instability, planovalgus deformity, and early osteoarthritis
Ana tomy: Lisfranc Complex Lisfranc Ligament • Intermetarsal base ligaments exist between 2-5 • Lisfranc ligament= only direct stabilizing feature between base of 1 st and 2 nd rays • Interosseous and thicker plantarly
Lisfranc Injury Pattern • In the NFL, almost 70% are non-contact injuries • Many are not surgical cases • But huge time loss before RTP
We are talking about subtle injuries If you miss these, you aren’t looking very closely!
Lateral subluxation Hard to miss!!
Lisfranc Injury
Lisfranc Experimental Conditions • 13 limbs, 62 distinct loading events • Parameters Varied: Axial load, Magnitude of twist, Toe flexion, Boundary at met heads, Axis of twist, Direction of axial force vector
Cuneiform Coordinates Cuneiform Cuneiform
Lisfranc Injury Mechanism
Don’t miss this injury: Steps 1-8 not to miss • Approximately 20% of Lisfranc injuries can be misdiagnosed or simply missed which can lead to potentially significant sequelae Myerson et al. Foot Ankle 1986;6:225–42.
#1-Physical Examination • Unexplained swelling http://www.footeducation.com/lisfranc-injury-fracture-midfoot-sprain/
#2-Physical examination • Careful inspection of skin and soft tissue • Plantar ecchymosis sign
#3-Physical examination • Nothing beats palpation of the foot • Where is the tenderness?
#4-Physical Exam • Provocative Maneuvers • Compression of midfoot • Dorsal and plantar deviation of the first met • Passive pronation abduction • Squeeze 1 st /2 nd interspace in coronal plane Myerson, M, J. Bone Joint Surg., 2008
The start!!! • Listening to the patient • And touching (examining) the patient
Imaging (5-8) #5- Your first image • Plain radiographs are the initial evaluation • 3 views
You may see nothing!
You may see something obvious!
Subtle subluxation without fracture wt bearing AP & lateral x-rays and compare to uninjured foot TC
Subtle subluxation
Plain Radiographs • May be obvious (large bony Lisfranc fragment)
May be a subtle fleck sign • The fleck sign – Avulsion of base of 2 nd met – Pathognomic for Lisfranc injury – Present in approximately 90% of Lisfranc injuries
The Normal Foot Alignment • Space between 1 st and 2nd MT • Medial border of 2 nd MT aligns exactly with medial border Middle Cuneiform • Medial border of 4 th MT aligns with medial border Cuboid • Aligned TMT on lateral views
No dorsal stepoff Dorsal stepoff Plantar aspect of medial cuneiform is dorsal to plantar aspect of 5 th met Mann's Surgery of the Foot and Ankle, 9th ed., 2014. Chapter 35 Dislocations of the Foot.
Physical Exam-leads you to be suspicious!
#6 When in doubt Stress Radiographs • May be a subtle in ligamentous Lisfranc • B/L Weight bearing foot on same cassette X-ray to differentiate stable vs unstable sprain – Image oppositesfoot to compare • External rotation stress X-ray
#6--Stress Radiographs
#7-CT scan • CT scan – MRI You may see none of the se fracture patterns on plain radiographs
#7 Advanced imaging: CT • Means to show occult fractures and fracture extension into midfoot • Means to show subluxed TMT (<2mm unable to be seen on plain films)
#7 Advanced imaging: CT
#7 Advanced imaging: CT
#7-additional Spect scan
Normal xray but pain
Spect scan
#8 Advanced Imaging MRI • Evaluate Lisfranc ligamentous sprain when X-ray are inconclusive
#8-MRI-Imaging Radiographics. 2014 Mar-Apr;34(2):514-31. doi: 10.1148/rg.342125215. Evaluation of the tarsometatarsal joint using conventional radiography, CT, and MR imaging. Siddiqui NA 1 , Galizia MS, Almusa E, Omar IM.
Treatment Options • CRIF, ORIF, bridge plating • Arthrodesis
Open Reduction with Internal Fixation
Primary Arthrodesis
Steps 1-4 (physical examination) • 1.Unexplained midfoot swelling • 2.Plantar ecchymoses • 3.Midfoot tenderness on palpation • 4.Provocative moves
Steps 5-8 (imaging) • 5.Plain radiographs • 6.Stress radiographs • 7.CT/ spect imaging • 8.MRI
References 1. Gilgenkrantz, Simone (2006). "[The Baron Guillaume Dupuytren]". Med Sci (Paris) 22 (8–9): 771–2. doi:10.1051/medsci/20062289771 2. Fischer, LP. Hist Sci Med. 2005 Jan-Mar;39(1):17-34. [Jacques Lisfranc de Saint-Martin (1787-1847)]. 3. Mann's Surgery of the Foot and Ankle, 9th ed., 2014. Chapter 35 Dislocations of the Foot. 4. Fractures and Dislocations of the Midfoot: Lisfranc and Chopart Injuries. An Instructional Course Lecture, American Academy of Orthopaedic Surgeons. Stephen K. Benirschke, MD, Eric Meinberg, MD, Sarah A. Anderson, MD, Clifford B. Jones, MD, and Peter A. Cole, MD. JBJS VOLUME 94-A d NUMBER 14 d JULY 18, 2012 5. Netter's Concise Orthopaedic Anatomy, 2nd ed., 2010. Chapter 10, Foot/Ankle 6. de Palma L, Santucci A, Sabetta SP, Rapali S: Anatomy of the Lisfranc joint complex. Foot Ankle Int 18:356-364, 1997. 7. Wiley JJ: The mechanism of tarso-metatarsal joint injuries. J Bone Joint Surg Br 53:474-482, 1971 8. Radiographics. 2014 Mar-Apr;34(2):514-31. doi: 10.1148/rg.342125215. Evaluation of the tarsometatarsal joint using conventional radiography, CT, and MR imaging. Siddiqui NA 1 , Galizia MS, Almusa E, Omar IM. 9. Aitken, A, Poulson, D. Dislocations of the Tarsometatarsal joint. JBJS Vol 45-A, 263. 1963 10. Fracture Dislocations of the Tarsometatarsal Joints: End Results Correlated with Pathology and Treatment Mark S. Myerson, Robert T. Fisher, Andrew R. Burgess, and John E. Kenzora. Foot Ankle Int, April 1986; vol. 6, 5: pp. 225-242. 11. http://www.braceability.com/conditions/foot-orthotics/lisfranc-fracture-treatment 12. http://heelpadavulsion.blogspot.ch/2012/03/major-crush-injury-foot-with-heel-pad.html 13. J Orthop Trauma. 1996;10(2):119-22. Plantar ecchymosis sign: a clinical aid to diagnosis of occult Lisfranc tarsometatarsal injuries. Ross G 1 , Cronin R, Hauzenblas J, Juliano P. 14. Peicha G, Labovitz J, Seibert FJ, et al.The anat- omy of the joint as a risk factor for Lisfranc dislo- cation and fracture-dislocation: an anatomical and radiological case control study. J Bone Joint Surg Br 2002;84(7):981–985. 15. Watson TS, Shurnas PS, Denker J. Treatment of Lisfranc joint injury: current concepts. J Am Acad Orthop Surg 2010;18(12):718–728. 16. Kuo RS, Tejwani NC, Digiovanni CW, et al. Out- come after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am 2000; 82(11):1609–1618.
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