Lisfranc Injury Imaging and Surgical Management

Abstract

When Jacques Lisfranc served as a military surgeon in Napoleon's army, he described a quick forefoot amputation through the tarsometatarsal (TMT) joint to treat the extended dislocation that occurred when the foot was trapped in the stirrup falling from a horse. Although he did not describe any fracture or dislocation, many midfoot structures and injuries were subsequently named for Lisfranc including the TMT joint, the interosseous ligament between the first cuneiform bone and the base of the second metatarsal bone, and the spectrum of injuries along the TMT joints including their stabilizing ligamentous complexes. 1-3There are two different groups of injuries: those secondary to high-energy trauma, with fractures or fracture dislocation of the midfoot, and those secondary to low-energy trauma, with often subtle Lisfranc injuries or sprains. Lisfranc fractures and injuries are rare and frequently overlooked. Delayed diagnosis and treatment can lead to long-term pain and disability, secondary to early osteoarthritis (OA), flattening of the arch, chronic instability, and pain in the midfoot. 2,3Lisfranc injuries and fractures have been cited among the most common reasons for legal claims. The fact that these injuries may occur in the context of polytrauma and may be subtle explains why they are often overlooked. 4,5 Relevant AnatomyThe Lisfranc joint, or TMT joint, is the transition between the rigid midfoot and the relatively flexible forefoot, and structurally it supports the transverse arch of the foot. It includes the joints between the cuneiforms and cuboid with the bases of the five metatarsal bones. Stability is achieved together with the intervening ligamentous structures. These form three different biomechanical and synovial compartments. The medial column or first ray is formed by the first cuneiform (C1) and first metatarsal (M1) and covered by the medial synovial membrane. The intermediate or middle column consists of the second and third ray, formed by the second and third cuneiform (C2 and C3) with the corresponding second and third metatarsals (M2, M3); it is closely related to the cuneoscaphoid joint. The lateral column includes the cuboid, the fourth and fifth metatarsal (M4 and M5), comprising the fourth and fifth ray; its synovial membrane does AbstractThe Lisfranc joint is composed of the cuneiform bones and the cuboid and metatarsal bases, united by a synovial capsule and ligamentous complex. Familiarity with the anatomy is essential for image planning and for understanding injury patterns. The more important structures are the Lisfranc ligament and the plantar ligaments that can be visualized with MR, although careful attention to technique and orientation of scan planes is required for accuracy. A combination of conventional radiographs, computed tomography, and MR allow precise diagnosis of Lisfranc fractures, fracture dislocation, and subtle Lisfranc injuries to guide clinical management and surgical planning.

Clinical Study on Different Methods of Internal Fixation for Treatment of Lisfranc Joint Injury

“…The Lisfranc joints play an important role in connecting the forefoot and midfoot and maintaining the stability of the arch of the foot [ 1 – 3 ]. With the rapid development of transportation and construction industry in recent years, the incidence of Lisfranc injury has been increasing year by year, and if not treated in time, it will lead to poor walking, pain in the back of the foot, and even disability in severe cases [ 4 – 6 ].…”

Outcomes of Surgically Treated Purely Ligamentous Stage II Lisfranc Injuries

“…27 When available, bilateral weightbearing radiographs (Figure 1), rather than only unilateral weightbearing, were used as they are the gold standard for diagnosing Lisfranc injuries. 1,6,7,14,20,24 Injuries were classified as acute if they were surgically repaired within 6 weeks of injury and classified as chronic if after 6 weeks.…”

“…6,26 As there are no interosseous ligaments spanning directly from the first to the second metatarsal, the Lisfranc ligament plays a large role in maintaining stability between the first and second metatarsals. 9,17 Lisfranc injuries can occur secondary to low- or high-energy mechanisms, 14 and are relatively rare, occurring in only 14/100 000 people each year. 25 Low-energy mechanisms are understood to be more common for Lisfranc injuries, 25 but they frequently go undiagnosed because of their insidious onset.…”

“…The term "Lisfranc injury" is used to describe various injuries occurring at the tarsometatarsal (TMT) joints 3,8,14,26 and refers specifically to injury of the Lisfranc ligament, which spans from the anterolateral aspect of the medial cuneiform to the base of the second metatarsal. 6,26 As there are no interosseous ligaments spanning directly from the first to the second metatarsal, the Lisfranc ligament plays a large role in maintaining stability between the first and second metatarsals.…”

Case Study: The Conservative Management of a Complex Mid Foot Injury in an Elite Professional Footballer

“…Highlighting, the importance of patient presentation, clinical assessment and appropriate imaging (Eleftheriou et al, 2013;Keiserman et al, 2003;Sherief et al, 2007). Subtle LFI may not be identified via NWB radiographs due to osseous overlap at the TMTJ and possible spontaneous reduction after trauma therefore important to obtain weight-bearing films if possible (Llopis et al, 2016;Myerson et al, 1986;Raikin et al, 2009). Further review by a foot and ankle specialist (MD) with associated weight-bearing (stork view) x-ray confirmed initial suspicion of LFI.…”