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Lisfranc’s Fracture / TarsoMetatarsal Injuries

- See: Midfoot/Forefoot Fractures

- Discussion:
    - anatomy of the midfoot
    - mechanism:
          - because 2nd metatarsal is the longest metatarsal proximally, it will often be frxed at its base,
                    with the other metatarsals dislocated;
          - dorsal capsule of Lisfranc's joint, lacking sufficienct reenforcement, will to support the load
                    and will collapse, resulting in dorsal frx dislocation of the metatarsal bases; 
          - references:
                 - Lisfranc joint injuries: trauma mechanisms and associated injuries.
                 - Pediatric Lisfranc injury: "bunk bed" fracture. 
    - classification:
          - homo-lateral:
                 - all 5 metatarsals are displaced in the same direction;
                 - w/ lateral displacement look for cuboid frx;
          - isolated: one or two metatarsals are displaced from the others;
          - divergent:
                 - metatarsals are displaced in saggital and coronal planes;
                 - look for extension into the intercuneiform area and navicular frx;
    - diff dx and associated injuries:
          - longitudinal stress injuries;
          - frx of base of second metatarsal;
          - cuboid frx;
          - navicular compression fractures;
          - rupture of posteior tib tendon;
          - compartment syndrome 
    - prognosis:
          - Lisfranc injuries w/o fracture have poor prognosis, with late midfoot collapse a common sequela;
          - metatarsalgia: may occur from displacement in the saggital plane;
          - posttraumatic arthritis and planovalgus deformity are common and may occur in upto 50%;
                  - however, x-ray findings may not correlate w/ clinical findings;
                  - w/ symptomatic posttraumatic arthritis, consider arthrodesis;

- Physical Exam:
    - pain & swelling in midfoot w/ tenderness along Lisfranc's joint;
    - tenderness w/ passive abduction & pronation of forefoot w/ hindfoot held fixed in the examiner's opposite hand;
    - dorsalis pedis may be diminished or absent;
    - always consider compartment syndrome of the foot;

- Radiographs:
    - fracture characteristics may be subtle;
    - on non-stressed views, frx at base of 2nd metatarsal or anterior aspect of cuboid may most obvious
           indications of Lisfranc injury;
           - w/ questionable injury, consider wt bearing AP view to assess 1-2 interval;
           - if standing AP is unacceptable to the patient then consider CT scan;
    - intercuneiform region injuries: these may occur in upto 10-15 % of patients;
    - lateral radiographs:
           - lateral talometatarsal angle is formed by intersection of a line along the long axis of talus w/ long
                   axis of 1st metatarsal and normally forms a straight line 
    - ref: Prediction of midfoot instability in the subtle Lisfranc injury. Comparison of magnetic resonance imaging with intraoperative findings.  

- Treatment of Sprains and Minimally Displaced Frx: 
      - Subtle injuries of the Lisfranc joint
      - ref:  Outcomes of Lisfranc Injuries in the National Football League

- Operative Treatment:
    - Closed Reduction Percutaneous Pinning 
    - Open Reduction Internal Fixation:
           - fractures presenting w/ more than than 2 mm of displacement and greater than 15 deg of
                    talometatarsal angulation require operative treatment;
           - young competitive atheletes may require anatomic reduction;
           - disrupted skin and excessive swelling are relative contra-indications for ORIF;
           - note that pure dislocations w/o fracture may have a worse outcome despite ORIF; 
           - ref: Arthrodesis versus ORIF for Lisfranc fractures.  
    - Primary Arthrodesis:
           - Salvage of Lisfranc's tarsometatarsal joint by arthrodesis. 
           - Severe Lisfrancs injuries: primary arthrodesis or ORIF? 
           - Open reduction internal fixation versus primary arthrodesis for lisfranc injuries: a prospective randomized study. 
           - Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study.
           - Arthrodesis versus ORIF for Lisfranc fractures.
           - Does Open Reduction and Internal Fixation versus Primary Arthrodesis Improve Patient Outcomes for Lisfranc Trauma?

    - post op:
           - fixation must be rigid enough to prevent transverse plane & dorsoplantar motion of TMT joint and be maintained for at
                     least 12-16 weeks

Outcomes of Lisfranc Injuries in the National Football League.

Isolated fracture-dislocations of the first tarsometatarsal joint.

Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment.

Lisfranc's fracture-dislocations: etiology, radiology, and results of treatment. A review of 20 cases.

The diagnosis and treatment of injuries to the Lisfranc joint complex.

Fractures and fracture-dislocations of the tarsometatarsal joint

Anatomical restraints to dislocation of the second metatarsophalangeal joint and assessment of a repair technique.

The treatment of tarsometatarsal injuries.

Fracture dislocations at the tarsometatarsal joints, end results correlated with pathology and treatment

Fractures and fracture dislocations of the tarsometatarsal joint.    

Functional outcome following anatomic restoration of tarsal-metatarsal fracture dislocation.

PLA screw fixation of Lisfranc injuries.