Tarsometatarsal fracture-dislocation

Lisfranc Injuries

Lisfranc injuries were thought to primarily occur during high-energy events, leading to a preference for fusion treatment; however, recent data have shifted this perspective by highlighting a greater occurrence of low-energy injuries and reshaping the focus on open reduction internal fixation. This multifaceted process is guided by various factors, including the nature of the injury, specific anatomic considerations, and the involved joints. Our overarching goal remains to achieve anatomic reduction, with flexibility in hardware fixation methods. In cases of comminution, bridge plating may be warranted, potentially followed by arthrodesis in the future.

Diabetic Lisfranc fracture-dislocations and Charcot neuroarthropathy

The goal with Lisfranc fracture-dislocations is to regain joint congruity and reestablish midfoot stability to avoid debilitating posttraumatic arthrosis and chronic pain in the sensate patient. In the diabetic population, dense peripheral neuropathy and/or vascular disease are equally important and may alter the surgical approach to traumatic tarsometatarsal injuries. The initial diagnosis in the diabetic population may be delayed due to subtle radiographic findings and/or patient unawareness of trauma in the insensate foot. Failure to initiate treatment in the early stages of acute diabetic neuropathic Lisfranc injuries can predispose the patient to midfoot instability, potential ulceration, infection, and Charcot neuroarthropathy.

Age, sex, causal and injury patterns in tarsometatarsal dislocations: a literature review of over 2000 cases

BACKGROUND

The causes and mechanisms of tarsometatarsal (TMT) dislocations are poorly characterized. Unfortunately, the rarity of these injuries makes it difficult and costly to gather the epidemiological data needed to better understand the populations at risk and the circumstances under which injury is most likely to occur.

METHODOLOGY

To address this issue, literature reports of TMT dislocations were identified and analyzed to generate statistical descriptions of the common causes of injury, the age and sex of those injured, and the pattern of injury. Over 2000 injuries were identified from 187 articles.

RESULTS

The analysis reveals that over 40% of injuries were related to traffic accidents. Based on the Hardcastle classification system, more than 60% of TMT dislocation were partial (type B) injuries. Over 55% of the injured were between 15 and 35 years of age, and males were injured more than twice as frequently. Conversely, the victims of falls tended to be older and represented a larger proportion of females. The age and sex of those injured by TMT dislocations vary by cause.

CONCLUSION

An improved understanding of the epidemiologic patterns will benefit research into the mitigation and prevention of these injuries.

Tarsometatarsal/Lisfranc joint

Accurate early diagnosis with adequate reduction and maintenance of anatomic alignment of the dislocation or fracture within the Lisfranc joint complex have been found to be the key to successful outcomes regarding this injury. Because of the anatomic variations, the thin soft tissue envelop, and the abundance of ligamentous and capsular structures in the region, repair of these injuries can be a challenge. The classification systems used to describe these injuries aid in describing the mechanism of injury or displacement type present, which may aid in determining what treatment modality can provide the best outcome.

Injury to the tarsometatarsal joint complex

Tarsometatarsal joint complex fracture-dislocations may result from direct or indirect trauma. Direct injuries are usually the result of a crush and may involve associated compartment syndrome, significant soft-tissue injury, and open fracture-dislocation. Indirect injuries are often the result of an axial load to the plantarflexed foot. Midfoot pain after even a minor forefoot injury should raise suspicion; up to 20% of tarsometatarsal joint complex injuries are missed on initial examination. An anteroposterior radiograph with abduction stress may reveal subtle injury, but computed tomography is the preferred imaging modality. The goal of treatment is the restoration of a pain-free, functional foot. The preferred treatment is open reduction and internal fixation, using screw fixation for the medial three rays and Kirschner wires for the fourth and fifth tarsometatarsal joints. Satisfactory outcome can be expected in approximately 90% of patients.

Abduction stress and AP weightbearing radiography of purely ligamentous injury in the tarsometatarsal joint

Twenty volunteers (40 feet) with no prior foot injury underwent standardized abduction stress and standing AP radiographs. Subsequently, the Lisfranc and dorsal tarsometatarsal ligaments in nine feet from cadavers were sectioned in a varying sequential manner, and interval standardized radiographs of abduction stress and AP simulated weightbearing were obtained. On abduction stress radiographs in 39 of 40 feet of volunteers and nine of nine feet of cadavers before sectioning, a line tangential to the medial aspect of the navicular and medial cuneiform (medial column line) intersected the base of the first metatarsal. Combining the sectioning of the Lisfranc and dorsal tarsometatarsal ligaments produced a disruption of the medial column line in all feet from cadavers. Disruption of this medial column line may be a simple and valuable diagnostic tool for determining significant ligamentous injury to the tarsometatarsal interval.

Radiographic and computed tomographic evaluation of Lisfranc dislocation: a cadaver study

Six cadaver feet were used for radiological and computed tomographic (CT) evaluation. The tarsometatarsal joints of each specimen were displaced dorsolaterally in successive 1-mm increments. None of the 1-mm and two thirds of the 2-mm dorsolateral Lisfranc dislocations could be visualized on routine radiographs; they could all be noted on CT scans. There was good assessment on CT scan for the extent of the minor lesions that are normally obscured by overlapping projection in routine radiographs. A Lisfranc injury that appears undisplaced on radiographs or acceptable after closed reduction may still have an unpredictable outcome because of the presence of an occult joint subluxation. CT scanning is more sensitive than radiography for detecting the minor amounts of Lisfranc displacement. If there is any doubt on the radiographs, a CT scan should be performed. The early diagnosis and treatment of Lisfranc injuries may minimize development of post-traumatic degenerative arthritis.

Rupture of Lisfranc's ligament in athletes

Ligamentous injuries to the tarsometatarsal joints are uncommon and usually result from violent trauma to the forefoot. A more subtle tarsometatarsal injury consisting of an isolated diastasis of the first and second tarsometatarsal rays has recently been described. This injury is thought to be caused by a rupture of Lisfranc's ligament. Nine injuries that occurred during athletics are described. History and physical findings are crucial for arousing the clinician's suspicion for this injury, but confirmation can best be obtained by comparison weight-bearing radiographs; the space between the first and second metatarsal bases may be widened 2 to 5 mm. Nonoperative treatment consisting of casting and the use of crutches for 4 to 6 weeks was successful in returning patients back to athletics; however, the time to return to competition averaged 4 months.