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Diabetic foot before Surgery and Diabetic foot after Surgery
Claw toe deformity in Rhuematoid patient and Claw toe deformity in Rhuematoid patient after surgery
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Lisfranc or Midfoot


Fractures of the Midfoot Tarsometatarsal (Lisfranc) joint

Injuries to the tarsometatarsal or lisfranc joints are not that common.

What is the Lisfranc joint?

The foot can be thought to consist of three main parts. The forefoot or front area consisting of the toes; the midfoot or middle part which is made up of the small bones called the navicular, cuneiform, and cuboid; and the hindfoot or rear part consisting of the talus (lower half of ankle) and calcaneus (heel). The Lisfranc joint is the space between the bones of the forefoot and midfoot.

 
Pictures  showing areas of foot
 
Lisfranc Injury
       

The Lisfranc injury is an injury to the lisfranc ligaments that connects these joints. Sometimes the injury is a simple dislocation (ligament injury) or a fracture and dislocation. The dislocation is a separation of the normal joints between the forefoot and midfoot. The fracture usually occurs in the midfoot bones.
Historically this type of injury classically occurred when a horseman fell while riding, having trapped his foot in the stirrup. In those days, the foot was violently wrenched in the stirrup and the only way that this could be treated at that time was by partial amputation of the foot by the renowned surgeon of Napoleon, Lisfranc. The term Lisfranc injury has stuck, although fortunately, treatment by amputation is almost never required.

At present, such an injury happens typically in activities such as when one tries to stop a moving scooter or motorbike by using his or her foot as an anchor to the ground, or when one steps into a hole and the foot twists heavily. Falling from a height of two or three stories can also cause this fracture.

They are mainly divided into 3 types:

  • 1. Homolateral: All 5 metatarsals are displaced in the same direction. Lateral displacement may also suggest cuboidal fracture.
  • 2. Isolated: 1 or 2 metatarsals are displaced from the others.
  • 3. Divergent: metatarsals are displaced in a sagittal or coronal plane. May also involve intercuneiform area and a navicular fracture.
 
Classification Lisfranc injury
   
       

Anatomy

The anatomy of the tarsometatarsal joint is quite complex. It consists of the articulations of multiple bones (the five metatarsals, the three cuneiforms and the cuboid bone).

 
Anatomy of Lisfranc Joints
 
Ligaments of Tarsometatarsal joints
       

As seen in the picture the base of 2nd metatarsal is wedged between medial & lateral cuneiforms. Strong ligaments link bases of 2nd-5th MT and Lisfranc ligament attaches base of 2nd MT to medial cuneiform. No ligamentous connection between base of 1st & 2nd MT. Dorsalis pedis artery and nerve runs between 1st & 2nd MT, may be damaged due to injury. 

Diagnosis

Injuries of the tarsometatarsal joint can be quite subtle and are not always easy to diagnose on x-ray. In order to diagnose the injury, sometimes it is necessary to get CT Scan of the foot. 3 views of the foot and an x-ray view of the normal foot as well as the abnormal foot are useful in order to better define the injury.

X-ray Diagnosis

Following parameters are helpful in diagnosing these fractures

Xray - AP / lateral / oblique views

1.
AP view – see that the medial border of 2nd MT is in line with medial border of middle cuneiform.
   
2.
Oblique view – see that medial border of 4th MT in line with medial border of cuboid.
   
3.
Lateral view – see that there is no dorsal/plantar displacement of Metatarsal.    
       
       
 
Normal Foot AP and Oblique X-rays
 
Normal Foot lateral X-ray
       

About 20 % of these injuries are initially missed and about 40% do not receive any treatment in first week. Surgery is required for the majority of these injuries. The treatment of tarsometatarsal injuries is best done by reduction of the fraction or dislocation and stabilising them by means of screws or plates.

 
Lisfranc Fracture X-ray AP view
 
Lisfranc Fracture X-ray Oblique view
 
Lisfranc Fracture fixation AP view
 
Lisfranc Fracture fixation Lateral view

The metalwork is typically left in for approximately four to five months following the surgery. Often after this time they are removed. There is no cast after the surgery. Walking on the foot is not permitted for about six weeks and then walking is initiated with a removable boot.

If untreated, a Lisfranc fracture or Lisfranc fracture dislocation of the tarsometatarsal joint will often lead to painful arthritis that requires treatment. Arthritis is common if the joints are not carefully lined up and held with metalwork. If arthritis does occur, then these joints need to be fused.

 
 
Lisfranc Fracture with Painful Arthritis and after Fusion