II. Pathophysiology

  1. Lisfranc Joint:Tarsometatarsal articulation of foot
    1. First and second Metatarsal
    2. First and Second Cuneiforms
  2. Lisfranc ligament
    1. Attaches second Metatarsal to medial Cuneiform (plantar surface stronger, dorsum weaker)
  3. Keystone wedging of base of second Metatarsal
    1. Articulates with Second Cuneiform
    2. Straddled by first and Third Cuneiform
  4. Lisfranc joint transfers force from mid to forefoot
    1. Critical to plantar and dorsiflexion

III. Mechanism

  1. Plantar hyperflexion with axial loading
  2. Displaces second Metatarsal dorsally

IV. Causes

  1. Lateral Ankle Sprain
  2. High energy injury
    1. Motor vehicle accident
    2. Fall from high height

V. Symptoms: Persist >5 days after injury

  1. Midfoot swelling
  2. Difficult weight bearing

VI. Signs

  1. Tenderness at tarsometatarsal joint
  2. Difficult weight bearing while on tiptoes

VII. Imaging: XRay foot

  1. Consider Bone scan or Foot CT if XRay not diagnostic
    1. Foot CT is commonly needed for diagnosis (but start with xray)
  2. Efficacy: Initial False Negative Rate approaches 50%
    1. Weight bearing images are critical for accurate diagnosis
  3. Views
    1. Lateral weight bearing foot XRay
    2. Anteroposterior weight bearing foot XRay
    3. Oblique view of foot (30 degrees)
  4. Anteroposterior foot xray
    1. Widening of space between first and second Metatarsal heads (diastasis)
    2. Avulsed bone fragments (fleck sign)
    3. Malalignment Second Cuneiform and Metatarsal
    4. Proximal second metarsal is most common associated Fracture
  5. Lateral foot xray: Step-off on dorsal foot surface
    1. Loss of arch height (Stage III injury)
    2. Proximal second Metatarsal displaced upward
    3. Middle Cuneiform top below Metatarsal top

VIII. Management: Conservative Management

  1. Splint patients if any suspicion of Lisfranc Injury
  2. Short-leg walking cast (or CAM walker) for 4-6 weeks
    1. Non-weight bearing if XRay widening between first and second metarsals (standing xray)
    2. Bobby Jones splint with crutch walking only
  3. Rehabilitation after cast removal
  4. Reassess 2 weeks after starting rehabilitation
    1. Repeat weight bearing XRays to assess for instability

IX. Management: Surgery

  1. Indications (controversial)
    1. Displacement greater than 2 mm
  2. Timing
    1. Best performed within first 24 hours of injury
    2. Some prefer to wait 7-10 days for less swelling

X. Complications

  1. Post-Traumatic arthrosis

XI. Prognosis

  1. High risk of morbidity

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