Lisfranc Injuries: Causes, Symptoms, and Treatment Options

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The Lisfranc joint is named after Jacques Lisfranc de St. Martin, a surgeon in the army of Napoleon Bonaparte. In the early 19th century, Lisfranc noted the importance of this joint and the severity of injuries that can occur to it, though it was another doctor, Jacques Mathieu Delpech, who first described a specific injury to the Lisfranc joint. This injury was an amputation of the midfoot through the tarsometatarsal joint, which is now referred to as a “Lisfranc amputation”. This injury was said to have led to rapid deterioration in the general health of the patient, and in 3 of the 8 cases cited by Delpech, death resulted. Today, a Lisfranc amputation is an extremely rare injury and would likely be treated through the surgical reattachment of the amputated bones.

Lisfranc fracture-dislocation is a severe injury of the midfoot involving a break between the base of the second metatarsal and the middle cuneiform, which often extends to a break between the first and second metatarsals. This class of injury is named after Jacques Lisfranc de St. Martin, a Napoleonic surgeon who treated soldiers of the era. The Lisfranc joint is the point at which the long bones that lead up to the toes (the metatarsals) connect with the bones in the arch of the foot (the tarsals). The term “Lisfranc injury” refers to an injury of the foot in this area; however, it is commonly used to describe a variety of injuries including sprains, dislocations, and fractures. Because of the possibility of an inaccurate diagnosis and long-term complications such as pain and osteoarthritis, it is important to understand the causes of a Lisfranc injury, the various forms it can take, and the most effective methods of treatment.

Overview of Lisfranc Fracture Dislocation

Lisfranc injuries are named after Jacques Lisfranc de St. Martin (1790-1847), a gynecologist and field surgeon in Napoleon’s army, who reportedly experienced this injury as a result of getting his foot caught in a stirrup when he was thrown from his horse. It was his observation that such injuries led to significant morbidity for patients, which prompted him to publish reports on amputations of the forefoot at the tarsometatarsal joint and on required surgical techniques. Emergency room physicians, orthopaedic surgeons, and podiatrists should recognize Lisfranc fracture dislocation as a relatively common low-velocity/high-impact injury seen in traffic accidents and industrial mishaps. Also, it is a common high-velocity injury sustained by individuals involved in motocross racing and equestrian events. High-energy trauma accounts for approximately 20% of all Lisfranc injuries.

Lisfranc fracture dislocation is a severe injury of the foot. About 20% of cases are missed at initial assessment. Isolated injury to the tarsometatarsal joint complex is thought to be uncommon. However, missed Lisfranc fracture dislocation may lead to the development of a painful pseudarthrosis and early degenerative changes in the foot. Nonanatomic reductions of the joint congruity and malalignments in the widely varied patterns of Lisfranc fracture dislocation can contribute to poor functional outcomes. The lack of a medical consensus on the best way to manage these injuries invites further studies on the mechanism of trauma, classification of injury, and short-term and long-term results of different treatment methods.

Importance of Lisfranc Ligament and Soft Tissue

It is getting more frequent. The majority of Lisfranc injuries result from activities that cause increased stress on the midfoot. Lisfranc injuries have been reported occurring in American football, windsurfing, equestrian sports, running, and skydiving. Injuries have also been reported in industry-related activities such as motor vehicle crashes and crush injuries. It is essential to understand the anatomy and biomechanics of the midfoot to understand the importance and pathogenesis of Lisfranc injuries. The Lisfranc joints are a series of articulations between the medial cuneiform and first metatarsal, and the bases of the second metatarsal and second cuneiform. This forms a partially rigid structure which acts as a strut to the entire foot. Abduction and adduction forces of the forefoot on the rearfoot are absorbed through these joints. It is critical for maintenance of normal foot alignment and function that there is little or no impediment to motion through these joints. Any malalignment or dislocation can have a significant impact on the biomechanics of the foot. Due to the increased incidence of degenerative changes in the adjacent joints and the arthritis in Lisfranc injury survivors, it has been suggested that arthrodesis does not fully recover the normal foot motion and arrangement. With the possibility of early onset degenerative changes, prevention of disability in the arthritic form is indeed the best treatment. This is making patients and surgeons much more aware of the importance of trying to preserve the native joint pattern and foot alignment. This still does hold true even in the case of minor injuries, yet the high rate of misdiagnosis and resultant poor functional outcomes highlight the need for further medical and public education on the significance of proper treatment for even low-grade Lisfranc injuries.

High Energy Impact and Tarsometatarsal Joints

To this date, tarsometatarsal fracture dislocations are often referred to as “Lisfranc’s fractures.” However, Lisfranc only described amputations through the tarsometatarsal joint, and the associated joint injury was first described by Jacques Lisfranc de St. Martin in the Napoleonic Wars. Anatomically, this joint complex consists of 3 cuneiforms, 3 first metatarsals, and a cuboid. The articulation of the cuneiforms and the metatarsals forms a very stable structure that allows minimal motion at the joint. The midfoot is essential in providing both a stable foot in weightbearing as well as a mobile adapter during ambulation on uneven terrain. Battlefield injuries were often from having a mounted soldier fall from his horse with his foot still in the stirrup. Lisfranc amputations were commonly done in very proximal foot injuries to prevent the short, hyperpronated foot that is unsuitable for weightbearing. This injury mechanism has changed; it is no longer seen in motor vehicle accidents with the advent of a crash pad mounted on the steering wheel. Now, Lisfranc fractures are resulting from high-velocity injuries such as motor vehicle accidents and industrial accidents. These high-energy injuries can result in a spectrum of injury ranging from simple ligament disruption to complex fracture dislocations. The type of injury is often missed on the initial presentation. A study from the British Journal of Bone and Joint Surgery found that 20% of patients had undergone a missed or delayed diagnosis of their Lisfranc injury. An untreated injury can eventually lead to the collapse of the midfoot and arthrosis. Step deformity is often seen in any type of Lisfranc instability. This has led to a call for an improved classification of these injuries to help guide treatment. Thus, it was W. Beertolotti, back in 1986, who suggested that a new classification needed to be based on both radiographic and clinical findings. This has led to various classification systems, the most popular to this day is the classification guide by Hardcastle and colleagues.

Understanding Lisfranc Fracture Dislocation

A high index of suspicion is critical when evaluating foot injuries. Lisfranc injuries are often initially misdiagnosed as sprains leading to prolonged periods of pain and disability. A patient with a Lisfranc injury will have general foot pain and difficulty bearing weight. Swelling will occur on the top of the foot and there may be some bruising on the bottom of the midfoot. Due to the disruption of the normal anatomy, the arch of the foot may collapse. This is best seen by comparing the injured foot to the non-injured foot. Often times, the injury is more readily apparent in the acute setting. Patients and physicians should take note if what at first seemed to be a minor injury is taking an abnormal amount of time to heal.

Lisfranc fracture dislocations occur at the tarsometatarsal joint complex. This region in the foot represents the articulation between the midfoot and forefoot. The articulation is composed of three facets on the proximal (rear) part of the first through third cuneiforms, and the corresponding distal (forward) part of the cuboid and the five metatarsal bases. The articulation allows for a minimal degree of movement and plays a crucial role in maintaining the structure of the arch during gait. Ligamentous injuries disrupt the alignment of the articulation and can be more debilitating than fracture dislocations. Pure ligamentous injuries may also occur in the Lisfranc region. These injuries are difficult to diagnose and treatment protocols are not well defined. Sprains only involve a stretching of the ligaments with no tearing, while subluxations denote partial ligamentous disruption with partial joint dislocation.

Lisfranc Joint Complex and Ligamentous Injuries

The Lisfranc joint complex is the anatomic area of the foot involving the articulation between the midfoot and forefoot. There are three joints in this area which include the 1st and 2nd tarsometatarsal (TMT) joints and the 3rd, which is also known as the cuneonavicular joint. The Lisfranc joint complex is named after Jacques Lisfranc de St. Martin, a French surgeon who served in the Napoleonic army. He described an amputation performed through this area in soldiers who fell from a seated position from the high platform of a horse with the foot fixed within a stirrup. It’s believed that this type of injury, though rarely seen today, would likely result in a Lisfranc fracture dislocation. The injury is uncommon and often is missed or diagnosed late. This can result in development of disabling arthritis of the affected joint. Lisfranc injuries are caused by a twist or impact to the foot. They can occur in a variety of settings including the workplace, motor vehicle accidents, motorcycle crashes, horse riding accidents and athletic activities such as football and windsurfing. In athletic individuals, cleated shoes have been associated with Lisfranc injuries. The patient will typically complain of pain and swelling in the midfoot after an injury. Walking is difficult and bruising may be apparent on the top and/or bottom of the foot. The examination will reveal pain and difficulty with weight bearing. With severe ligamentous injuries or fractures, the foot may widen and a dislocation may be apparent. An x-ray is the best way to identify a Lisfranc injury. In some cases, the injury is not initially apparent and the x-ray may need to be repeated in 2 weeks. In these cases, a comparison with the opposite foot is helpful. High quality x-rays with a view from the top are the most accurate way to identify a Lisfranc injury. If the diagnosis is unclear or if more information is needed about associated injuries, a CT or MRI may be ordered.

Signs and Symptoms of a Lisfranc Injury

Bruising or swelling on the top of the foot is a sign of a Lisfranc injury. Pain in the midfoot when standing or during other movements can be a symptom of a Lisfranc injury. The pain may subside after a period of rest, but it is likely to return after activity. In some cases of severe Lisfranc injury, the pain in the midfoot may be too intense to put weight on the affected foot. Additionally, the pain can be focused on one spot in the midfoot, or there can be a more generalized soreness. Pain on the bottom of the foot in the midfoot area can also be characteristic of a Lisfranc injury. A patient may have difficulty walking or an abnormal, awkward gait. The patient may feel as if the midfoot is wider or higher than the other foot. In cases of severe Lisfranc injury, the injury to the midfoot may alter the biomechanics of the foot, leading to increased stress on the involved joint and adjacent joints. This can lead to degenerative arthritis. An individual has sustained a Lisfranc injury and is unable to identify a specific onset of pain, but has persistent midfoot pain due to a prior injury.

Diagnosis through Physical Examination and CT Scan

Frequently the findings from a physical examination can indicate to a healthcare provider that a Lisfranc injury has occurred. If the physical examination suggests a Lisfranc injury, the diagnosis will be confirmed with a 2-view X-ray of the foot. The X-ray will be best viewed if it includes the lateral and axial views of the foot. Magnetic Resonance Imaging (MRI) is now becoming the standard imaging modality for patients with a suspected Lisfranc injury. It has the advantage of allowing evaluation of soft tissue structures as well as bony anatomy. MRI has been shown to be highly accurate in diagnosing complete ligament tears, which is the most significant and serious injury to the Lisfranc joint. Published reports have shown that missed or delayed diagnoses of Lisfranc injuries occur in approximately 20% of all cases, primarily due to misunderstanding or misinterpretation of X-ray findings. High clinical suspicion of a Lisfranc injury and a history typical of this injury should prompt the practitioner to seek a weightbearing X-ray or referral without delay to a foot and ankle specialist. Configuration changes in the anatomy of the middle bony anatomy of the foot from initial films would also have bearing on obtaining additional radiographic imaging. Radiographs are still the initial and most common imaging study performed for a Lisfranc injury. High-quality AP, lateral, and 45 degrees oblique views are sufficient in many cases to determine an injury of the Lisfranc joint. However, routine radiographs may not accurately diagnose a Lisfranc injury because the midfoot often appears normal on X-ray even when significant ligamentous injury has occurred. In a recent study comparing radiography to CT scan for detection of Lisfranc injury, it was found that radiographs had low sensitivity and low positive predictive value compared to CT scan. A CT scan with 3-D reconstruction of a Lisfranc injury has been found to be more accurate than radiographs, and studies have demonstrated that a CT scan can evaluate the extent of a Lisfranc injury, classify the injury according to severity, and can be used to preoperatively plan out a reduction or a fusion of the Lisfranc joint. An initial 3-view X-ray is still useful in determining common associated fractures around the Lisfranc joint or with the midfoot. However, with the possibility of surgery and the ability for the patient to weightbear with little to no immobilization, CT scans are becoming more common and are sometimes the preferred imaging study. An administrative title search and a 2-word abstract are sufficient for a CT negative survey. An additional study with reconstructions is usually not indicated.

Treatment Options for Lisfranc Fracture Dislocation

Operative treatment and open reduction Anatomical reduction and stable internal fixation is being increasingly recognized as a decision for the treatment of Lisfranc injuries, in particular for subtle instability. With advances in techniques and implants, operative treatment has provided patients the possibilities of restoring normal anatomy and function, as well as an aggressive rehabilitation program and possibly a quicker return to work. An open reduction internal fixation is indicated for any intra-articular trauma. On the other hand, primary arthrodesis is an alternative for patients with severe arthritis that has resulted from a Lisfranc joint injury.

Non-operative treatment for Lisfranc injuries Non-operative treatment for a Lisfranc injury is indicated for any ligament sprain or extra-articular fracture, regardless of the stabilization of the joints. Treatment is aimed at preserving the current anatomical alignment of the joints and to restore optimal function of the foot. Immobilization with a non-weight bearing short leg cast or a boot and no change in position of the foot and ankle is required for six weeks. The patient can gradually start to put weight on the foot and try range of motion exercises at this point. Pain is the limiting factor of the rehabilitation and it should be made clear to the patient that it might take 3-4 months for the pain to be at a manageable level. Although long-term results for non-operative treatment have been encouraging, some patients, particularly those with ligament injuries, may develop late onset of arthrosis and deformity of the midfoot.

Non-Operative Treatment for Lisfranc Injuries

Non-operative care for Lisfranc injuries has conventionally been the treatment of choice. However, because of poor results, it has become more popular to treat these injuries with surgical intervention. Isolated ligament injuries may do well with cast immobilization; however, most injuries result in varying degrees of instability between the medial cuneiform and base of the 2nd metatarsal. This represents an injury to the “Lisfranc” ligament complex, which is the keystone stabilizing the arch of the foot. Studies have shown that even with 3-4 mm of diastasis between the 1st and 2nd metatarsal base, stable reduction and maintaining the reduction are difficult to achieve without surgical stabilization. Step cut and displacement type fractures of the medial c-1 or cuneiform injury do best with ORIF to re-establish joint congruency and typically do poorly if allowed to collapse and arthrose. Isolated fractures of the bases of 2nd-4th metatarsals can usually be treated non-operatively, but may require percutaneous reduction and screw placement to maintain reduction in an active patient. Open reduction and internal fixation, as well as primary arthrodesis, have developed into broadly accepted treatment for primarily though not exclusively. It has been stated that a patient who would like to return to pre-injury activity level and demands minimal midfoot arthrosis should be offered surgical intervention, which will allow for anatomic reduction and stable fixation. Closed reduction and primary arthrodesis have been known to provide acceptable results in low demand patients due to minimal dissection and restoration of joint function, but likely will not obtain an anatomic reduction.

Operative Treatment and Open Reduction

Operative treatment of Lisfranc joint injury has gained more popularity and success in these types of injuries. In recent studies comparing operative and nonoperative results of high-energy Lisfranc injuries, the authors have found better results in those who underwent ORIF. These studies have discussed operative treatments including primary arthrodesis, ORIF of individual joints and the use of mini external fixator, but the good results obtained from these treatments were related to anatomic reduction and stable internal fixation. Anatomic reduction indicated restoration of the normal anatomy of the affected joints and stable internal fixation implying that the reduction is maintained and secured until healing process occurs. This can result in a less residual pain and a less radiographic posttraumatic changes and abnormal findings in the future. ORIF has often been performed with screws and plate and screws fixation and has yielded good results. But due to recent development of technologies and equipment use, mini fragment and small fragment screw and plate fixation have been preferred as the incisions required are small and soft tissue pain and damage can be reduced. It is also known that the smaller the fragment that is fixed, the more biomechanically solid the construct is. This results in an early mobilization of the joints and restoration of the foot function. Rehabilitation can be started earlier and the patients are able to return to work in a shorter period of time. The operative treatment procedures have been chosen very carefully depending on the types of the injuries and patients. Primary arthrodesis indicated fusion of the joint and is usually best for those who have advanced degenerative changes in the joints or those who have previous injuries and fulfill the demands of high level athletes for a quick return to work. This treatment is not recommended for young patients and the types of the injury that is associated with acute traumatic joint injury as the early arthritis changes will have negative effects for fusion of the joints in young and middle aged patients. Open reduction and internal fixations are best for those who have displaced fractures, fracture dislocations, or subluxations of the joints with or without ligament injuries. It is known that the fixation of the ligament injuries is important for the restoration of the normal foot function but recent studies suggest that primary ligament repair is not necessary for those where the ligament reduces anatomically after the reduction of the fracture dislocations. If the ligament does not reduce anatomically, secondary repair of the ligament with screw and washer or suture button constructs may be considered. A temporary transarticular or K wires fixation is done before the ligament repair in order to maintain the reduction. Usually the K wire is the chosen method as it enables early mobilization of the joints. High grade ligament injuries involving the dorsal or plantar dislocation of the metatarsal to the tarsal bone with diastasis is called for ORIF of the joint and repair of the associated ligament injuries. This has been regarded as the most difficult situation to treat but the recent developments of the operative treatment methods have shown better results. In massive bony or ligamentous injuries with multiple joint dislocations and in patients with systemic illness and poor soft tissue and bone qualities, ORIF has often been chosen and staged procedure with gradual correction using frame external fixation and conversion to definitive internal fixation has been performed in order to avoid further complications.

Importance of Medial Cuneiform and Dorsal Ligaments

The Lisfranc fracture dislocation is a combination of ligamentous and bony injury involving the tarsometatarsal joint of the foot. The cuneiform and the intercuneiform ligament ensure a rigid interlocking of the midfoot bones during the gait cycle. The medial cuneiform is firmly fixed to the base of the first metatarsal by the plantar and dorsal ligaments. These ligaments prevent a dissociation of the first metatarsal from the medial cuneiform, which is crucial for maintenance of the longitudinal arch of the foot. Coughlin found that if a dorsiflexion force is applied to the midfoot when the first and second metatarsals are fixed, a fracture or complete tear of these ligaments will occur. This injury model is similar to a Lisfranc fracture dislocation, suggesting that rupture of the ligaments connecting the first metatarsal to the medial cuneiform is an essential component of a Lisfranc injury. The loss of stability provided by these ligaments is a critical component of a Lisfranc injury, and maintenance of reduction of the first metatarsal with the medial cuneiform is necessary for successful treatment.

Role of Metatarsal Bones in Lisfranc Joint Injury

This can be further classified by adding that the injury occurred with a pronation force about the hindfoot and in the setting of a severe hindfoot or midfoot injury. This patient would need a complete orthopaedic and podiatric examination with treatment decision making ensuing from assessment of the overall injury and impairment to the function.

An additional example is an avulsion of the metatarsal base by the peroneus longus. The injury dimension is thought of as an avulsion of the peroneus longus tendon off the 5th metatarsal or as a proximal 5th metatarsal fracture. Both would be viewed as disruptions to the articulation between the hindfoot and the forefoot but would be described by the peroneus longus surgeon as a peroneus longus tendon injury and by the orthopaedic surgeon as a metatarsal fracture. This essentially says the same thing as it describes the injury and the location of the injury shown by the two X-ray views.

An example is a tarsal fracture associated with a tibial pilon fracture. The classification system for the tibial pilon fracture is used along with the descriptive tarsal fracture designation. Treatment decision making would then be based on the higher degree of injury sustained at the tibial pilon.

Fractures and/or diastasis of the articulation between the middle columns and the medial column can be associated with injuries proximal or distal to the joint itself [1, 2]. For these injuries, there is no independent classification system. The pattern of injury can be described using the classification system for the articulation itself along with a description of the injury proximal or distal to the articulation. This is then followed by treatment decision making using the summary statements from the forensic analysis.

Recovery and Long-Term Effects

Rehabilitation of the Lisfranc injury is similar to that following surgery. After a period of immobilization in a cast or walking boot, a gradual return to weight-bearing is commenced and can take up to three months. During this time, patients may benefit from a single leg heel raise or towel scrunch exercises to maintain strength and prevent atrophy in the calf and intrinsic foot musculature. It is important to avoid excessive swelling of the foot during this period as it will impede rehabilitation, so continued rest, ice, and elevation of the foot is encouraged. Range of motion exercises can be commenced at six to eight weeks providing that there is enough evidence of start of bone healing at the fracture site. Full weight-bearing can be commenced at 10-12 weeks post-injury. An individualized exercise program mimicking that of the surgical patient would then be devised by the physiotherapist focusing on restoring function, strength, and balance of the foot. This may include specific motor control or strengthening exercises, aquatic therapy, and if indicated a gradual return to sport-specific activities.

Without proper treatment or with inaccurate reduction of this injury, patients may suffer from chronic pain and dysfunction of the foot and ankle. In a study by Myerson, the largest long-term follow-up study of missed Lisfranc injuries, 17 out of 21 patients interviewed had pain in their injured foot with increased time on their feet. Pain in the later years was attributed to post-traumatic arthritis of the midfoot with three of the patients having undergone arthrodesis of the midfoot for intractable pain. There is significant evidence that development of post-traumatic arthritis of the midfoot after Lisfranc injury is almost inevitable. In another study by Coss, 67% of patients had evidence of arthritic changes of the midfoot despite anatomic midfoot and/or tarsometatarsal joint and only 33% reporting good or excellent long-term results so patients may experience pain and disability despite anatomical restoration of the joint.

Chronic Pain and Foot & Ankle Function

After a Lisfranc injury, chronic pain or discomfort can impede the return of good foot function during daily activities. The amount of pain experienced is not always consistent with the severity of the injury, and some patients with severe injuries have surprisingly little pain. Pain in the Lisfranc joint may be due to arthritis that develops after this injury. The development of both early and late arthritis is common after a Lisfranc injury and this can cause persistent pain and swelling in the midfoot. Patients with late arthritis and persistent pain benefit from rigid type orthotics with a Lisfranc extension or an AFO to limit motion across the midfoot and offload the pressure in this area. An AFO is a custom-made brace that is formed to the leg and foot and can be used to limit motion in the joints of the leg. This can be helpful during the late stages of arthritis when motion across the midfoot worsens pain and inflammation. Patients who develop late arthritis at one joint in the Lisfranc complex but not the others may benefit from a fusion of that joint. Fusion of the joint is a procedure where the articular cartilage is removed and the bone ends are locked together with screws until the bone heals across the joint. Fusion is very effective in eliminating pain at a single joint; however, it also limits motion at that joint. Patients must weigh the benefits of pain relief with the potential functional limitations from restricted joint motion. Late arthritis in the entire Lisfranc complex with severe pain and disability is best treated with arthrodesis of all affected joints. This is a salvage procedure for the painful arthritic foot. The midfoot is compressed and held in a corrected position by screws until the joints heal together. After successful fusion of the affected joints, patients usually have very little pain, although there is some permanent loss of motion in the foot.

Rehabilitation and Physical Therapy for Lisfranc Injuries

Rehabilitation and subsequent physical therapy are critical in an attempt to restore the range of motion in the affected tarsometatarsal joints. A nonoperative approach should include remobilization of the foot with the use of a bone stimulator and physical therapy for range of motion and strengthening exercises of the tarsometatarsal joints. Weightbearing may not be a realistic goal for an individual sustaining a high energy Lisfranc injury, however, an attempt to normalize gait and mechanics of the foot is important in an attempt to decrease stresses across the midfoot. This can be done with or without surgery, but for the former is crucial in an attempt to avoid further degeneration of the joints. If this can be achieved within 3 months’ time and maintained, arthritis can be deferred for many years. If surgically addressed, care must be taken to not stagnate the foot with no remobilization downstream from the fusion. This is a pitfall for many long-term fusion patients and can be magnified when the fusion is extended to other joints of the foot. Postoperative therapy will vary, but should focus around remobilization of the affected joints and return to weightbearing either in a normal or custom orthotic shoe. Simulation of walking in a pool has been shown to be a less stressful, yet effective method for remobilization prior to returning to full weightbearing. This can often be timed or augmented into the above-mentioned bone stimulation therapy as new, more advanced techniques allow for protection of the wound.

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Sarah Taylor

Obstetrics & Gynaecology