Missing the Lisfranc fracture: a case report and review of the literature

Injuries to the tarsometatarsal joint are infrequent and the presentation varies. The radiologic evaluation can be difficult, and injuries are missed initially in up to one third of cases. A 60-year-old female sports instructor presented to the emergency department with a Lisfranc fracture dislocation of the foot as result of an indirect trauma. The patient attended to a hospital the day she sustained the injury, where the Lisfranc fracture was missed. At our hospital, the patient underwent immediate restoration of the dislocation. Because of swelling, internal fixation was applied 2 weeks later. Postoperatively, the patient was mobilized in a non-weight-bearing plaster cast for 6 weeks, continued by progressive weight-bearing in a walker. The fixation screws were removed 3 months after surgery. Lisfranc fractures are rare injuries and can be missed at first sight. Careful clinical examination and radiographs in 3 different planes are required to identify the injury. Computed tomography might be helpful when the findings from the above-mentioned examinations are inconclusive. Operative treatment, including anatomic reduction and fixation, is required in almost all cases to achieve the best satisfactory result. Long-term complications include secondary arthritis and foot deformities, which can be treated by foot ortheses or arthrodesis.     

Verletzungen der Fußwurzel, Luxationen und Frakturen im Lisfranc-Gelenk

Lisfranc injuries are rare, accounting for under 1% of all fractures. In 90% of cases the dislocation is combined with a fracture, while in the remaining 10% the ligaments only are affected. The injury can present in various ways. Isolated complex foot trauma is not difficult to diagnose, but in more than 20% of all Lisfranc luxations the diagnosis is missed. This is because when confronted with a multiply traumatised patient physicians concentrate on any life-threatening injuries and not on the foot, but the diagnosis of Lisfranc injury is very often missed even after low-energy trauma because the presentation is occult. In addition to the history, knowledge of the condition of the soft tissues and skill in the interpretation of X-rays and also of the results of computer tomography are necessary. The treatment of choice is open reduction and internal fixation with Kirschner wires ore single screws. Concomitant compartment syndrome is present in up to 60% of cases. Good functional results can be achieved by timely diagnosis, early internal fixation with anatomical reduction and consistent management of soft tissue.     

Combined Medial Column Primary Arthrodesis,Middle Column Open Reduction Internal Fixation,and Lateral Column Pinning for Treatment of Lisfranc Fracture-Dislocation Injuries

Lisfranc fracture-dislocation can be a devastating injury with significant long-term sequelae, including degenerative joint disease, progressive arch collapse, and chronic pain that can be potentiated if not effectively treated. We present a case to demonstrate our preferred surgical approach, consisting of combined medial column primary arthrodesis, middle column open reduction internal fixation, and lateral column pinning, with the primary goal of minimizing common long-term complications associated with Lisfranc injuries. We present the case of a typical patient treated according to this combined surgical approach to highlight our patient selection criteria, rationale, surgical technique, and operative pearls. A 36-year-old male who had sustained a homolateral Lisfranc fracture-dislocation injury after falling from a height initially underwent fasciotomy for foot compartment syndrome. The subsequent repair 16 days later involved primary first tarsometatarsal joint fusion, open reduction internal fixation of the second and third tarsometatarsal joints, and temporary pinning of the fourth and fifth tarsometatarsal joints. He progressed well postoperatively, exhibiting an American College of Foot and Ankle Surgeons forefoot score of 90 of 100 at 1 year after surgery with no need for subsequent treatment. Lisfranc fracture-dislocations often exhibit primary dislocation to the medial column and are conducive to arthrodesis to stabilize the tarsometatarsal complex. The middle column frequently involves comminuted intra-articular fractures and will often benefit from less dissection required for open reduction internal fixation instead of primary fusion. We propose that this surgical approach is a viable alternative technique for primary treatment of Lisfranc fracture-dislocation injuries.     

Premier métatarsien flottant : à propos d’un cas

Bipolar dislocation of the first metatarsal or floating first metatarsal is an exceptional foot injury. The authors report a case of open floating first metatarsal in a 32-year-old woman. The injury was resulting from a road traffic accident. The floating metatarsal was associated with a dorsal dislocation of the second tarsometatarsal joint and ipsilateral metatarsal fractures. The treatment included debridement followed by reduction of dislocations and stabilization by Kirschner wires. Fractures were closed reduced and the foot was immobilized in a below-the-knee posterior splint. Two years after surgery, the patient complained of intermittent pain in the midfoot and had osteoarthritis of the Lisfranc and first metatarsophalangeal joints.     

The floating metatarsal: first metatarsophalangeal joint dislocation with associated lisfranc dislocation

The authors report a case of an irreducible dorsal dislocation of the first metatarsophalangeal joint, with concomitant Lisfranc dislocation and fractures of the second, third, and fourth metatarsals. This combination has been reported only once in the literature. This extremely rare combined injury results in a floating metatarsal. Open reduction of the metatarsophalangeal joint dislocation and fixation of Lisfranc joint and metatarsal fractures with Kirschner wires was performed. One year after surgery, the patient is active and the first metatarsophalangeal joint is asymptomatic, but there is mild pain in the Lisfranc joint.     

Rekonstruktionsmaßnahmen nach veralteten Frakturen und Luxationen des Fußes

Inveterated fractures or dislocations of the foot which are defined as being more than 6–12 weeks old can be secondarily reconstructed anatomically in only very rare cases. All other cases need reorientation of all axes of the foot requiring single or combined joint fusion. In cases of significant posttraumatic bone necrosis the dead bone has to be radically resected and substituted by an autogenous bone graft from the iliac crest. Old cases of dislocation, for example after subtalar dislocation without anatomical reduction, need reorientation of the foot axes by performing arthrodesis. Subluxation of the medial Lisfranc joint after an unrecognized rupture of Lisfranc ligament can be controlled later by anatomical repair of this ligament by using half of the extensor digitorum longus tendon and thus avoiding arthrodesis.     

Rekonstruktionsmaßnahmen nach veralteten Frakturen und Luxationen des Fußes

Inveterated fractures or dislocations of the foot which are defined as being more than 6–12 weeks old can be secondarily reconstructed anatomically in only very rare cases. All other cases need reorientation of all axes of the foot requiring single or combined joint fusion. In cases of significant posttraumatic bone necrosis the dead bone has to be radically resected and substituted by an autogenous bone graft from the iliac crest. Old cases of dislocation, for example after subtalar dislocation without anatomical reduction, need reorientation of the foot axes by performing arthrodesis. Subluxation of the medial Lisfranc joint after an unrecognized rupture of Lisfranc ligament can be controlled later by anatomical repair of this ligament by using half of the extensor digitorum longus tendon and thus avoiding arthrodesis.     

Lisfranc fracture dislocation in a child

A case of Lisfranc fracture dislocation complicated by compartment syndrome is reported in a 9-year-old boy who fell from a 5 ft high wall which subsequently collapsed onto him crushing his lower limbs. The patient also sustained an undisplaced, open fracture of the contralateral tibia. The Lisfranc fracture dislocation was treated with open reduction and internal fixation using Kirschner wires (K-wires). Fasciotomy was performed to decompress the foot. The open tibia fracture was treated with wound debridement and plaster cast. The K-wires were removed at 10 weeks follow up. The patient had no complaints on examination and radiographs revealed good evidence of healing. We emphasize the importance of prompt diagnosis and treatment.     

一期内固定治疗C型Lisfranc骨折脱位疗效分析

目的研究分析微型钢板结合空心钉辅助克氏针一期内固定治疗24例MyersonC型lisfranc骨折脱位患者的中短期疗效。方法2006年6月至2011年9月,采用微型钢板结合空心钉辅助克氏针一期内固定治疗24例MyersonC型Lisfranc骨折脱位患者（20-50岁,平均29．24±5．32岁）,其中（C1型16例,C2型8例。根据美国足踝骨科协会（AOFAS）踝后足评分和疼痛视觉模拟评分（VAS）评价治疗效果。结果术后24例均获10-49个月（平均11．32±7．32个月）随访。手术时间平均80．3±11．2min。X线片检查显示24足均获解剖复位,足弓形态恢复正常。所有骨折皆一期愈合,无再次骨折脱位情况发生。术后2例出现浅表感染,2例出现皮缘坏死,2例出现足拇趾外翻畸形,5例出现负重及行走痛（2例较轻,3例口服消炎止痛药物可明显缓解,均不影响生活）。末次随访时AOFAS评分为68-98分,平均81．35±3．24分;C1、C2型评分差异无统计学意义（P=0．751）。VAS评分为0～6分,平均3．6±0．5分。结果优13例,良8例,一般2例,差1例,优良率为87．5％。结论采用微型钢板结合空心钉辅助克氏针内固定治疗C型Lisfranc骨折脱位,可达到一期解剖复位固定效果。尽管仍存在一些并发症,但对症处理效果满意,整体疗效良好。     

Newly developed anatomical and functional ligament reconstruction for the Lisfranc joint fracture dislocations: A case report

A 15-year-old male complained of pain in the left foot that occurred when changing direction while running and at presentation, he had difficulty in walking due to pain and swelling. Plain X-ray of the foot revealed a Myerson Type B2 Lisfranc fracture dislocation, and 3-D computed tomography (CT) revealed proximal fractures of the 2nd–4th metatarsals. The Lisfranc ligament was anatomically reconstructed using a graft of the gracilis tendon. During aftercare, partial weight bearing was permitted at 6 weeks postoperatively and full weight bearing at 8 weeks postoperatively. The patient resumed sporting activities 3 months postoperatively. A plain X-ray taken 12 months postoperatively showed favorable joint congruency, and the patient scored 100 points on the Japanese Society for Surgery of the Foot standard rating system midfoot scale. Our anatomical ligament reconstruction is a useful new method of anatomical reduction and maintenance, and it shortens the duration of aftercare.     

Primary internal fixation and soft-tissue reconstruction in the treatment for an open Lisfranc fracture-dislocation

The importance of anatomical reduction for improved outcome has been recognised in the management of Lisfranc injuries. Operative fixation is indicated in case of dislocation or unstable ligamentous injury, because discongruity of the Lisfranc joint can lead to deleterious functional outcome. Screws are the recommended method of fixation of the medial en middle column, and K-wires are used for stabilisation of the unstable lateral column. Primary arthrodesis can provide advantages in pure ligamentous injury. In the management of complex open Lisfranc fractures, external fixation with K-wires can be used, but often results in a high percentage of arc deformities and functional limitations. In recent years, there is a progressive change from external to internal fixation in primary stabilisation of open fractures. This case report describes the treatment for a grade III open Lisfranc fracture-dislocation by use of primary internal fixation and soft-tissue reconstruction.     

手术治疗Lisfranc骨折脱位临床体会

目的探讨切开复位内固定治疗Lisfranc骨折脱位的临床经验。方法自2001年3月至2009年3月,我科对37例Lisfranc骨折脱位患者切开复位皮质骨螺钉配合克氏针内固定治疗。其中男25例,女12例,年龄17～61岁;新鲜损伤33例,陈旧损伤4例。结果37例获得随访,随访时间24-49个月,平均28个月。采用美国矫形足踝协会的评分标准进行评价,好24例,较好11例,差2例。结论对于Lisfranc骨折脱位应手术治疗,解剖复位和坚强内固定是获得良好疗效的必要条件,陈旧性损伤应行关节融合术。     

Dorsal Dislocation of the Intermediate Cuneiform with Fracture of the Lisfranc Joint: A Case Report

Tarsal cuneiform dislocation in association with Lisfranc fracture-dislocation is a rare pedal injury. In this report, we describe the case of a patient who sustained a dorsal dislocation of the intermediate cuneiform in association with tarsometatarsal fracture-dislocation following traumatic axial loading and torsion of his foot. A satisfactory outcome was achieved by treating the injury by means of closed reduction and percutaneous Kirschner wire fixation. ACFAS Level of Clinical Evidence: 4.     

Isolated injury of the second tarsometatarsal joint. A case report

Injuries to tarsometatarsal (Lisfranc) joints are subtle, potentially disabling, and are still often overlooked. This case report of a rare isolated second Lisfranc joint dislocation (LJD) in a 46-year-old woman illustrates the typically subtle roentgenographic findings. A careful scrutiny of the base of the second metatarsal bone, especially on the lateral roentgenogram, shows alignment with the middle cuneiform. On an oblique view of the foot, the fourth metatarsal base should be aligned to the medial edge of the cuboid. Closed reduction of LJD is often unsuccessful and, if achieved, is often unstable. Soft-tissue or chondral fragment interposition impedes reduction. Open reduction and internal fixation are recommended.     

早期切开减压并螺钉固定治疗Lisfranc损伤并足骨筋膜室综合征

目的:探讨早期切开减压并螺钉固定治疗Lisfranc损伤并足骨筋膜室综合征的临床疗效.方法:回顾性分析2017年1月至2018年12月收治的5例Lisfranc损伤并足部骨筋膜室综合征患者的临床资料,其中男4例,女1例;年龄19～62岁.均为闭合性损伤.受伤至就诊时间1～14h.根据Myerson分型法,A型1例,B型...     

Metatarsus

The metatarsus of the human foot does not consist solely of the five metatarsals, but also includes the Lisfranc joint in the proximal direction, the five metatarso-phalangeal joints of the toes further distally, and the sesamoid bones. Possible corrections, such as arthrodesis for realignment following malunion, are observed mostly after Lisfranc dislocation fractures that have gone unrecognised or been inadequately treated. Bony malalignment of the metatarsals is relatively rare overall, arising mostly when metatarsal heads have been too far towards the plantar surface after healing. This leads to considerable problems with metatarsal head pain, so that improvement cannot be expected except from a deflecting osteotomy. Nonunions are sometimes following a conservatively treated avulsion fracture at the base or after a Jones fracture, which can generally be healed by freshening, locoregional cancellous bone transplantation, and tension wiring or plating. Even when an old fracture of a sesamoid bone has not healed and there is still a gap a secondary correction with miniscrews and/or tension wiring can benefit the patient greatly.     

Arthrodesis versus ORIF for Lisfranc fractures

The Lisfranc joints make up the bony structural support of the transverse arch in the midfoot and account for approximately 0.2% of all fractures. Early recognition and treatment of this injury are paramount to preserving normal foot biomechanics and function. Controversy exists regarding the optimal treatment of patients with Lisfranc injuries, particularly when the instability is entirely ligamentous.The authors performed a qualitative, systematic review of the literature to compare the 2 most common procedures for Lisfranc fractures: primary arthrodesis and open reduction and internal fixation (ORIF). Six articles with a total of 193 patients met the inclusion criteria. At 1-year follow-up, the mean American Orthopaedic Foot and Ankle Society score of ORIF patients was 72.5 and of arthrodesis patients was 88.0. Fisher's exact test revealed no significant effect of treatment group on the percentage on patients who had an anatomic reduction (P=.319).This study highlights that both procedures yield satisfactory and equivalent results. A slight advantage may exist in performing a primary arthrodesis for Lisfranc joint injuries in terms of clinical outcomes.     

陈旧性Lisfranc损伤的成因与治疗

目的 分析陈旧性Lisfranc损伤的形成原因,探讨其手术治疗方法及效果. 方法2004年8月至2008年6月共收治20例陈旧性Lisfranc损伤患者,男16例,女4例;年龄21～49岁.术前均行CT三维重建,按照Myerson分型:Ⅰ型3例,Ⅱ型13例,Ⅲ型4例.17例患者行切开复位内固定,采用克氏针或螺钉固定,3例行关节融合术.术后按照Maryland足功能评分标准进行疗效评定. 结果 18例患者术后获6个月～4年(平均27个月)随访,2例失访.18例患者术后无内固定断裂、再骨折脱位等并发症发生.按照Maryland足功能评分标准评定疗效:66～96分,平均85分;其中优3例,良12例,可3例,优良率为83.3%.疗效欠佳的主要表现为中足疼痛、活动度减少. 结论影像学表现不典型、治疗不及时、方法选择有误等均可能造成陈旧性Lisfranc损伤.解剖复位、牢固内固定、重建足弓、恢复维持足部内外侧纵弓及横弓解剖形态是治疗的关键.     

钉板系统结合空心钉治疗C型Lisfranc损伤的疗效探讨

目的：探讨运用微型钢板结合空心钉治疗C型Lisfranc损伤的临床疗效。方法回顾性分析2009年8月至2014年6月运用微型钢板结合空心钉治疗的25例C型Lisfranc损伤病人的临床资料,其中男16例,女9例;年龄为19~62岁,平均为（39.6±11.7）岁。运用微型钢板坚强固定内侧柱、中间柱,以空心钉替代损伤的Lisfranc韧带,外侧柱予克氏针弹性固定;术后随访时采用美国足踝外科医师协会（AOFAS）踝与后足功能评分系统评价治疗效果。结果所有病人均获随访,随访时间为6~36个月（平均为12.5个月）,术后正、侧位及斜位X线片示所有病例均达到解剖复位,未出现再次脱位,未见伤口感染、皮缘坏死等并发症。其中3例出现钢板断裂,予以取出内固定。参照AOFAS踝与后足功能评分系统,优16例,良5例,可4例,优良率为84.0%。结论运用微型钢板结合空心钉治疗C型Lisfranc损伤,符合足部生物力学,避免了单纯螺钉、克氏针固定引起的断钉无法取出、固定不稳定等不良后果,可以达到良好的解剖复位,术后可早期行功能锻炼。尽管存在一些并发症,但总体疗效满意。     

Lisfranc fracture-dislocation in patients with multiple trauma: diagnosis with multidetector computed tomography

BACKGROUND: We assessed acute phase multidetector computed tomography (MDCT) findings of Lisfranc fracture-dislocations in patients with multiple trauma referred to a Level I trauma center over a 29-month period. METHODS: Two hundred and eighty two patients (208 male and 74 female) between the ages of 13 and 89 (mean 42) years had, at the request of emergency room physicians, MDCT of the foot and ankle after acute injury. RESULTS: A total of 21 Lisfranc fracture-dislocations were found in 19 (7%) patients. Two main injury mechanisms were established: falling from high places in 10 injuries (48%) and traffic accidents in five (24%). Primary radiographs were available in 17 (81%) feet, and four (24%) had false negative radiographic results when compared to MDCT. In all Lisfranc fracture-dislocations MDCT showed the joint anatomy and the extent of dislocation better than primary radiographs, and in six (46%) of 13 true positive primary radiographs, MDCT revealed additional occult fractures in the Lisfranc joint. Multidetector CT revealed additional occult fractures in other parts of the foot and ankle in six (35%) of 17 feet. CONCLUSIONS: Standard radiography remains a primary diagnostic modality in acute foot and ankle trauma. Multidetector CT with high-quality multiplanar reconstruction (MPR) is recommended as a complementary examination in high-energy injury in patients with multiple trauma or in patients in whom radiographic images are equivocal. This may reveal Lisfranc fracture-dislocations, show the extent of the fracture-dislocation, and reveal occult fractures in other parts of the foot and ankle.