This issue of eMedRef provides information to clinicians on the pathophysiology, diagnosis, and therapeutics of Lisfranc injuries

Barnett, Tiffany

Chan, Jonathan

Diaz, Manual

English

University of Missouri: MOspace

Sports Lisfranc Injury Page 1 of 2    5.14.08 Lisfranc Injury  See also Lisfranc Fx/Dislocation  Background 1. Lisfranc joint:  o Articulation of first and second metatarsals medial/middle cuneiform 2. Lisfranc complex:  o Tarsometatarsal articulation of midfoot 3. Lisfranc ligament connects lateral surface of medial cuneiform to second metatarsal base 4. Disruption of Lisfranc ligament results in tarsometatarsal instability  Pathophysiology 1. Rare: <1% of all fractures 2. Occurs in 4% of football players 3. Athletes: low-energy loading mechanism  o Baseball player sliding into fixed base o Windsurfer/ equestrian hyperplantarflexing foot while foot caught in strap o Offensive lineman tackled from behind 4. General population: high-energy loading mechanism (MVA/ industrial trauma)  Diagnostics 1. 20% missed on ER evaluation 2. Physical exam  o Midfoot instability o Inability to bear wt o Plantar midfoot ecchymosis/ edema o Medial/ lateral tarsometatarsal region tenderness o Dorsalis pedis pulse/ cap refill must be evaluated 3. Radiography  o Wt-bearing AP, lateral, 30 degree oblique o Findings   Incr diastasis between base of first/ second metatarsal   Incongruity of first metatarsal lateral margin w/medial cuneiform lateral margin  Incongruity of second metatarsal medial margin w/middle cuneiform middle margin  Incr diastasis between medial and middle cuneiform  "Fleck Sign": small avulsion fracture of second metatarsal base or first cuneiform (occurs in 90% of injuries)  4. MRI/ CT: can be helpful in acute injuries 5. MRI: for evaluation of chronic injuries 6. Injury grading  o Grade I: joint pain, minimal swelling, no instability (most common) o Grade II: incr pain and swelling w/mild laxity, no instability o Grade III: complete ligamentous disruption, may be fracture/dislocation    Sports Lisfranc Injury Page 2 of 2    5.14.08 Therapeutics 1. Athlete will be sidelined for 12-16 wks w/conservative or operative tx 2. Grade I & II injury w/normal radiographs or metatarsal diastasis <2mm  o Conservative tx: cast immobilization or walking boot for 4-6 wks o Ambulation and rehabilitation should begin after immobilization o Repeat wt bearing X-rays to evaluate delayed joint separation if pain w/rehabilitation 3. Grade III injury or metatarsal diastasis >2mm  o Surgical referral for ORIF in all athletes o Immobilization for 8 wks o Partial wt-bearing for 4 wks o Full wt-bearing w/protective shoe/ well-molded orthotic 12 wks post immobilization o Hardware removal   12-16 wks in athletes <200 lbs  24 wks in athletes >200 lbs  Prognosis 1. Return to play  o Athlete faces 3-6 month recovery period o Do no clear until completely pain-free in sport-specific activities 2. Complications  o Post-traumatic arthritis o Misalignment o Pain w/wt bearing o Arch collapse 3. Career-ending injury if dx missed or severe complications arise  Patient Education 1. http://orthoinfo.aaos.org/topic.cfm?topic=A00162 2. http://orthopedics.about.com/cs/footproblems/a/lisfranc.htm  References  1. Burrroughs KE, Reimer CD, Fields KB. Lisfranc injury of the foot: a commonly missed diagnosis. Am Fam Physician 1998; 58(1):118-124. 2. Pommering TL, Kluchurosky L, Hall SL. Ankle and Foot Injuries in Pediatric and Adult Athletes. Prim Care Clin Office Pract 2005; 32: 133-161. 3. Umans HR. Imaging sports medicine injuries of the foot and toes. Clin Sports Med 2006; 25:763-780. 4. http://www.aafp.org/afp/980700ap/burrough.html 5. http://www.emedicine.com/orthoped/topic511.htm 6. https://ukhealthcare.uky.edu/cartilage/articles/practicalmgt.pdf   Authors:  Jonathan Chan, DO, Manual Diaz, DO, & Tiffany Barnett, MD  Editor:  Carol Scott, MD, University of Nevada Reno FPRP  

Lisfranc injury

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Lisfranc injury

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University of Missouri: MOspace