Lisfranc injury | |
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Other names | Lisfranc fracture, Lisfranc dislocation, Lisfranc fracture dislocation, tarsometatarsal injury, midfoot injury |
An X-ray of a Lisfranc injury | |
Specialty | Orthopedics |
A Lisfranc injury, also known as Lisfranc fracture, is an injury of the foot in which one or more of the metatarsal bones are displaced from the tarsus. [1] [2]
The injury is named after Jacques Lisfranc de St. Martin, a French surgeon and gynecologist who noticed this fracture pattern amongst cavalrymen in 1815, after the War of the Sixth Coalition. [3]
The midfoot consists of five bones that form the arches of the foot (the cuboid, navicular, and three cuneiform bones) and their articulations with the bases of the five metatarsal bones. It is these articulations that are damaged in a Lisfranc injury. Such injuries typically involve the ligaments between the medial cuneiform bone and the bases of the second and third metatarsal bones, and each of these ligaments is called Lisfranc ligament. [4]
Lisfranc injuries are caused when excessive kinetic energy is applied either directly or indirectly to the midfoot and are often seen in traffic collisions or industrial accidents. [5]
Direct Lisfranc injuries are usually caused by a crush injury, such as a heavy object falling onto the midfoot, or the foot being run over by a car or truck, or someone landing on the foot after a fall from a significant height. [6] Indirect Lisfranc injuries are caused by a sudden rotational force on a plantar flexed (downward pointing) forefoot. [5] Examples of this type of trauma include a rider falling from a horse but the foot remaining trapped in the stirrup, or a person falling forward after stepping into a storm drain. [6]
In athletic trauma, Lisfranc injuries occur commonly in activities such as windsurfing, kitesurfing, wakeboarding, or snowboarding (where appliance bindings pass directly over the metatarsals). [7] American football players occasionally acquire this injury, and it most often occurs when the athlete's foot is plantar flexed and another player lands on the heel. This can also be seen in pivoting athletic positions such as a baseball catcher or a ballerina spinning.[ citation needed ]
In a high energy injury to the midfoot, such as a fall from a height or a motor vehicle accident, the diagnosis of a Lisfranc injury should, in theory at least, pose less of a challenge. There will be deformity of the midfoot and X-ray abnormalities should be obvious. Further, the nature of the injury will create heightened clinical suspicion and there may even be disruption of the overlying skin and compromise of the blood supply. Typical X-ray findings would include a gap between the base of the first and second toes. [8] The diagnosis becomes more challenging in the case of low energy incidents, such as might occur with a twisting injury on the racquetball court, or when an American Football lineman is forced back upon a foot that is already in a fully plantar flexed position. Then, there may only be complaint of inability to bear weight and some mild swelling of the forefoot or midfoot. Bruising of the arch has been described as diagnostic in these circumstances but may well be absent. [9] Typically, conventional radiography of the foot is utilized with standard non-weight bearing views, supplemented by weight bearing views which may demonstrate widening of the interval between the first and second toes, if the initial views fail to show abnormality. Unfortunately, radiographs in such circumstances have a sensitivity of 50% when non-weight bearing and 85% when weight bearing, meaning that they will appear normal in 15% of cases where a Lisfranc injury actually exists. [10] In the case of apparently normal x-rays, if clinical suspicion remains, advanced imaging such as magnetic resonance imaging (MRI) or computed tomography (CT scan) is a logical next step. [11]
There are three classifications for the fracture: [12]
Options include operative or non-operative treatment. One study claims that in athletes, and if the dislocation is less than 2 mm, the fracture can be managed with casting for six weeks. [13] The person's injured limb cannot bear weight during this period. In the majority of cases, early surgical alignment of bone fragments to their original anatomical position (open reduction) and stable fixation is indicated. [14] A 2005 study suggests that closed reduction and Kirschner wire (K-wire) stabilisation or open reduction and stabilisation - generally using screws to avoid the complication of K-wires and maintain a stable reduction - are the treatments of choice. [14]
According to a 1997 study, for severe Lisfranc injuries, open reduction with internal fixation (ORIF) and temporary screw or Kirschner wire fixation is the treatment of choice. [15] The foot cannot be allowed to bear weight for a minimum of six weeks. Partial weight-bearing may then begin, with full weight bearing after an additional several weeks, depending on the specific injury. K-wires are typically removed after six weeks, before weight bearing, while screws are often removed after 12 weeks. [15]
When a Lisfranc injury is characterized by significant displacement of the tarsometatarsal joint(s), nonoperative treatment often leads to severe loss of function and long-term disability secondary to chronic pain and sometimes to a planovalgus deformity. In cases with severe pain, loss of function, or progressive deformity that has failed to respond to nonoperative treatment, mid-tarsal and tarsometatarsal arthrodesis (operative fusion of the bones) may be indicated. [16]
During the Napoleonic Wars, Jacques Lisfranc de St. Martin encountered a soldier who had developed vascular compromise and secondary gangrene of the foot after a fall from a horse. [3] Subsequently, Lisfranc performed an amputation at the level of the tarsometatarsal joints, [3] and that area of the foot has since been referred to as the namesake "Lisfranc joint". [17] Although Lisfranc did not describe a specific mechanism of injury or classification scheme, a Lisfranc injury has come to mean a dislocation or fracture-dislocation injury at the tarsometatarsal joints. [18]
The foot is an anatomical structure found in many vertebrates. It is the terminal portion of a limb which bears weight and allows locomotion. In many animals with feet, the foot is a separate organ at the terminal part of the leg made up of one or more segments or bones, generally including claws and/or nails.
The metatarsal bones or metatarsus are a group of five long bones in the midfoot, located between the tarsal bones and the phalanges (toes). Lacking individual names, the metatarsal bones are numbered from the medial side : the first, second, third, fourth, and fifth metatarsal. The metatarsals are analogous to the metacarpal bones of the hand. The lengths of the metatarsal bones in humans are, in descending order, second, third, fourth, fifth, and first. A bovine hind leg has two metatarsals.
There are three cuneiform ("wedge-shaped") bones in the human foot:
Pes cavus, also known as high arch, is a human foot type in which the sole of the foot is distinctly hollow when bearing weight. That is, there is a fixed plantar flexion of the foot. A high arch is the opposite of a flat foot and is somewhat less common.
A bone fracture is a medical condition in which there is a partial or complete break in the continuity of any bone in the body. In more severe cases, the bone may be broken into several fragments, known as a comminuted fracture. A bone fracture may be the result of high force impact or stress, or a minimal trauma injury as a result of certain medical conditions that weaken the bones, such as osteoporosis, osteopenia, bone cancer, or osteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture.
A joint dislocation, also called luxation, occurs when there is an abnormal separation in the joint, where two or more bones meet. A partial dislocation is referred to as a subluxation. Dislocations are often caused by sudden trauma on the joint like an impact or fall. A joint dislocation can cause damage to the surrounding ligaments, tendons, muscles, and nerves. Dislocations can occur in any major joint or minor joint. The most common joint dislocation is a shoulder dislocation.
A Jones fracture is a broken bone in a specific part of the fifth metatarsal of the foot between the base and middle part that is known for its high rate of delayed healing or nonunion. It results in pain near the midportion of the foot on the outside. There may also be bruising and difficulty walking. Onset is generally sudden.
Neuropathic arthropathy, also known as Charcot joint after the first to describe it, Jean-Martin Charcot, refers to progressive degeneration of a weight-bearing joint, a process marked by bony destruction, bone resorption, and eventual deformity due to loss of sensation. Onset is usually insidious.
Morton's neuroma is a benign neuroma of an intermetatarsal plantar nerve, most commonly of the second and third intermetatarsal spaces, which results in the entrapment of the affected nerve. The main symptoms are pain and/or numbness, sometimes relieved by ceasing to wear footwear with tight toe boxes and high heels. The condition is named after Thomas George Morton, though it was first correctly described by a chiropodist named Durlacher.
A hip dislocation is when the thighbone (femur) separates from the hip bone (pelvis). Specifically it is when the ball–shaped head of the femur separates from its cup–shaped socket in the hip bone, known as the acetabulum. The joint of the femur and pelvis is very stable, secured by both bony and soft-tissue constraints. With that, dislocation would require significant force which typically results from significant trauma such as from a motor vehicle collision or from a fall from elevation. Hip dislocations can also occur following a hip replacement or from a developmental abnormality known as hip dysplasia.
The tarsometatarsal joints are arthrodial joints in the foot. The tarsometatarsal joints involve the first, second and third cuneiform bones, the cuboid bone and the metatarsal bones. The eponym of Lisfranc joint is 18th–19th-century surgeon and gynecologist Jacques Lisfranc de St. Martin.
The Lisfranc ligament is one of several ligaments which connects the medial cuneiform bone to the second metatarsal. Sometimes, the term Lisfranc ligament refers specifically to the ligament that connects the superior, lateral surface of the medial cuneiform to the superior, medial surface of the base of the second metatarsal.
The fifth metatarsal bone is a long bone in the foot, and is palpable along the distal outer edges of the feet. It is the second smallest of the five metatarsal bones. The fifth metatarsal is analogous to the fifth metacarpal bone in the hand.
Foot and ankle surgery is a sub-specialty of orthopedics and podiatry that deals with the treatment, diagnosis and prevention of disorders of the foot and ankle. Orthopaedic surgeons are medically qualified, having been through four years of college, followed by 4 years of medical school or osteopathic medical school to obtain an M.D. or D.O. followed by specialist training as a resident in orthopaedics, and only then do they sub-specialise in foot and ankle surgery. Training for a podiatric foot and ankle surgeon consists of four years of college, four years of podiatric medical school (D.P.M.), 3–4 years of a surgical residency and an optional 1 year fellowship.
March fracture is the fracture of the distal third of one of the metatarsals occurring because of recurrent stress. It is more common in soldiers, but also occurs in hikers, organists, and people whose duties entail much standing. March fractures most commonly occur in the second and third metatarsal bones of the foot. It is a common cause of foot pain, especially when people suddenly increase their activities.
The Ponseti method is a manipulative technique that corrects congenital clubfoot without invasive surgery. It was developed by Ignacio V. Ponseti of the University of Iowa Hospitals and Clinics, US, in the 1950s, and was repopularized in 2000 by John Herzenberg in the US and Europe and in Africa by NHS surgeon Steve Mannion. It is a standard treatment for clubfoot.
Comparative foot morphology involves comparing the form of distal limb structures of a variety of terrestrial vertebrates. Understanding the role that the foot plays for each type of organism must take account of the differences in body type, foot shape, arrangement of structures, loading conditions and other variables. However, similarities also exist among the feet of many different terrestrial vertebrates. The paw of the dog, the hoof of the horse, the manus (forefoot) and pes (hindfoot) of the elephant, and the foot of the human all share some common features of structure, organization and function. Their foot structures function as the load-transmission platform which is essential to balance, standing and types of locomotion.
Syndesmosis procedure is one of the more than twenty bunion surgeries currently being performed. While the majority of bunion surgeries involve the breaking and shifting of bones, syndesmosis procedure is one of few surgical techniques that use a soft-tissue or non-osteotomy (non-bone-breaking) approach to afford the same correction. More than 130 different surgical techniques have been described for correction of one single condition of the foot: the bunion deformity.
Orthopedic surgery is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal injuries, sports injuries, degenerative diseases, infections, bone tumours, and congenital limb deformities. Trauma surgery and traumatology is a sub-specialty dealing with the operative management of fractures, major trauma and the multiply-injured patient.
A Cuneiform fracture is an injury of the foot in which one or more of the Cuneiform bones are fractured. The annual incidence of cuboid fracture is 1.8 injuries per 100,000 population.