Lisfranc injuries – Causes, Symptoms, Diagnosis, Treatment

Lisfranc injuries also called Lisfranc fracture-dislocations, are the most common type of dislocation involving the tarsometatarsal joints of the foot and correspond to the dislocation of the articulation of the tarsus with the metatarsal bases and it (fracture-dislocation) involve disruption of ≥ 1 ligaments that stabilize the midfoot, sometimes disrupting ≥ 1 tarsometatarsal joints. The Lisfranc joint is comprised of the articulation between the first, second, and third metatarsals bones with the cuneiform bones. Injuries of the joint can range from complete tarsometatarsal displacement frequently with associated fractures and ligamentous tears to partial sprains with no displacement.

Classification

There are three classifications for the fracture:

1. Homolateral: All five metatarsals are displaced in the same direction. Lateral displacement may also suggest cuboidal fracture.
2. Isolated: one or two metatarsals are displaced from the others.
3. Divergent: metatarsals are displaced in a sagittal or coronal plane and may also involve the intercuneiform area and include a navicular fracture.

Subtypes

There are several types of Lisfranc fracture-dislocation:

• homolateral: a homolateral injury is a lateral displacement of the 1^st to 5^th metatarsals or of 2^nd to 5^th metatarsals where the 1^st MTP joint remains congruent
• divergent: a divergent injury is a lateral dislocation of the 2^nd to 5^th metatarsals with medial dislocation of the 1^st metatarsal
• isolated: this involves one or two metatarsals that dislocate dorsally in isolation

Causes

The midfoot consists of 5 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, and these articulations are damaged during a Lisfranc injury. Such injuries typically involve the ligaments between the medial triquetral and therefore the bases of the second and third metatarsal bones, and every of those ligaments is named a Lisfranc ligament. ^[rx]

• The repetitive impact – to the metatarsals bone with weight-bearing exercises cause microfractures, which consolidate to stress fractures.[rx]
• The most common location of metatarsal stress fractures – anatomically second metatarsal neck as it is less flexible and prone to torsional forces given its strong ligamentous attachment to the 1 and 2 cuneiforms and the second metatarsal bone is the longest of the metatarsals, subjected to the most force.[rx]
• Heavy impact – The force of a jump or fall down from height can result in a broken ankle. It can happen in metatarsal bone fractures even if you jump from a low height.
• Missteps – You can cause a fracture of the ankle if you put your foot down awkwardly abnormally. Your ankle might twist or roll your foot joint to the side as you put weight on it. It can also happen in stare up or stare down unawkwardly.
• Sports – High-impact sports such as football cricket, hockey, volley boll involve intense movements that place stress on the joints, including the ankle bone fracture examples of high-impact sports include, cricket, racer of the bike, soccer, football, Horseback riding, Hockey, Skiing Snowboarding In-line skating, Jumping on a trampoline and basketball.
• Car collisions – The sudden, heavy impact of a car accident, bike accident can cause metatarsal bone fractures. Often, these types of injuries need surgical repair. The crushing types of injuries common in car accidents may cause breaks that require surgical repair.
• Falls from height – Tripping, and falling when walking on uneven surfaces can break bones in your ankles and metatarsal bone, phalanges fractures, as can landing on your feet after jumping down from just a slight height.
• Missteps – Sometimes just putting your foot down the wrong way can result in a twisting injury that can cause a broken bone. Fracture also occurs when stairs up or stairs down, especially older people.
• Unconsciously Toilet Use – It is a very common and day by day increasing incidence of fracture of the ankle joint, foot bone, metatarsal bones, tarsal bone, phalanges, especially high comodo using time and lower limb fractures.
• High hell Use – It is the most common cause of fracture in the ankle, foot, lower limb fracture, especially for women, abnormal arch, foot angle, the lake of the flat foot, abnormal sole of your footwear, muscle, tendon, cartilage, ligament weakness in the knee, ankle joints.
• On a battlefield – with the increasing of technology, nuclear weapons, one country is involved in the war from one country to another country. On the battlefield, millions of armies and general people are falling in injury that is gradually causing ankle, foot, metatarsal, tarsal bone fractures.
• Have osteoporosis –  a disease of your bone that weakens your bones gradually due to inadequate intake of calcium or vitamin D.
• Weak low muscle mass or poor muscle strength – lack agility or older age muscle strength, mass, power, endurance become weak, and poor balance conditions make you more likely to fall and cause a fracture.
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing,  Skiing Snowboarding, in-line skating, Jumping, playing lead to fracture of the bone in the lower limb.

Symptoms

Symptoms of bone fractures include

• Intense pain, swelling, tenderness, limited range of motion is the first
• Pain with or after normal activity
• Pain that goes away when resting time and then returns when standing, walking, or during activity
• Pinpoint pain at the site of the fracture when touched
• Swelling but no bruising may be present if it becomes microtrauma
• Bruising or discoloration that extends to nearby parts of the foot bones.
• Pain with walking and weight-bearing
• Swelling in the heel area
• Pain may decrease with rest but increases again with activity.
• Pain at the site of the fracture, which in some cases can extend from the foot to the knee.
• Significant swelling may occur along the length of the leg or may be more localized.
• Blisters may occur over the fracture site after some days.
• Bruising that develops soon after the injury time.
• Inability to walk; it is possible to walk with less severe breaks, and fractures so never rely on walking as a test of whether or not a bone has been fractured.
• Change in the color and appearance of the ankle will look different from the other ankle.
• Bone protruding fracture through the skin is a sign that immediate emergency care is needed. Fractures that pierce the skin require attention because they can lead to severe infection and take a prolonged time to recover.
• This pain may occur or feel in the setting of acute trauma or repetitive microtrauma over weeks to months. One should be suspicious of stress fracture with pain or pain of worsening quality or duration over time.

Diagnosis

Laboratory tests should be done as an adjunct in overall medical status for surgical treatment.

• CBC, ESR test
• Random blood sugar, glucose, and routine diabetes test if the patient has diabetes mellitus.
• Microscopic urine examination test, and stool test.
• ECG, EKG test for heart abnormality is present
• Ultrasonography test in some cases.
• Normalized hemoglobin, hematocrit test
• Coagulation profile with bleeding time and coagulation time test, prothrombin time (PT) test for surgery if needed,
• Thromboplastin time and platelet counts will be needed for operative intervention.
• Serum creatinine test,
• Serum lipid profile
• Serum uric acid test

Imaging Test

Plain radiograph/CT

These injuries are well demonstrated on the quality views of the foot. Still, subtle injuries could also be missed and need further imaging like CT, MRI or radiographic stress views with forefoot abduction. CT is, however, favored because it also will demonstrate unsuspected associated fractures.

The key finding is malalignment of the second tarsometatarsal joint, like lateral displacement of the second metatarsal base on AP view and/or dorsal step-off check-in lateral view 10. a further abnormality is a diastasis >2 mm between the first and 2nd metatarsal bases 10.

Other possible findings are malalignment between the lateral border of the bottom of the first metatarsal and, therefore, the lateral border of the medial cuneiform; malalignment between the medial border of the bottom of the 4th metatarsal and the cuboid (on the oblique view); increased distance between the medial cuneiform and the 2nd metatarsal; and increased distance between the medial and intermediate cuneiforms (C2).

Associated fractures most frequently occur at the bottom of the second metatarsal, seen because of the fleck sign. they’ll even be seen within the 3rd metatarsal, 1st or 2nd cuneiform, or navicular bones.

If the diagnosis is unsure, it’s going to be useful to get weight-bearing x-rays and comparison views of the contralateral side.

Ultrasound

Useful for assessing the ligamentous injury. Non-visualization of the dorsal C1-M2 ligament and a C1-M2 distance >2.5 mm is indirectly indicative of a Lisfranc ligament tear and dynamic evaluation with weight-bearing may show widening of the space between C1 and M2.

MRI

Again could also be useful for assessing ligamentous injury, especially when there’s a high clinical concern with routine radiographs being inconclusive.

Treatment

Initial Treatment Includes

• Get medical help immediately – If you fall on an outstretched leg, play cricket gets into a car accident, or are hit while playing a sport and feel intense pain in your leg area, then get medical care immediately. Cause significant pain in your leg, foot, ankle joint, and part of your leg closer to the base of your leg. If the accident is major you keep your leg at the same heart position and then clean and treat any wounds on the skin of the injured leg.
• Aggressive wound care – It is very important for patients to reach a safe position with the proper ventilation needed for contaminated wounds. Injured are clear with disinfectant material [rx]
• ICE and elevation – It help for prevention swelling, edema
• Rest – Sometimes rest is all, that is needed to treat a traumatic fracture of the foot, ankle, tarsal and metatarsal fracture. Sometimes rest is the only treatment needed to eradicate healing of a stress or traumatic fracture of a metatarsal bone fracture.
• Compression – a bandage will limit swelling, edema, and help to rest the joint. A tubular compression bandage is frequently used but should be removed at night by easing it off gradually. Put it on again before you are from out of bed in the morning. Mild to moderate pressure that is not too uncomfortable or too tight, and does not stop blood flow, is ideal. Depending on the amount of swelling. pain, edema you may be advised to remove the bandage for good after 48 hours.
• Elevation – Elevation initially aims to limit and reduce any swelling. For example, keep the foot upright on a chair or pillow to at least hip level when you are sitting. When you are in bed, put your foot on a pillow. Sometimes rest is the only treatment that is needed, even in fractures.
• Splinting – The toe may be fitted with a splint to keep it in a fixed position.
• Rigid or stiff-soled shoes – Wearing strong stiff-soled shoes to protect the toe and help keep it properly positioned. Use of a postoperative splint, shoe, or boot walker is also helpful.
• Avoid the offending activity – Because fractures result from repetitive stress, the trauma it is important to avoid the activity that led to the fracture more seriously. Crutches or a wheelchair, or other types of supporting splint are sometimes required to offload weight from the foot to give it time to heal.
• Immobilization, casting, or rigid shoe – A stiff-soled shoe or another form of immobilization may be used to protect the fractured bone while it is healing. The use of a postoperative shoe or boot walker is also helpful.
  
• Casting, or rigid shoe – A stiff-soled shoe or another form of immobilization may be used to protect the fractured bone while it is healing. The use of a postoperative shoe or boot walker is also helpful.
• Stop stressing the foot – If you’ve been diagnosed with a stress fracture, avoiding the activity that caused it is important for healing. This may mean using crutches or even a wheelchair.

Do no HARM for 72 hours after injury

• Heat – Heat applied to fracture and injured side by hot baths, electric heat, saunas, heat packs, etc has the opposite effect on the blood flow. Heat may cause more fluid accumulation in the fracture joints by encouraging blood flow. Heat should be avoided when inflammation is developing in the acute stage. However, after about 72 hours, no further inflammation is likely to develop and heat can be soothing.
• Alcohol –  stimulates the central nervous system that can increase bleeding and swelling and decrease healing.
• Running and movement – Running and walking may cause further damage, and causes healing delay.
• Massage – A massage also may increase bleeding and swelling. However, after 72 hours of your fracture, you can take a simple message, and applying heat may be soothing the pain.

Medication

The following medications may be considered by your doctor to relieve acute and immediate pain, long term treatment

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any other cephalosporin/quinolone, meropenem antibiotic must be used to prevent infection or clotted blood removal to prevent further swelling, inflammation, and edema.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include first choice NSAIDs is Ketorolac, then Etoricoxib, then Aceclofenac, naproxen. As you are taking pain medication or NSAIDs, your doctor must prescribe a standard anti-ulcer drug, such as omeprazole, pantoprazole, esomeprazole, dexlansoprazole, etc.
• Muscle Relaxants –  These medications provide relief from spinal muscle spasms, spasticity.  Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, and cyclobenzaprine, may be prescribed to control postoperative muscle spasms, spasticity, stiffness, contracture.
• Calcium & vitamin D3 – To improve bone health, blood clotting, helping muscles to contract, regulating heart rhythms, nerve functions, and healing fractures. As a general rule, too absorbed more minerals for men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day to heal back pain, fractures, osteoarthritis.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, tingling sensation, and paresthesia.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tighten the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. The dosage of glucosamine is 15oo mg per day in divided dosage and chondroitin sulfate approximately 500mg per day in different dosages, and diacerein minimum of 50 mg per day may be taken if the patient suffers from osteoarthritis, rheumatoid arthritis, and any degenerative joint disease.[rx]
• Topical Medications and essential oil – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation in acute trauma, pain, swelling, tenderness through the skin. If the fracture is closed and not open fracture then you can use this item.
•  Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins in your body’s natural painkillers. It also helps in neuropathic pain, anxiety, tension, and proper sleep.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation. To heal the nerve inflammation and clotted blood in the joints.
• Dietary supplement – To eradicate the healing process from fracture your body needs a huge amount of vitamin C, and vitamin E. From your dietary supplement, you can get it, and also need to remove general weaknesses &  improved health.
• Cough Syrup – If your doctor finds any chest congestion or fracture-related injury in your chest, dyspnoea, post-surgical breathing problem, then advice you to take bronchodilator cough syrup.

What To Eat and What  to avoid

Eat Nutritiously During Your Recovery

All bones and tissues in the body need certain micronutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones and all types of fractures. Therefore, focus on eating lots of fresh food produce (fruits and veggies), whole grains, cereal, beans, lean meats, seafood, and fish to give your body the building blocks needed to properly repair your fracture. In addition, drink plenty of purified mineral water, milk, and other dairy-based beverages to augment what you eat.

• Broken bones or fractures bones need ample minerals (calcium, phosphorus, magnesium, boron, selenium, omega-3) and protein to become strong and healthy again.
• Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, sea fish, and salmon.
• Important vitamins that are needed for bone healing include vitamin C (needed to make collagen that your body essential element), vitamin D (crucial for mineral absorption, or machine for mineral absorber from your food), and vitamin K (binds calcium to bones and triggers more quickly collagen formation).
• Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, fried fast food, most fast food items, and foods made with lots of refined sugars and preservatives.

Surgery

Cases with displaced or unstable Lisfranc joint injuries bear surgical treatment in order to achieve anatomic reduction The threat of post-traumatic OA will depend on the quality of the reduction.

In high-energy injuries, similar as business accidents, it’s important to consider a possible cube pattern and, if the dubitation is high, perform a fasciotomy. If there’s a large delegation of the metatarsals, it’s necessary to perform an axial alignment and stabilization with Kirschner cables (K- cables) or an external fixator as a first measure in the exigency department. This approach will allow better mending of the soft napkins and will reduce the threat of a cube pattern.

The definitive surgical intervention must be remitted ten to 15 days until the mending of the soft apkins and the appearance of wrinkles on the skin ( wrinkle sign).

Our surgical fashion in Lisfranc injuries ( high or low energy)

We place the case in the supine position with a bumper under the ipsilateral ham and we use support to maintain the knee in 90º flexion, which helps us perform reduction and bone obsession.

We generally perform open surgery. However, we use a double approach, making a longitudinal gash in the first inter-metatarsal space and another longitudinal gash in line with the fourth metatarsal, If there’s the involvement of the third TMT or insecurity of the fourth or fifth metatarsals. We perform a reduction from the medium to the side direction. We start by reducing the first cuneiform-metatarsal joint with K- cables and bone obsession with two non-cannulated3.5-mm screws, from the first metatarsal to the first cuneiform. Also, we use an alternate screw from the first cuneiform to the first metatarsal.

The coming step is to reduce the space between the first and alternate metatarsals. To this end, we use a reduction clamp between the medium zone of the first cuneiform bone and the side zone of the alternate metatarsal, and we perform bone obsession with an anon-cannulated screw of 4 or4.5 mm from the first cuneiform to the base of the alternate metatarsal (Fig. 10). The coming screw goes from the alternate metatarsal to the alternate cuneiform once the joint has been reduced. Through the gash on the fourth metatarsal, the third tarsal-metatarsal joint is estimated and reduced if necessary. Bone obsession is performed using two crossed3.5-mmnon-cannulated screws or an a3.5-Amnon-cannulated screw and a K- line. Each joint must be stabilized with two screws or a screw and a K-wire.However, they will be stabilized with K- cables between the metatarsal and the blockish bone, which are removed at six weeks, If there’s an injury to the fourth and fifth metatarsals.

Intra-operative images (a) note the separation between the first and alternate metatarsals ( black arrow) that causes insecurity due to rupture of the Lisfranc ligament complex ( black line). (b) Reduction and check of the first intermetatarsal space.

Still,), we use rearward plates for the stabilization of the corresponding joint; still, If there’s a fracture or comminution of the bases of the metatarsals or of the cuneiform bones. In Lisfranc lesions that are purely ligamentous, we also perform this same surgical fashion.

Surgical treatment of Lisfranc lesion

(a) milled fracture of the alternate, third and fourth metatarsal bases. Although there was no clear increase inter-metatarsal space, there was ligamentous insecurity.

(b)Post-operative anteroposterior (AP) protuberance. ORIF of the first column was performed and stabilization of the alternate and third shafts with a Lisfranc screw and rearward plates. Osteosynthesis of the base of the fourth metatarsal was also performed. The joint between the fourth and fifth metatarsals and the cuboid weren’t fixed, given that they’re articulations of adaption to the ground and must have mobility.

(c)Post-operative side protuberance.

After the surgery, we immobilize the branch with a flake that’s maintained for two to three weeks. At that time, the aches are removed and the case uses an orthopedic-weight-bearing perambulator charge for four to six further weeks. During this period, the charge can be removed to perform ankle dorsiflexion exercises. After that period, we allow weight-bearing with a perambulator charge and an interior insole with a medium discharge bow for four further weeks. Sports exertion is allowed for eight to 12 months, depending on the clinical and radiographic elaboration. We don’t routinely perform tackle junking.

Osteosynthesis versus primary arthrodesis

The traditional treatment for Lisfranc lesions is open reduction and internal obsession (ORIF). Still, some authors believe that primary partial arthrodesis offers better results and a lower rate of operations. It has indeed been shown that Lisfranc lesions of purely ligamentous low energy have better functional results with a primary arthrodesis.1 – 4

In a meta-analysis, Smith et al plant no significant differences in terms of functional results or in terms of non-anatomical reduction when comparing the two ways.19 There were only significant differences in the there-operation rate for tackle junking when ORIF was used.

The rate ofre-operations can impact decision– timber. Still, Buda et al in a recent composition concluded that if we count tackle junking, cases with Lisfranc lesions treated with ORIF don’t have an advanced rate ofre-operation (29.5) compared with those who are treated with a primary partial arthrodesis (29.6).20 The most common causes ofre-operation are post-traumatic OA in cases treated with ORIF and non-union in those treated with primary arthrodesis.

In a prospective and randomized trial conducted in cases with purely ligamentous Lisfranc lesions, in those for whom a Lisfranc arthrodesis was performed, better functional results were observed in the short and medium-term, with cases reaching up to 92 of their former position of exertion in the post-operative period. In the case of ORIF, they only reached 65 of their former position of exertion.19 In clinical practice, orthopedic surgeons are frequently reticent to perform arthrodesis on youthful and active cases with subtle lesions of the Lisfranc joint.

Painfulpost-traumatic OA after anon-anatomical reduction of a Lisfranc injury. Arthrodesis of the Lisfranc joint was performed with complete relief of symptoms (a) Side view before the arthrodesis; (b) AP radiograph before the arthrodesis; (c) AP view after the arthrodesis; (d) side radiograph after the arthrodesis.

Another case of post-traumatic OA of the Lisfranc joint due to anon-anatomical reduction associated with insecurity of Lisfranc joint (a) AP view before the arthrodesis; (b) side radiograph before the arthrodesis; (c) radiograph after the arthrodesis. The result was satisfactory.

ORIF transarticular screws versus rearward ground plates

Obsession with screws offers a rapid-fire recovery of conditioning and a low prevalence of secondary relegation compared with the fashion of bone obsession with K- cables.21 K- cables are easy to fit and remove, but have shown up to 32 secondary relegation or sour reduction.22 Therefore, they’re reserved only for injuries of the side column (fourth and fifth metatarsals).

A biomechanical study in courses showed that cortical screws and cannulated screws with distal thread have an analogous setting force and equal resistance to distortion with partial weight-bearing.23 Thus, cannulated screws with partial thread can simplify the surgical procedure without immolating the strength of the obsession.

The use of transarticular screws has been questioned because they produce common damage (2 to 6). For this reason, rearward plates with screws that don’t cross the joint have been used in recent times. These plates give stability without compromising the cartilage. In a biomechanical study comparing osteosynthesis with transarticular screws and rearward plates, it was verified that the two styles had an analogous efficacity in reducing and defying the TMT joint to relegation on weight-bearing.24

In a retrospective study lately published by Kirzner et al, it has been observed that cases treated with a rearward ground plate had significantly better functional and radiological results than those treated with transarticular screws or a combination of plate and screws.25 In addition, complete Lisfranc lesions, homolateral or divergent, had poorer results anyhow of the modality of obsession. Plates don’t beget common damage, but they do bear a wider surgical exposure and can increase soft-towel vexation.

In our experience, we reserve the use of rearward ground plates combined with transarticular screws for cases in which there’s comminution of the cuneiform bones or the base of the metatarsals, given that in these cases the screws don’t give the necessary stability.

In the case of arthrodesis of the Lisfranc joint, a plantar plate plus a contraction screw appear to be superior and is more in line with the biomechanical principles of the Association for the Study of Internal Obsession (ASIF) because the plate is located on the side of lesser pressure.26 Plantar plates have demonstrated that they acclimatize better to the figure of the bone, dwindling vexation to soft apkins and furnishing them better content. In a biomechanical study in courses, Klos et al have demonstrated that plantar plates give lesser stability and severity to the arthrodesis than dorsomedial plates.27

Which surgical approach is more applicable?

The classic approach used for open Lisfranc fracture- disturbance surgery is the one described over. A gash in the first intermetatarsal space allows us to pierce the first and alternate TMT joints; if necessary, an alternate longitudinal gash is made in line with the fourth metatarsal.

When we make two lacerations, soft-towel complications can arise due to the narrow skin islands we produce. Of the complications reported in the literature, 0 to 9 of cases develop a superficial infection and 0 to 13 experience detention in the mending of the surgical injuries
.
Philpott et al have described a revision of the classic rearward approach.28 They make a single longitudinal gash on the alternate metatarsal, beginning at the TMT joint and extending to the MTF joint. From this single gash, they develop intervals or windows to pierce each of the TMT joints. These authors stated that the approach was a feasible volition with a rate of crack complications similar to preliminarily reported approaches. Up to 25 of differences in perceptivity and 8 of cutaneous necroses were observed after a transverse gash, which is a superficial gash to the neurovascular pack that allows us to pierce each of the TMT joints through small windows.

References

Show More