Basic Postoperative Outpatient Evaluation and Management, Advanced Postoperative Outpatient Evaluation and Managementanagement, 2022 Lineage Medical, Inc. - Salvage of Lisfranc's tarsometatarsal joint by arthrodesis. and will collapse, resulting in dorsal frx dislocation of the metatarsal bases; (c) Long-axis reformatted CT image of the forefoot shows a mildly comminuted M2 base fracture (arrow) that was not well depicted at radiography, as well as lateral M2 and M3 displacement. C = cuneiform, Cu = cuboid, M = metatarsal. Higher-grade Lisfranc sprains (stages II and III) demonstrate instability or frank dislocation and should be treated surgically. 3, Techniques in Foot & Ankle Surgery, Vol. The fibers are sharply defined, and there is no periligamentous edema. All courses are CME/CPD accredited in accordance with the CPD scheme of the Royal College of Radiologists - London - UK. . 2013. In one study, nearly 25% of Lisfranc injuries were missed or appeared normal on initial radiographs because of subtle diastasis (12). Figure 12a Radiographs of the left foot in a 26-year-old male parachute jumper who had marked plantar flexion while landing. Subtalar Arthrodesis. In addition, a nonfat-saturated T1-weighted sequence in at least one plane, either the horizontal long axis or short axis, is helpful to assess for fractures that might otherwise be difficult to perceive. Diagnosis is missed in about 25-30% of cases especially in multiple trauma patients. Foot Ankle Surg, Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment, Treatment of Lisfranc joint injury: current concepts, Rupture of Lisfrancs ligament in athletes, Midfoot sprains in collegiate football players, Lisfrancs fracture-dislocation: a clinical and experimental study of tarso-metatarsal dislocations and fracture-dislocations, Injuries of the tarso-metatarsal joints: etiology, classification and results of treatment, Injuries of Lisfrancs joint: severe sprains, dislocations, fractures study of 39 personal cases and biomechanical classification [in French], Injuries to the tarsometatarsal joint: incidence, classification and treatment, An analysis of pathomorphic forms and diagnostic difficulties in tarso-metatarsal joint injuries, Developments and advances in the diagnosis and treatment of injuries to the tarsometatarsal joint, Lisfrancs tarsometatarsal fracture-dislocation, Abduction stress and AP weightbearing radiography of purely ligamentous injury in the tarsometatarsal joint, Bone scintigraphy findings in Lisfranc joint injury, Sonographic evaluation of Lisfranc ligament injuries, CT evaluation of tarsometatarsal fracture-dislocation injuries, Radiographic and computed tomographic evaluation of Lisfranc dislocation: a cadaver study, Lisfranc fracture-dislocation in patients with multiple trauma: diagnosis with multidetector computed tomography, Conventional radiography, CT, and MR imaging in patients with hyperflexion injuries of the foot: diagnostic accuracy in the detection of bony and ligamentous changes, Tarsometatarsal joint: anatomic details on MR images, Ligaments of the Lisfranc joint in MRI: 3D-SPACE (sampling perfection with application optimized contrasts using different flip-angle evolution) sequence compared to three orthogonal proton-density fat-saturated (PD fs) sequences, Magnetic resonance imaging of the Lisfranc ligament of the foot, MR imaging evaluation of subtle Lisfranc injuries: the midfoot sprain, Prediction of midfoot instability in the subtle Lisfranc injury: comparison of magnetic resonance imaging with intraoperative findings, MRI of injuries to the first interosseous cuneometatarsal (Lisfranc) ligament, MR imaging of entrapment neuropathies of the lower extremity. The diagnosis and treatment of injuries to the Lisfranc joint complex. Diagnosis is confirmed by radiographs which may show widening of the interval between the 1st and 2nd ray. Figure 3d Normal anatomy of the Lisfranc ligament complex. When Lisfranc injuries are missed or undertreated, they can lead to significant midfoot instability, planovalgus deformity, and osteoarthritis (15). Functional outcome following anatomic restoration of tarsal-metatarsal fracture dislocation. (a) Axial CT image in a 52-year-old woman who experienced persistent left midfoot pain 6 months after ORIF of the first and second tarsometatarsal joints shows a fracture of one of the tarsometatarsal screws (arrow). The C1 fracture is well seen as cortical buckling along the medial surface (arrowhead). If the address matches an existing account you will receive an email with instructions to reset your password. In cases of trauma, radiographic assessment consists of unilateral anteroposterior, lateral, and 30 internally rotated oblique nonweight-bearing images (29). (h) Long-axis three-dimensional (3D) sampling perfection with application optimized contrasts using different flip-angle evolutions (SPACE; Siemens Medical Solutions, Erlangen, Germany) MR image shows the right interosseous Lisfranc ligament (arrows). Previous Next S; Enter (frontside only) 20% 1; N 40% 2; H 60% 3 F; Enter (backside only) 80% 4; E 100% 5; M . A widening of more than 2 mm between C1 and C2 suggests additional C1-C2 intercuneiform ligament injury. Injury. On the x-ray of the side of the foot the blue lines should line up. - Does Open Reduction and Internal Fixation versus Primary Arthrodesis Improve Patient Outcomes for Lisfranc Trauma? Table 3: Nunley-Vertullo Classification of Low-Grade Midfoot Sprains. Arrowhead indicates the peroneus longus tendon, which could become entrapped at the site of injury and prevent adequate healing. Lateral subluxation of the fourth and fifth metatarsal bones was seen before surgery but was reduced without surgical fixation. Data Trace Publishing Company Fractures and concomitant disarticulations of this joint are termed Lisfranc fracture-dislocations Lisfranc Joint (orthoinfo.aaos.org) (a) Preoperative anteroposterior radiograph shows a divergent Lisfranc fracture-dislocation. Isolated fracture-dislocations of the first tarsometatarsal joint. 2 public playlists include this case Related Radiopaedia articles However, bone scintigraphy may be useful for diagnosis of low-grade injuries when other imaging modalities do not depict abnormalities. The red arrow indicates the major line of compressive force on the midfoot, and the yellow arrows indicate which metatarsals dislocate and in which direction they travel. (a) Diagram of the dorsal aspect of the left forefoot in the long axis depicts the two major ligaments between the medial and middle columns: the dorsal Lisfranc ligament (dC1-M2) and the dorsal intercuneiform ligament (dC1-C2). At the midfoot level, the nerve has divided into a sensory medial branch that provides sensation to the first web space and a sensorimotor lateral branch that innervates the extensor hallucis brevis and extensor digitorum brevis muscles. (b) Short-axis proton-densityweighted magnetic resonance (MR) image of the left midfoot through the metatarsal bases (M1M5) shows the trapezoidal (keystone) shape of the middle three metatarsal bases. The literature supporting the use of one modality over the other is sparse. Get an accredited certificate of achievement by completing one of our online course completion assessments. Forced plantar-flexion injuries occur when the forefoot is rigidly planted in the plantar-flexed position and a force is applied through the metatarsals along the longitudinal axis, resulting in a compressive force through the tarsometatarsal joint. (c) Reformatted 3D CT image of the forefoot better shows the chip fracture (arrow) and osseous malalignment. If closed reduction can be achieved with fluoroscopy, fixation with percutaneous screws can be performed. (a) Preoperative anteroposterior radiograph shows a divergent Lisfranc fracture-dislocation. After completing this journal-based SA-CME activity, participants will be able to: Describe the osseous and ligamentous anatomy that helps stabilize the Lisfranc joint complex. Lisfranc (Midfoot) Injury Lisfranc (midfoot) injuries result if bones in the midfoot are broken or ligaments that support the midfoot are torn. (a) Initial anteroposterior nonweight-bearing radiograph of the foot shows normal osseous alignment of the medial and middle columns. - intercuneiform region injuries: these may occur in upto 10-15 % of patients; Missed Lisfranc ligament injuries are among the most common causes of litigation against radiologists and emergency department physicians. A widening of more than 2 mm between C1 and C2 suggests additional C1-C2 intercuneiform ligament injury. 1, American Journal of Roentgenology, Vol. High-impact injuries that result in Lisfranc fracture-displacements are typically due to direct forces applied to the joint, such as in motor vehicle or industrial accidents with a crush-type mechanism, and often include additional traumatic osseous and soft-tissue injuries that may complicate radiographic evaluation. - post op: - Lisfranc injuries w/o fracture have poor prognosis, with late midfoot collapse a common sequela; Radionuclide bone scans will often show abnormal radiotracer uptake in patients with midfoot injuries and are most helpful for detection of low-grade injuries when the radiographic findings are normal or equivocal (41). 4, Annales franaises de mdecine d'urgence, Vol. This causes lots of swelling which can be seen in the picture of his foot. Page author: The tarsometatarsal joint is named after Jacques Lisfranc de Saint-Martin (17871847), a French army field surgeon who described a forefoot amputation through the first tarsometatarsal joint (1,2). (b) Drawing shows the forced plantar-flexion mechanism, with a compressive force along the long axis of the plantar-flexed foot and the second metatarsal displaced dorsally. Comparison of magnetic resonance imaging with intraoperative findings. A high index of suspicion is needed to prevent progression of the foot deformity, chronic pain and dysfunction. Figure 8a Nunley-Vertullo stage II left midfoot Lisfranc injury in a 58-year-old man who fell while bicycling. 42, No. Bookshelf These injuries have typically been divided . (d) Short-axis proton-densityweighted MR image through the right tarsometatarsal joint shows the three components of the Lisfranc ligament complex: the dorsal ligament (white arrow), interosseous ligament (arrowhead), and plantar ligament (black arrow). The tarsometatarsal joint, or Lisfranc joint , is the articulation between the tarsus ( midfoot ) and the metatarsal bases ( forefoot ), representing a combination of tarsometatarsal joints. Flashcards (0) Cards 1 of 0. Figure 8b Nunley-Vertullo stage II left midfoot Lisfranc injury in a 58-year-old man who fell while bicycling. There is mild widening between C1 and M2 and between M1 and M2. The peroneus longus (PL) and flexor hallucis longus (FHL) tendons are also shown. 7, No. Figure 2b Diagrams show the normal three-column anatomy of the Lisfranc ligament complex in the left foot. Pediatric Lisfranc injury: "bunk bed" fracture. 18, No. - dorsalis pedis may be diminished or absent; Nav = navicular. Additional modalities such as radiographic stress imaging, CT, and MR imaging can be used to detect Lisfranc injuries and assess the degree of injury. (h) Long-axis three-dimensional (3D) sampling perfection with application optimized contrasts using different flip-angle evolutions (SPACE; Siemens Medical Solutions, Erlangen, Germany) MR image shows the right interosseous Lisfranc ligament (arrows). Figure 3b Normal anatomy of the Lisfranc ligament complex. Particularly in the divergent pattern of fracture-displacement shown in c, the force can propagate proximally to injure the C1-C2 intercuneiform ligament and cause instability at this joint. Although CT can be helpful for assessing ligamentous integrity, it is less useful in the evaluation of low-impact injuries, where ligamentous injuries rather than osseous fractures are suspected. When findings on weight-bearing or stress radiographs are equivocal, bone scintigraphy, CT, or MR imaging may be performed to better evaluate the joint. Data Trace is the publisher of Named after Jacques Lisfranc, a field surgeon in Napoleon's army, who described a new technique for an amputation used to treat frostbite of the forefoot in soldiers on the Russian front. 111, No. 17, No. 39, No. Anatomical restraints to dislocation of the second metatarsophalangeal joint and assessment of a repair technique. 56, No. (c) Long-axis fat-suppressed proton-densityweighted MR image of the left midfoot demonstrates the oblique course of the interosseous Lisfranc ligament (arrows). Figure 12b Radiographs of the left foot in a 26-year-old male parachute jumper who had marked plantar flexion while landing. - ref: Prediction of midfoot instability in the subtle Lisfranc injury. Subtle radiographic changes can represent significant ligamentous Lisfranc injury. - disrupted skin and excessive swelling are relative contra-indications for ORIF; Finally, the medial branch of the deep peroneal nerve and the perforating branch of the dorsalis pedis artery travel between M1 and M2 toward the first intermetatarsal space. Bone scintigraphy of patients with unexplained midfoot pain may show focal increased radiotracer uptake in this region, a finding suggestive of Lisfranc injuries. Tarsalmetatarsal Arthrodesis. Dr Graham Lloyd-Jones BA MBBS MRCP FRCR - Consultant Radiologist - The severity of a Lisfranc injury can vary widely from a simple injury involving one midfoot joint to a complex injury involving many midfoot joints and broken bones. Treatment is immobilzation or surgical reconstruction depending on patient activity levels, degree of separation and degree of ligament injury. The second cuneometatarsal, or central, ligament is variable in configuration, with the most common appearance being a triangular band extending from C2 or C3 anteriorly to M2 and M3 (21). Finally, the use of a similar planar orientation for the anatomic and fluid-sensitive sequences allows the anatomic sequences to serve as an imaging road map for signal abnormalities seen on the fluid-sensitive images. - Severe Lisfrancs injuries: primary arthrodesis or ORIF? (b) Drawing of the plantar aspect of the left forefoot shows the major ligaments that stabilize the medial and middle columns: the plantar Lisfranc ligament (pC1-M2M3) and the first and second plantar tarsometatarsal ligaments. J Chiropr Med. A study of 15 patients with subtle Lisfranc injuries reported normal-appearing findings on initial nonweight-bearing radiographs in 50% of patients, with diastasis and loss of the normal longitudinal midfoot arch identified later on weight-bearing radiographs (13). When the bones don't line up it can put pressure on the blood vessels of the foot. Radiologists must have a thorough understanding of anatomy, mechanisms, and patterns of these injuries to diagnose and help clinicians assess treatment options and prognosis. Occasionally, MR findings that suggest injury to the deep peroneal nerve can be seen. Given the complexity of the Lisfranc joint and the relatively small size of the supporting soft-tissue structures, proper selection of MR imaging sequences and the orientation of imaging planes can help in injury detection. 5, Archives of Orthopaedic and Trauma Surgery, Vol. - however, x-ray findings may not correlate w/ clinical findings; The fibers are sharply defined, and there is no periligamentous edema. Figure 3a Normal anatomy of the Lisfranc ligament complex. - note that pure dislocations w/o fracture may have a worse outcome despite ORIF; Two patterns of type B injuries are described: type B1 injuries denote isolated displacement of the first tarsometatarsal joint, and type B2 injuries refer to displacement of one or more of the lesser tarsometatarsal joints. C = cuneiform, p = plantar. Nav = navicular. A common mechanism of injury is forced plantar-flexion of the foot which can occur with missing a step when descending stairs, as described in this case. - w/ questionable injury, consider wt bearing AP view to assess 1-2 interval; C = cuneiform, M = metatarsal. METHODS: Seventy-eight Lisfranc injuries with first TMT joint dislocation were finally enrolled and analyzed in a prospective, randomized trial comparing ORIF and PA. 11, 9 September 2019 | RadioGraphics, Vol. . (h) Long-axis three-dimensional (3D) sampling perfection with application optimized contrasts using different flip-angle evolutions (SPACE; Siemens Medical Solutions, Erlangen, Germany) MR image shows the right interosseous Lisfranc ligament (arrows). Severe Lisfrancs injuries: primary arthrodesis or ORIF? (g) Axial fat-suppressed proton-densityweighted MR image through the dorsum of the left midfoot shows the dorsal Lisfranc ligament in the long axis (arrow). The 'Lisfranc' ligament stabilises the mid-forefoot junction. The dorsal Lisfranc ligament provides a rigid connection that maintains stability between the medial and middle columns and supports the base of M2 in its recess between C1 and C3. The x-ray beam is centered on the M2 base for all radiographs and should be angulated toward the heel by 1015 on anteroposterior views to depict the tarsometatarsal joints in profile (Fig 7). Disclaimer, National Library of Medicine 56, No. The Myerson system provides a standardized approach for reportable injury patterns and results in a high degree of interobserver reliability for data communication. Radiograph illustrating diabetic patient with first ray instability of the right foot. For treatment of the lateral column, if the fourth and fifth tarsometatarsal joints are reduced, no treatment is necessary. Figure 11a Nunley-Vertullo stage I Lisfranc sprain in a 21-year-old man who hyperextended his right foot while it was stuck in a stool. Midfoot swelling in the presence of plantar ecchymosis should be considered to be a Lisfranc injury until proven otherwise. Figure 4a Common indirect forces that result in Lisfranc joint complex injury in the right foot. CT images can help verify radiographic findings and locate subtle fractures. - Primary Arthrodesis: (a) Anteroposterior weight-bearing radiograph of the midfoot shows a small chip fracture (arrow) from the medial margin of the M2 base, a finding called the fleck sign. Several classification systems have been developed to describe injuries of the tarsometatarsal joint. - mechanism: The Neurologic Conditions. (b) Sagittal reformatted CT image in the same patient shows advanced tarsometatarsal arthropathy and fragmentation (arrow), findings that suggest developing neuropathic arthropathy. Does Open Reduction and Internal Fixation versus Primary Arthrodesis Improve Patient Outcomes for Lisfranc Trauma? (h) Long-axis three-dimensional (3D) sampling perfection with application optimized contrasts using different flip-angle evolutions (SPACE; Siemens Medical Solutions, Erlangen, Germany) MR image shows the right interosseous Lisfranc ligament (arrows). These injuries have typically been divided into high-impact fracture-displacements, which are often seen after motor vehicle collisions, and low-impact midfoot sprains, which are more commonly seen in athletes. Figures 5-6: This patient had a crush injury to his foot. Although these findings are relatively easy to obtain and reproducible, physician unfamiliarity with the US appearance of the ligament and its injuries and the inability to adequately see deeper structures, such as the interosseous and plantar Lisfranc ligaments, are barriers to the more widespread use of US. HHS Vulnerability Disclosure, Help As with many other traumatic injuries, men are at least twice as likely as women to present with acute Lisfranc joint complex injuries, and athletes in particular have a greater likelihood of sustaining these injuries (7,8). (a) Anteroposterior nonweight-bearing radiograph shows medial dislocation of M1, with lateral dislocation of M2M5 and a cuboid fracture. The nerves at this level are very thin and may be difficult to detect or to discriminate from adjacent vessels, even with high-resolution imaging. - if standing AP is unacceptable to the patient then consider CT scan; C = cuneiform, Cu = cuboid, M = metatarsal. Figure 6b Left midfoot divergent Lisfranc fracture-dislocation in a 32-year-old woman who jumped from a 12-ft height. There is mild widening between C1 and M2 and between M1 and M2. - fixation must be rigid enough to prevent transverse plane & dorsoplantar motion ofTMT joint and be maintained for at 1, American Journal of Roentgenology, Vol. Please enable it to take advantage of the complete set of features! (b) Lateral nonweight-bearing radiograph shows the typical dorsal subluxation of M1 relative to C1 (arrow). Dr. Wheeless enjoys and performs all types of orthopaedic surgery but is renowned for his expertise in total joint arthroplasty (Hip and Knee replacement) as well as complex joint infections. Diagnosis is made with bilateral focused shoulder radiographs to assess for AC and CC interval widening. Figure 11b Nunley-Vertullo stage I Lisfranc sprain in a 21-year-old man who hyperextended his right foot while it was stuck in a stool. An official website of the United States government. ray amputation or fusion. 64, No. Base of radial styloid. The articular surfaces of the second and first metatarsal are level in the transverse plane, indicating proximal migration of the first ray. Lateral subluxation of the fourth and fifth metatarsal bones was seen before surgery but was reduced without surgical fixation. 2, Seminars in Roentgenology, Vol. document.write(theYear) | Figure 6c Left midfoot divergent Lisfranc fracture-dislocation in a 32-year-old woman who jumped from a 12-ft height. Salvage of Lisfranc's tarsometatarsal joint by arthrodesis. - Arthrodesis versus ORIF for Lisfranc fractures. (h) Long-axis three-dimensional (3D) sampling perfection with application optimized contrasts using different flip-angle evolutions (SPACE; Siemens Medical Solutions, Erlangen, Germany) MR image shows the right interosseous Lisfranc ligament (arrows). The fibers are sharply defined, and there is no periligamentous edema. The ligament can either be uniformly low in signal intensity or striated with intermediate signal intensity, as shown. (b) Long-axis T2-weighted fast SE MR image of the midfoot shows complete disruption of the interosseous Lisfranc ligament (arrow), with edema tracking along the lateral margin of M1. - lateral radiographs: Zhang H, Min L, Wang G, Liu L, Fang Y, Tu C. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. This column is the most mobile and is generally safeguarded against posttraumatic instability and arthritis. (b) Lateral weight-bearing radiograph demonstrates continuity of the dorsal surface of the M1 base and C1 (dashed white line). A prospective, randomized study. The plantar surface of the M1 base (black line) is superior to the plantar surface of the M5 base (solid white line). Fracture dislocations at the tarsometatarsal joints, end results correlated with pathology and treatment. perform passive range of motion of the metatarsal heads and passive abduction through the forefoot. (e) Short-axis fat-suppressed proton-densityweighted MR image through the left midfoot shows portions of the plantar Lisfranc ligament (pC1-M2M3; arrow). - posttraumatic arthritis and planovalgus deformity are common and may occur in upto 50%; On the basis of their experience with athletes, Nunley and Vertullo (4) developed a three-stage classification system that addresses low-impact injuries and helps direct treatment by evaluating clinical findings, comparative weight-bearing radiographs, and images from bone scintigraphy (Table 3). The first cuneometatarsal ligament (pC1-M1) originates near the plantar aspect of the articular surface of C1 and extends distally to attach to the lateral aspect of M1. (e) Short-axis fat-suppressed proton-densityweighted MR image through the left midfoot shows portions of the plantar Lisfranc ligament (pC1-M2M3; arrow). (d) Short-axis proton-densityweighted MR image through the right tarsometatarsal joint shows the three components of the Lisfranc ligament complex: the dorsal ligament (white arrow), interosseous ligament (arrowhead), and plantar ligament (black arrow). - diff dx and associated injuries: C = cuneiform, Cu = cuboid, M = metatarsal. The interosseous and plantar components provide the primary ligamentous stability for the Lisfranc joint. - prognosis: Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username. Osteoarthritis is a well-recognized outcome of Lisfranc injuries, with about 50% of patients showing radiographic signs of Lisfranc osteoarthritis after ORIF. FOIA Weight-bearing x-rays are an alternative to MRI to assess the integrity of the Lisfranc joint. The intertarsal ligaments (C1-C2, C2-C3, and C3-cuboid) are thick strong attachments that bridge the adjacent cuneiforms and the cuboid. proximal fragment pulled into flexion by interossei. government site. - dorsal capsule of Lisfranc's joint, lacking sufficienct reenforcement, will to support the load Figure 3g Normal anatomy of the Lisfranc ligament complex. - fracture characteristics may be subtle; The fibers are sharply defined, and there is no periligamentous edema. (Read bio). (g) Axial fat-suppressed proton-densityweighted MR image through the dorsum of the left midfoot shows the dorsal Lisfranc ligament in the long axis (arrow). The .gov means its official. This orientation allows the Lisfranc joint to be seen on true axial and coronal planes (47). (b) Long-axis reformatted CT image of the midfoot shows the M2 chip fracture and mild C1-M2 widening (arrow) and also depicts proximal C1 and C2 fractures (arrowheads) not identified on the initial radiographs. 24, No. - Lisfranc joint injuries: trauma mechanisms and associated injuries. Discuss the common mechanisms of tarsometatarsal joint complex injuries. (c) Long-axis reformatted CT image of the forefoot shows a mildly comminuted M2 base fracture (arrow) that was not well depicted at radiography, as well as lateral M2 and M3 displacement. (b) Sagittal reformatted CT image in the same patient shows advanced tarsometatarsal arthropathy and fragmentation (arrow), findings that suggest developing neuropathic arthropathy. (a) Diagram of the dorsal aspect of the left forefoot in the long axis depicts the two major ligaments between the medial and middle columns: the dorsal Lisfranc ligament (dC1-M2) and the dorsal intercuneiform ligament (dC1-C2). 1, Health Information Management Journal, Vol. Arthrodesis may be preferred in some situations, especially when there are comminuted fractures at the first and second metatarsal bases, because stiffness is preferred to instability to maintain the rigidity of the medial and middle columns during gait (55,58). Figure 1a Normal osseous anatomy of the Lisfranc joint complex. The peroneus longus (PL) and flexor hallucis longus (FHL) tendons are also shown. This injury can affect the ligaments soft tissue that connects bone to bone of these bones andor include fractures of the bones themselves. NAV = navicular. (a) Axial CT image in a 52-year-old woman who experienced persistent left midfoot pain 6 months after ORIF of the first and second tarsometatarsal joints shows a fracture of one of the tarsometatarsal screws (arrow). Most authors advocate screw fixation of the medial and middle tarsometatarsal compartments instead of fixation with Kirschner wires to maintain the rigidity of the columns (Fig 12) (57). Careers. The dorsal ligamentous components have been found to be the weakest, a finding that likely explains the typical dorsal displacement seen with Lisfranc injuries (23). Radiology Masterclass, Department of Radiology, (b) Short-axis proton-densityweighted magnetic resonance (MR) image of the left midfoot through the metatarsal bases (M1M5) shows the trapezoidal (keystone) shape of the middle three metatarsal bases. 12, Archives of Orthopaedic and Trauma Surgery, Vol. - Operative Treatment: At radiography, injuries are nondisplaced, with no diastasis between C1 and the base of M2 and no loss of the midfoot arch height on lateral weight-bearing radiographs. [Clinical and radiographic evaluation of open reduction and internal fixation with headless compression screws in treatment of lisfranc joint injuries]. Figure 5b Common patterns of Lisfranc fracture-displacement in the left foot, according to the Quen and Kss (36) classification system. Fixation of the lateral column is performed to maintain its mobility and thus avoid an overload of the lateral foot (55). However, only about 8% of these patients become symptomatic enough to require arthrodesis. C = cuneiform, Cu = cuboid, M = metatarsal. Contact us. There is mild widening between C1 and M2 and between M1 and M2. C = cuneiform, M = metatarsal. (b) Drawing of the plantar aspect of the left forefoot shows the major ligaments that stabilize the medial and middle columns: the plantar Lisfranc ligament (pC1-M2M3) and the first and second plantar tarsometatarsal ligaments. 59, No. Magn Reson Imaging Clin N Am. Updated: Jan 5 2021. (a) Anteroposterior weight-bearing radiograph shows continuity of the lateral margins of the first metatarsal base (M1) and medial cuneiform (C1) and the medial margins of the second metatarsal base (M2) and middle cuneiform (C2). - fractures presenting w/ more than than 2 mm of displacement and greater than 15 degof (e) Short-axis fat-suppressed proton-densityweighted MR image through the left midfoot shows portions of the plantar Lisfranc ligament (pC1-M2M3; arrow). Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. - frx of base of second metatarsal; (c) Long-axis fat-suppressed proton-densityweighted MR image of the left midfoot demonstrates the oblique course of the interosseous Lisfranc ligament (arrows). (c) Short-axis T2-weighted fast SE MR image of the tarsometatarsal joint shows disruption of the dorsal, interosseous, and plantar components of the Lisfranc ligament complex (arrows). The middle column is composed of the articulations of M2 and M3 with C2 and C3 and is the most rigid. The tarsometatarsal, or Lisfranc, joint complex provides stability to the midfoot and forefoot through intricate osseous relationships between the distal tarsal bones and metatarsal bases and their connections with stabilizing ligamentous support structures. The stiffness provided by the medial and middle columns is essential to allowing the foot to function as a lever in normal gait. 6, Foot & Ankle International, Vol. The ligament can either be uniformly low in signal intensity or striated with intermediate signal intensity, as shown. (b) Short-axis T2-weighted fast SE MR image of the tarsometatarsal joint shows a high-grade tear of the plantar Lisfranc ligament (arrow) with intact dorsal and interosseous Lisfranc ligaments (arrowhead). - w/ lateral displacement look for cuboid frx; Type C injuries have a divergent pattern, with M1 displaced medially and M2M5 displaced laterally (Fig 6). Peroneal Tendon Tears and Instability. 41, No. Lisfranc injuries occur as a result of direct or indirect forces to the foot. It classified Lisfranc fracture-displacements, including dislocations in which the joint surfaces no longer articulate and subluxations in which the articular surfaces partially contact one another, according to the positions of the metatarsal bones, without regard to the mechanism of injury. Use of ultrasonography (US) is rarely reported for the imaging workup of Lisfranc ligament injuries, although US may be useful for assessing the dorsal Lisfranc ligament and radiographically occult tarsometatarsal subluxation. (f) Axial proton-densityweighted MR image of the left midfoot demonstrates the M3 bundle of the plantar Lisfranc ligament (pC1-M2M3; arrow). These chip fractures are virtually pathognomonic of high-impact Lisfranc fracture-displacements and are seen in about 90% of these injuries (7). (b) Lateral nonweight-bearing radiograph shows the typical dorsal subluxation of M1 relative to C1 (arrow). 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