. Page author: Initial radiographic findings were unremarkable. The .gov means its official. - Primary Arthrodesis: (c) Long-axis fat-suppressed proton-densityweighted MR image of the left midfoot demonstrates the oblique course of the interosseous Lisfranc ligament (arrows). 5, Archives of Orthopaedic and Trauma Surgery, Vol. Lisfranc injury is very important to recognize as it can lead to arthritis and disability if not repaired. Midfoot swelling in the presence of plantar ecchymosis should be considered to be a Lisfranc injury until proven otherwise. C = cuneiform, M = metatarsal. Figure 3a Normal anatomy of the Lisfranc ligament complex. The tarsometatarsal joint is named after Jacques Lisfranc de Saint-Martin (1787-1847), a French army field surgeon who described a forefoot amputation through the first tarsometatarsal joint (1,2). 12, SN Comprehensive Clinical Medicine, Vol. Figure 10c Nunley-Vertullo stage II left midfoot Lisfranc sprain in a 41-year-old man after a softball twisting injury. The middle column is composed of the articulations of M2 and M3 with C2 and C3 and is the most rigid. (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). Drawings show homolateral (a), isolated (b), and divergent (c) fracture-displacements. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. (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. Figure 5c Common patterns of Lisfranc fracture-displacement in the left foot, according to the Quen and Kss (36) classification system. Comparison of primary arthrodesis versus open reduction with internal fixation for Lisfranc injuries: Systematic review and meta-analysis. Accessibility apex volar angulation due to. - because 2nd metatarsal is the longest metatarsal proximally, it will often be frxed at its base, 1, American Journal of Roentgenology, Vol. The lateral column consists of the articulation of M4 and M5 with the cuboid. (Read bio). ray amputation or fusion. Low-impact midfoot sprains usually result from indirect forces and account for most sports-related injuries to this area. Initial radiographic findings were unremarkable. (c) Long-axis fat-suppressed proton-densityweighted MR image of the left midfoot demonstrates the oblique course of the interosseous Lisfranc ligament (arrows). Epub 2014 Dec 10. sampling perfection with application optimized contrasts using different flip-angle evolutions, Indian Journal of Radiology and Imaging, Vol. Figure 3b Normal anatomy of the Lisfranc ligament complex. It should be noted, however, that conservative treatment may predispose patients to later development of degenerative arthritis (7). Towson, MD 21204 Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 56, No. [1] The severity of the injury can range from simple to complex and may involve several joints and bones of the mid-foot. Viewer, http://www.acr.org//media/ACR/Documents/AppCriteria/Diagnostic/AcuteTraumaFoot.pdf, Adult Acquired Flatfoot Deformity: Anatomy, Biomechanics, Staging, and Imaging Findings, Pattern Recognition: A Mechanism-based Approach to Injury Detection after Motor Vehicle Collisions, Imaging of Acute Capsuloligamentous Sports Injuries in the Ankle and Foot: Sports Imaging Series, Acute Fractures and Dislocations of the Ankle and Foot in Children, Normal Anatomy and Traumatic Injury of the Midtarsal (Chopart) Joint Complex: An Imaging Primer, Pediatric Foot and Ankle Fractures: Patterns, Mimics, Complications, and Treatment, Dancing Feet: Biomechanism and Imaging Findings of Foot and Ankle Musculoskeletal Injuries in Dancers, Stuck in the Middle: Imaging Overview of the Midtarsal Chopart Joint, Lateral cuneiform cuboid osseous coalition. The second metatarsal dorsally dislocates, with lateral displacement of the lesser metatarsals. Although Lisfranc joint complex injuries are relatively uncommon, misdiagnosis or undertreatment of these injuries can lead to significant patient morbidities, such as midfoot pain, planovalgus deformity, and osteoarthritis. Bookshelf (e) Short-axis fat-suppressed proton-densityweighted MR image through the left midfoot shows portions of the plantar Lisfranc ligament (pC1-M2M3; arrow). Stage III injuries demonstrate more than 5 mm of diastasis and a loss in arch height, which is indicated by a decrease in the distance between the plantar aspect of M5 and C1 on lateral weight-bearing radiographs. Lines 3-6 are assessed on the oblique view. - anatomy of the midfoot doi: 10.1016/j.fcl.2005.12.005. The goal of surgical intervention is anatomic alignment because anything other than anatomic alignment may lead to midfoot arch collapse and osteoarthritis (56). However, disruption of the adjacent soft tissues, such as entrapment of the tibialis anterior tendon, can prevent a successful closed reduction (26). C = cuneiform, Cu = cuboid, M = metatarsal. How PASS is a win for everyone on the team Residents Chief Residents Fellows Program Coordinators Figure 8c Nunley-Vertullo stage II left midfoot Lisfranc injury in a 58-year-old man who fell while bicycling. - always consider compartment syndrome of the foot; - Radiographs: The Myerson system provides a standardized approach for reportable injury patterns and results in a high degree of interobserver reliability for data communication. Depending on the vector of the force, displacement of the metatarsal bases can be seen in either the plantar or dorsal direction (28). - Arthrodesis versus ORIF for Lisfranc fractures. 1, The Bone & Joint Journal, Vol. Lateral subluxation of the fourth and fifth metatarsal bones was seen before surgery but was reduced without surgical fixation. (c) Long-axis reconstructed computed tomography (CT) image of the midfoot shows the second metatarsal base (M2; arrow) recessed between the medial and lateral cuneiforms (C1 and C3) and forming a mortise-and-tenon joint that helps preserve joint alignment. 48, No. Terms and Conditions Prediction of midfoot instability in the subtle Lisfranc injury. One of the major determinants to the development of arthritis is whether postreduction anatomic alignment was achieved (59). FOIA distal fragment pulled into extension by central slip. Figure 12b Radiographs of the left foot in a 26-year-old male parachute jumper who had marked plantar flexion while landing. Given its ability to depict surrounding soft-tissue structures, MR imaging may be helpful in assessing the integrity of the distal peroneus longus and anterior tibialis tendons, which help to support the medial midfoot arch. 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. - diff dx and associated injuries: - post op: (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). - Open Reduction Internal Fixation: Moreover, reformatted 3D CT images can be helpful in assessing osseous alignment for preoperative planning (Fig 8c) (8,12). The literature supporting the use of one modality over the other is sparse. 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. 34, No. Pathology Anatomy Discuss the common mechanisms of tarsometatarsal joint complex injuries. Thirty articles were subdivided by imaging modality: conventional radiography (17 articles), ultrasonography (six articles), computed tomography (CT . 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). Three separate synovial articulations divide the midfoot into the lateral, middle, and medial columns (Fig 2) (19). In a study by Haapamaki et al (45), several patients had either false-positive or false-negative radiographic findings of injury when compared with CT findings, and the injuries of other patients were shown to be either overstaged or understaged at radiography when compared with CT findings. (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. 18, No. - Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. 6, Foot & Ankle International, Vol. 17, No. Lisfranc Open Reduction and Internal fixation - Foot Ankle - Orthobullets. Typical features of an avulsion fracture at the main insertion of the Lisfranc ligament. 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. Radiology Masterclass, Department of Radiology, This image shows a gap between the bases of the first and second metatarsals (MT); the second metatarsal is no longer correctly aligned with the intermediate cuneiform bone, This is a significant finding which indicates disruption of the Lisfranc ligament, Careful assessment of alignment is always required in suspected midfoot injury, If the initial X-ray is normal then repeat images with weight-bearing or CT may be required, Injury to the Lisfranc ligament is often accompanied by subtle fragmentation of the adjacent bones. The 'Lisfranc' ligament stabilises the mid-forefoot junction. Figure 3h Normal anatomy of the Lisfranc ligament complex. A widening of more than 2 mm between C1 and C2 suggests additional C1-C2 intercuneiform ligament injury. the lisfranc ligament is an important soft tissue stabilizer of the "lisfranc joint" and originates from the lateral surface of the medial cuneiform and inserts obliquely and downward into the lower half of the medial surface of the base of the 2nd metatarsal. 38, No. (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. Fracture dislocations at the tarsometatarsal joints, end results correlated with pathology and treatment. C = cuneiform, M = metatarsal. Arrowhead indicates the peroneus longus tendon, which could become entrapped at the site of injury and prevent adequate healing. (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). (f) Axial proton-densityweighted MR image of the left midfoot demonstrates the M3 bundle of the plantar Lisfranc ligament (pC1-M2M3; arrow). (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. Occasionally, MR findings that suggest injury to the deep peroneal nerve can be seen. Fractures and concomitant disarticulations of this joint are termed Lisfranc fracture-dislocations Lisfranc Joint (orthoinfo.aaos.org) Signs are often more apparent on the oblique view of the foot. 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 primary focus of the x-ray is the space between the base of the first and second metatarsal bones, also known as the Lisfranc . Disclaimer, National Library of Medicine There is no consensus in the literature about the appropriate location to measure the width of the C1 and M2 articulation. Homolateral injuries are the most common and involve displacement of all five metatarsal bases in the same direction. However, a finding of abnormal radiotracer uptake is nonspecific and can be seen with other causes, including infection, tumor, and osteoarthritis. The fibers are sharply defined, and there is no periligamentous edema. Diagnosis is missed in about 25-30% of cases especially in multiple trauma patients. The ligament can either be uniformly low in signal intensity or striated with intermediate signal intensity, as shown. 205, No. Professionalism & Rotation Evaluations Accurate ACGME levels AND summative faculty feedback the residents want. This site needs JavaScript to work properly. This orientation allows the Lisfranc joint to be seen on true axial and coronal planes (47). Lisfranc injuries range from sprain to fracture-dislocation. (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). Login or register to get started. 30, No. 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. - if standing AP is unacceptable to the patient then consider CT scan; (b) Lateral nonweight-bearing radiograph shows the typical dorsal subluxation of M1 relative to C1 (arrow). Treatment of Sprains and Minimally Displaced Frx, Outcomes of Lisfranc Injuries in the National Football League. - references: findings. Radiology Masterclass 2007 - now=new Date Plantar ecchymosis sign: a clinical aid to diagnosis of occult Lisfranc tarsometatarsal injuries. (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. Foot Ankle Clin. Nav = navicular. 2008 Feb;16(1):19-27, v. doi: 10.1016/j.mric.2008.02.007. (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. radial or dorsal wrist pain, maximal on radial deviation and wrist extension weakness and/or instability clicking wrist positive Watson test: during ulnar to radial deviation, pressure applied to the volar aspect of the scaphoid elicits an audible and/or palpable clunk (due to dorsal subluxation of the scaphoid with respect to the radius) Pathology (c) Sagittal reformatted CT image in a 48-year-old woman with progressive left flat-foot deformity who presented with plantar midfoot pain and a palpable abnormality 8 months after ORIF of the first and second tarsometatarsal joints shows the distal tip of one of the screws protruding into the plantar soft tissues (arrow) and causing mass effect on the flexor hallucis longus tendon, with effacement of the medial midfoot arch (arrowhead). Normal Lisfranc alignment: Lines of alignment are represented in red and joint lines are represented in yellow. A small field of view tailored to the midfoot or forefoot should be used to improve spatial resolution. - Lisfranc joint injuries: trauma mechanisms and associated injuries. (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). (c) Reformatted 3D CT image of the forefoot better shows the chip fracture (arrow) and osseous malalignment. On MR images, the ligament is best seen on the horizontal long-axis and short-axis planes and may appear striated or homogeneous, with low to intermediate signal intensity (21). 32, No. 39, No. Subtle radiographic changes can represent significant ligamentous Lisfranc injury. 42, No. Occasionally, cuboid compression fractures can also be seen if there is forefoot abduction (38). - w/ lateral displacement look for cuboid frx; The degree of malalignment is somewhat subtle but can be typical for these injuries. 2, Radiologic Clinics of North America, Vol. (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). PMC STAR Total Ankle Arthroplasty. These images are commonly obtained by immobilizing the hindfoot and applying supination and abduction to the forefoot (9,40). A Lisfranc injury occurs secondary to disruption of a major stabilizing ligament of the arch of the foot. - posttraumatic arthritis and planovalgus deformity are common and may occur in upto 50%; It is unclear to what degree disruption of these anatomic relationships results in instability of the Lisfranc joint. On nonweight-bearing images, small chip fractures that arise from the base of M2 or C1 (termed the fleck sign), may be the only indicator of an underlying Lisfranc injury (Fig 8) (28). Axial thin-section CT images can be reconstructed along the horizontal long and short axes of the joint, which are often oblique to the normal orthogonal planes of the body. An official website of the United States government. Fractures and fracture dislocations of the tarsometatarsal joint. CT is better suited for depicting and further characterizing fractures in radiographically apparent injuries (8,45), and orthopedic surgeons may request high-resolution reformatted 3D CT images for preoperative planning. 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. Neurologic Conditions. 2013 Oct;27(10):1196-201. The most common short-term postoperative complications include compartment syndrome, deep vein thrombosis, and infection, which can be clinically suspected. J Chiropr Med. (e) Short-axis fat-suppressed proton-densityweighted MR image through the left midfoot shows portions of the plantar Lisfranc ligament (pC1-M2M3; arrow). The dorsal structures are highlighted by the ligamentous connections of each cuneiform with the base of M2 (dC1-M2, dC2-M2, and dC3-M2) and C1 with M1 (dC1-M1). proximal phalanx. - fixation must be rigid enough to prevent transverse plane & dorsoplantar motion ofTMT joint and be maintained for at (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. The short-axis (coronal) view can be planned from the sagittal sequence and is oriented along the first and second tarsometatarsal joints, and the horizontal long-axis (axial) sequence should be planned from the short-axis sequence and obliquely oriented along the metatarsal bases. Federal government websites often end in .gov or .mil. Lisfranc injury. (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 fibers are sharply defined, and there is no periligamentous edema. 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. 1, Journal of the American Academy of Orthopaedic Surgeons, Vol. Lateral subluxation of the fourth and fifth metatarsal bones was seen before surgery but was reduced without surgical fixation. 39, No. and will collapse, resulting in dorsal frx dislocation of the metatarsal bases; - young competitive atheletes may require anatomic reduction; Removal of Plantar-Hindfoot-Midfoot Bony Mass. Thus, Nunley and Vertullo (4) hypothesized that Lisfranc ligament complex injuries initially involve the dorsal capsule, with subsequent involvement of the interosseous Lisfranc ligament and then the plantar Lisfranc ligament as greater forces are applied. However, given the superior depiction of soft-tissue supporting structures and the ability to detect soft-tissue injuries in patients with unstable injuries on MR images (51), the American College of Radiology Appropriateness Criteria guidelines slightly favor the use of MR imaging (54). 7, No. Indirect force commonly involves twisting the foot. (c) Long-axis fat-suppressed proton-densityweighted MR image of the left midfoot demonstrates the oblique course of the interosseous Lisfranc ligament (arrows). 108, No. These structures provide the stability and maintenance of the keystone position of M2 within the transverse arch. - Closed Reduction Percutaneous Pinning 5, The Journal of Emergency Medicine, Vol. 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. Figure 5a Common patterns of Lisfranc fracture-displacement in the left foot, according to the Quen and Kss (36) classification system. Table 3: Nunley-Vertullo Classification of Low-Grade Midfoot Sprains. (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. METHODS: Seventy-eight Lisfranc injuries with first TMT joint dislocation were finally enrolled and analyzed in a prospective, randomized trial comparing ORIF and PA. (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). This mus- cle provides inversion and plantar flexion power to the foot. 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. - ref: Prediction of midfoot instability in the subtle Lisfranc injury. 8, Journal of Orthopaedic Research, Vol. Although several researchers have noted the benefits of MR imaging of these structures, few have assessed its role in accurate diagnosis of these injuries. 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. Figure 2c Diagrams show the normal three-column anatomy of the Lisfranc ligament complex in the left foot. Note that there is less than 2 mm between C1 and M2 and between M1 and M2. This is the most common injury mechanism seen in football players and can occur when a force (eg, a falling body) is applied to the heel of a plantar-flexed foot in a player whose knee is on the ground (30). These factors may cause diagnostic delays and lead to subsequent morbidities, such as midfoot instability, deformity, and debilitating osteoarthritis. However, Lisfranc did not describe the injury patterns or mechanisms of injury that occur at this articulation. Diagnostic difficulties and injury sequelae likely contribute to the high rate of litigation surrounding Lisfranc injuries (16). C = cuneiform, M = metatarsal. Divergent injuries involve subluxation or dislocation of the first metatarsal medially, while the other metatarsal bones move laterally (Figs 5, 6). Lisfranc's fracture-dislocations: etiology, radiology, and results of treatment. - metatarsals are displaced in saggital and coronal planes; An estimated 20% of all Lisfranc injuries are initially undiagnosed clinically, which could reflect their subtle initial presentation or the fact that they may occur with polytrauma and may be overlooked while other critical injuries are being addressed (10,11). (a) Initial anteroposterior nonweight-bearing radiograph of the foot shows normal osseous alignment of the medial and middle columns. The treatment of tarsometatarsal injuries. However, injury to the lateral branch of the deep perineal nerve can result in extensor hallucis brevis and extensor digitorum brevis muscle edema in the acute setting and muscle atrophy with or without fatty infiltration in more chronic injuries (53). Diagnosis is made with bilateral focused shoulder radiographs to assess for AC and CC interval widening. (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. (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). (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. Several findings of Lisfranc joint injury have been described at MR imaging. C = cuneiform, M = metatarsal. Although the Myerson classification system is not always useful for directing treatment or determining clinical outcomes for lower-grade injuries, Gaweda et al (37) reported that type B injuries had the worst functional outcome in a study of 41 patients. 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. Figure 8b Nunley-Vertullo stage II left midfoot Lisfranc injury in a 58-year-old man who fell while bicycling. - navicular compression fractures; 6, Foot & Ankle International, Vol. Lisfranc's fracture-dislocations: etiology, radiology, and results of treatment. 3, Techniques in Foot & Ankle Surgery, Vol. 56, No. Recognize common radiographic, CT, and MR imaging findings of injuries to the Lisfranc joint complex. The intertarsal ligaments (C1-C2, C2-C3, and C3-cuboid) are thick strong attachments that bridge the adjacent cuneiforms and the cuboid. Figure 8a Nunley-Vertullo stage II left midfoot Lisfranc injury in a 58-year-old man who fell while bicycling. (a) Anteroposterior nonweight-bearing radiograph shows medial dislocation of M1, with lateral dislocation of M2M5 and a cuboid fracture. interosseous ligament ("Lisfranc ligament proper") plantar ligament: sends bundles to the second and third metatarsal bases (variable) Radiographic features MRI The Lisfranc ligament can have a homogeneous low signal or striated appearance with low-to-intermediate signal intensity on MR images 1,3,4. oblique coronal sequences 11, 9 September 2019 | RadioGraphics, Vol. 2022 Dec;21(4):316-321. doi: 10.1016/j.jcm.2022.02.018. The marrow edema seen at M1 likely represents an infraction, although no discrete fracture line was detected. The authors thank David C. Botos for providing the medical illustrations. 2013. (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). - ref: Outcomes of Lisfranc Injuries in the National Football League. (a) Preoperative anteroposterior radiograph shows a divergent Lisfranc fracture-dislocation. (c) Long-axis fat-suppressed proton-densityweighted MR image of the left midfoot demonstrates the oblique course of the interosseous Lisfranc ligament (arrows). 12, Archives of Orthopaedic and Trauma Surgery, Vol. - dorsal capsule of Lisfranc's joint, lacking sufficienct reenforcement, will to support the load These chip fractures are virtually pathognomonic of high-impact Lisfranc fracture-displacements and are seen in about 90% of these injuries (7). Data Trace is the publisher of A study by Preidler et al (46) showed that 50% more metatarsal and twice as many tarsal fractures were seen at CT than at radiography. 4, Magnetic Resonance Imaging Clinics of North America, Vol. In basic terms, it is a sprain of the Lisfranc ligament, also known as the oblique interosseous ligament. 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) Lateral weight-bearing radiograph demonstrates continuity of the dorsal surface of the M1 base and C1 (dashed white line). Figure 1c Normal osseous anatomy of the Lisfranc joint complex. NAV = navicular. 43, No. 24, No. When findings on initial radiographs are normal or questionable and true weight-bearing images cannot be obtained, stress images (usually obtained using anesthesia to minimize patient discomfort) can demonstrate instability or malalignment. Anatomical restraints to dislocation of the second metatarsophalangeal joint and assessment of a repair technique. talometatarsal angulation require operative treatment; (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. - however, x-ray findings may not correlate w/ clinical findings; Diagnosis is confirmed by radiographs which may show widening of the interval between the 1st and 2nd ray. We will review relevant anatomy and biomechanics, mechanisms of injury, clinical presentation, imaging studies, and diagnostic techniques and treatment. 64, No. Table 1: Quen and Kss Classification of High-Grade Lisfranc Fracture-Displacements. 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. (c) Long-axis fat-suppressed proton-densityweighted MR image of the left midfoot demonstrates the oblique course of the interosseous Lisfranc ligament (arrows). The left foot shows the advanced stage of an untreated Lisfranc injury with similar first ray instability. This is a significant finding which indicates disruption of the Lisfranc ligament Careful assessment of alignment is always required in suspected midfoot injury If the initial X-ray is normal then repeat images with weight-bearing or CT may be required Foot - Lisfranc injury Hover on/off image to show/hide findings Foot - Lisfranc injury (c) Long-axis reconstructed computed tomography (CT) image of the midfoot shows the second metatarsal base (M2; arrow) recessed between the medial and lateral cuneiforms (C1 and C3) and forming a mortise-and-tenon joint that helps preserve joint alignment. Isolated injuries are the least common and consist of displacement of one or two of the metatarsal bones. 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. The injury was seen only on an anteroposterior weight-bearing radiograph. - pain & swelling in midfoot w/ tenderness along Lisfranc's joint; The fibers are sharply defined, and there is no periligamentous edema. 5, 6 May 2019 | RadioGraphics, Vol. Although early researchers attempted to categorize injuries according to their mechanism (3234), the systems were often cumbersome and impractical for clinical use (35). MeSH The third cuneometatarsal, or lateral longitudinal, ligament (C3-M3) extends laterally between C3 and M3, and the plantar intermetatarsal ligaments (M2-M3, M3-M4, and M4-M5) bridge the lesser (second through fifth) metatarsals. The tarsometatarsal, or Lisfranc, joint complex is a complicated skeletal and capsuloligamentous structure that provides stability to the midfoot and forefoot. The Radiograph illustrating diabetic patient with first ray instability of the right foot. (b) Sagittal reformatted CT image in the same patient shows advanced tarsometatarsal arthropathy and fragmentation (arrow), findings that suggest developing neuropathic arthropathy. with the other metatarsals dislocated; (c) Long-axis reconstructed computed tomography (CT) image of the midfoot shows the second metatarsal base (M2; arrow) recessed between the medial and lateral cuneiforms (C1 and C3) and forming a mortise-and-tenon joint that helps preserve joint alignment. Drawings show homolateral (a), isolated (b), and divergent (c) fracture-displacements. - all 5 metatarsals are displaced in the same direction; The injury is named after Jacques Lisfranc de St. Martin, a French surgeon and gynecologist who noticed this fracture pattern amongst cavalry men, in 1815, after the War of the Sixth Coalition. Enter your email address below and we will send you the reset instructions. This system is a modification of an earlier method reported by Hardcastle et al (35), which is itself a modification of the original Quen and Kss system. He had a LisFranc injury with a break to the 2nd-4th rays. Flashcards (0) Cards 1 of 0. (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). CT images can help verify radiographic findings and locate subtle fractures. All rights reserved, University of Washington, Department of Orthopaedics and Sports Medicine, Lisfranc Open Reduction and Internal fixation, Proximal Chevron Osteotomy with Plate Fixation, Removal of Plantar-Hindfoot-Midfoot Bony Mass, AP, lateral and oblique of the affected foot, Bilateral weight-bearing views if non-weight-bearing views are inconclusive, identifies indications for nonoperative treatment, non-displaced injuries that are stable with weight bearing, nonoperative candidates: nonambulatory patients, presence of serious vascular disease, cast placement and close radiographic followup, check for diffuse swelling at the midfoot. 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. A nonweight-bearing cast should be used for 6 weeks; if pain continues after cast removal, a removable boot should be used for 4 additional weeks (55). (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). Note that there is less than 2 mm between C1 and M2 and between M1 and M2. Subtalar Arthrodesis. Figure 4a Common indirect forces that result in Lisfranc joint complex injury in the right foot. Additional soft-tissue structures that help stabilize the Lisfranc joint include the anterior tibial tendon and its broad insertion along C1 and the dorsomedial aspect of M1, the posterior tibialis and peroneus longus tendons, the plantar fascia and long plantar ligament, and the intrinsic midfoot and forefoot muscles. government site. Stage II injuries demonstrate a 25-mm diastasis between C1 and the base of M2, with no loss in arch height. The authors believed that this was related to initial misdiagnosis or undertreatment because type B injuries may be the most subtle radiographically and clinically. 1, Seminars in Roentgenology, Vol. Figure 3e Normal anatomy of the Lisfranc ligament complex. Lisfranc Open Reduction and Internal Fixation Ben Sharareh MD Ventura Orthopedics Orthobullets Team Orthobullets Team TECHNIQUE VIDEO TECHNIQUE STEPS 14 TECHNIQUE STEPS Preoperative Patient Care Operative Techniques Postoperative Patient Care Evidence ( 4 ) evidenceFootprint HIDE EVIDENCE Sort by EF L1\L2 Evidence Date EXPERT COMMENTS ( 4 ) - mechanism: (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 two most common mechanisms of indirect low-impact injuries are forefoot-abduction and forced plantar-flexion injuries (Fig 4). 32, No. Figure 13c Complications after surgical treatment of Lisfranc ligament complex injuries. 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). - Subtle injuries of the Lisfranc joint (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). II. The disadvantages of ORIF include the need to remove the screws, potential screw breakage, articular damage to the involved joints, and the risk of subsequent osteoarthritis (11,55). Quenand Kss.The earliest and most basic classification system was published in 1909 by Quen and Kss (36) (Table 1). The peroneus longus (PL) and flexor hallucis longus (FHL) tendons are also shown. Injury. Lisfranc joint injuries: trauma mechanisms and associated injuries. When Lisfranc injuries are missed or undertreated, they can lead to significant midfoot instability, planovalgus deformity, and osteoarthritis (15). Arrowhead indicates the peroneus longus tendon, which could become entrapped at the site of injury and prevent adequate healing. Several classification systems have been developed to describe injuries of the tarsometatarsal joint. Figure 6c Left midfoot divergent Lisfranc fracture-dislocation in a 32-year-old woman who jumped from a 12-ft height. (e) Short-axis fat-suppressed proton-densityweighted MR image through the left midfoot shows portions of the plantar Lisfranc ligament (pC1-M2M3; arrow). 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. (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). Lisfranc Fracture Dislocation. 59, No. - See: Midfoot/Forefoot Fractures The injury mechanism often influences the imaging findings, and classification systems based primarily on imaging features have been developed to help diagnose and treat these injuries. Bethesda, MD 20894, Web Policies C = cuneiform, Cu = cuboid, M = metatarsal. (a) Anteroposterior nonweight-bearing radiograph demonstrates subtle widening between C1 and M2 (arrows). (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. (b) Postoperative anteroposterior radiograph shows plate and screw fixation of the medial and middle columns of the midfoot, with anatomic alignment. Previous Next S; Enter (frontside only) 20% 1; N 40% 2; H 60% 3 F; Enter (backside only) 80% 4; E 100% 5; M . Proximal 2/3 of lateral supracondylar ridge of humerus. In cases of trauma, radiographic assessment consists of unilateral anteroposterior, lateral, and 30 internally rotated oblique nonweight-bearing images (29). 4, International Journal of Emergency Medicine, Vol. Currently, bone scintigraphy is rarely used for diagnosis of Lisfranc injuries and has been largely supplanted by CT and MR imaging, which offer better spatial resolution and more direct evaluation of the Lisfranc joint complex. MR imaging evaluation of subtle Lisfranc injuries: the midfoot sprain. Figure 1a Normal osseous anatomy of the Lisfranc joint complex. Missed Lisfranc ligament injuries are among the most common causes of litigation against radiologists and emergency department physicians. The ligament can either be uniformly low in signal intensity or striated with intermediate signal intensity, as shown. J Postgrad Med. (a) Drawing demonstrates the forefoot abduction mechanism, with the hindfoot in a fixed position and the forefoot rotated or abducted. (c) Long-axis fat-suppressed proton-densityweighted MR image of the left midfoot demonstrates the oblique course of the interosseous Lisfranc ligament (arrows). 1, American Journal of Roentgenology, Vol. Although initial image acquisition using this technique is long (>10 minutes), performing thin-section imaging through the region and obtaining multiplanar reformatted images may improve visualization of tarsometatarsal joint complex injuries (48). Please enable it to take advantage of the complete set of features! (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). Recently, 3D fast spin-echo (SE) volumetric SPACE MR imaging has been used to optimize assessment of the Lisfranc ligamentous complex (Fig 3). Orthopaedic Specialists of North Carolina. 51, No. (e) Short-axis fat-suppressed proton-densityweighted MR image through the left midfoot shows portions of the plantar Lisfranc ligament (pC1-M2M3; arrow). - Lisfranc injuries w/o fracture have poor prognosis, with late midfoot collapse a common sequela; For stage III injuries with more significant displacement, the Myerson classification system is used to describe the injury pattern. 24, No. It could be due to apparent sprain, obvious injury or severe dislocation. - cuboid frx; The Lisfranc (or Oblique) ligament secures the second metatarsal to the medial cuneiform, serving as a mortise joint anchoring the entire complex and preventing medio-lateral or plantar displacement. Data Trace Publishing Company The ligament can either be uniformly low in signal intensity or striated with intermediate signal intensity, as shown. Despite a lack of consensus about the workup of suspected midfoot sprains, conventional radiography is usually the initial imaging study performed. (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. The Myerson system subdivides injuries into categories of complete incongruity, in which all of the tarsometatarsal joints are disrupted, and partial incongruity, in which only some of the tarsometatarsal joints are disrupted. (a) Long-axis T2-weighted fast SE MR image of the midfoot shows elongation and thinning of the interosseous Lisfranc ligament, with periligamentous edema (arrow). Myerson.The most common classification system currently used to describe Lisfranc fracture-displacements was developed by Myerson et al (28) (Table 2). Injury to the interosseous and plantar Lisfranc ligaments is the primary cause of transverse midfoot instability that results in tarsometatarsal widening of C1-M2. However, the ligament is intact. (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). (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. Further stabilization of the tarsometatarsal joint is provided by a complex arrangement of ligaments that are divided into dorsal, interosseous, and plantar components that connect the tarsometatarsal, intertarsal, and intermetatarsal articulations. Types of Lisfranc Injuries There are three types of Lisfranc injuries, which sometimes occur together: Sprains. Lisfranc injuries are a spectrum of injuries of the tarsometatarsal joints. The ligament can either be uniformly low in signal intensity or striated with intermediate signal intensity, as shown. - tenderness w/ passive abduction & pronation of forefoot w/ hindfoot held fixed in the examiner's opposite hand; Objectives: To systematically review current diagnostic imaging options for assessment of the Lisfranc joint. A review of 20 cases, Anatomical restraints to dislocation of the second metatarsophalangeal joint and assessment of a repair technique, Fracture dislocations at the tarsometatarsal joints, end results correlated with pathology and treatment, Fractures and fracture dislocations of the tarsometatarsal joint, Orthopaedic Specialists of North Carolina. (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 peroneus longus (PL) and flexor hallucis longus (FHL) tendons are also shown. A Lisfranc injury is a tarsometatarsal fracture dislocation characterized by traumatic disruption between the articulation of the medial cuneiform and base of the second metatarsal. Han PF, Zhang ZL, Chen CL, Han YC, Wei XC, Li PC. This mechanism can result in a cuboid compression fracture (nutcracker injury). The osseous arrangement of these bones provides the inherent stability of the joint complex. Figure 4b Common indirect forces that result in Lisfranc joint complex injury in the right foot. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. The fibers are sharply defined, and there is no periligamentous edema. In some instances, both modalities may be needed to fully characterize bone and soft-tissue injuries. The injury was seen only on an anteroposterior weight-bearing radiograph. (b) Sagittal reformatted CT image in the same patient shows advanced tarsometatarsal arthropathy and fragmentation (arrow), findings that suggest developing neuropathic arthropathy. A prospective, randomized study. Tarsalmetatarsal Arthrodesis. 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. (OBQ20.15) Figure A is the radiograph of a 55-year-old female who is a poorly-controlled diabetic with neuropathy and peripheral vascular disease (PVD) that underwent ankle open reduction internal fixation (ORIF) two years ago at an outside facility. Dr Graham Lloyd-Jones BA MBBS MRCP FRCR - Consultant Radiologist - 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). He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. 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). - isolated: one or two metatarsals are displaced from the others; The tarsometatarsal joint, or Lisfranc joint , is the articulation between the tarsus ( midfoot ) and the metatarsal bases ( forefoot ), representing a combination of tarsometatarsal joints. The site is secure. However, at bone scintigraphy, increased radiotracer uptake is seen within the joint. Although several different mechanisms have been proposed, the exact mechanism in a particular case depends on the direction of the force and the position of the foot at impact. Magn Reson Imaging Clin N Am. Lateral border of 1st metatarsal is aligned with lateral border of 1st (medial) cuneiform. When the bones don't line up it can put pressure on the blood vessels of the foot. C = cuneiform, M = metatarsal. - w/ questionable injury, consider wt bearing AP view to assess 1-2 interval; C = cuneiform, Cu = cuboid, M = metatarsal. 10, BMC Musculoskeletal Disorders, Vol. The treatment of tarsometatarsal injuries. Lisfranc fracture-displacements are relatively rare, with a reported incidence of one per 55,000 people in the United States annually (5,6). Abstract. 19, No. Additional modalities such as radiographic stress imaging, CT, and MR imaging can be used to detect Lisfranc injuries and assess the degree of injury. axis of1st metatarsal and normally forms a straight line These structures can be injured, particularly during high-velocity mechanisms, and injury can lead to compartment syndromes and midfoot arthropathy (27). 25, No. (f) Axial proton-densityweighted MR image of the left midfoot demonstrates the M3 bundle of the plantar Lisfranc ligament (pC1-M2M3; arrow). Stage I injuries represent a low-grade sprain of the Lisfranc ligament complex and a dorsal capsular tear, where the joint itself remains stable. 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). - homo-lateral: Salisbury NHS Foundation Trust UK The ligament can either be uniformly low in signal intensity or striated with intermediate signal intensity, as shown. Although there are strong intermetatarsal ligaments between M2 and M5, no substantial intermetatarsal connection is seen between the dorsal M1 and M2 bases (22). (c) Sagittal reformatted CT image in a 48-year-old woman with progressive left flat-foot deformity who presented with plantar midfoot pain and a palpable abnormality 8 months after ORIF of the first and second tarsometatarsal joints shows the distal tip of one of the screws protruding into the plantar soft tissues (arrow) and causing mass effect on the flexor hallucis longus tendon, with effacement of the medial midfoot arch (arrowhead). While most metatarsal fractures can be treated with some form of immobilization and protected weight-bearing, this article will distinguish these more common injuries from those requiring surgical intervention. 8600 Rockville Pike (b) Lateral weight-bearing radiograph demonstrates continuity of the dorsal surface of the M1 base and C1 (dashed white line). (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. Figure 7a Radiographs of the left midfoot show the normal osseous relationships of the medial and middle columns. Loss of alignment of the 2nd metatarsal base with the intermediate cuneiform indicates injury to this important ligament. (b) Anteroposterior weight-bearing radiograph shows a gap of more than 2 mm between C1 and M2 and between M1 and M2 (arrow). - on non-stressed views, frx at base of 2nd metatarsal or anterior aspect of cuboid may most obvious ); and Department of Radiology, Northwestern University Feinberg School of Medicine, 676 N Saint Clair St, Suite 800, Chicago, IL 60611 (M.S.G., I.M.O.). The Lisfranc ligament complex is composed of three distinct obliquely oriented ligaments: the Lisfranc ligament proper, which is the interosseous C1-M2 ligament; the dorsal Lisfranc ligament, which connects the dorsum of C1 and M2; and the plantar Lisfranc ligament, which can have a variable appearance but most commonly has a single origin from the plantar surface of C1 and sends separate bundles to the plantar surface of the M2 and M3 bases (pC1-M2M3) (Fig 3) (21). (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). Treatment is immobilzation or surgical reconstruction depending on patient activity levels, degree of separation and degree of ligament injury. The fibers are sharply defined, and there is no periligamentous edema. These injuries also can occur in ballerinas, dancers, and gymnasts who forcefully land in a tiptoe plantar-flexed position and in nonathletes after a misstep or a fall from stairs or a curb (3,9,31). C = cuneiform, p = plantar. 28, No. A focused history and physical examination must be coupled with a thorough review of imaging studies to identify the correct diagnosis. (b) Postoperative anteroposterior radiograph shows plate and screw fixation of the medial and middle columns of the midfoot, with anatomic alignment. - frx of base of second metatarsal; For treatment of the lateral column, if the fourth and fifth tarsometatarsal joints are reduced, no treatment is necessary. 212, No. Careers. 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. 2, Seminars in Roentgenology, Vol. The radiographic signs of Lisfranc injuries can be subtle, and it is important to understand the patterns of these injuries to aid in diagnosis and help clinicians assess treatment options and prognosis. (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. Lisfranc (Midfoot) Injury Lisfranc (midfoot) injuries result if bones in the midfoot are broken or ligaments that support the midfoot are torn. In patients with clinically suspected Lisfranc injuries and normal or indeterminate radiographic findings, CT or MR imaging may be used. - disrupted skin and excessive swelling are relative contra-indications for ORIF; (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. The lateral (a), middle (b), and medial (c) columns are shown. (a) Anteroposterior nonweight-bearing radiograph demonstrates subtle widening between C1 and M2 (arrows). Figures 5-6: This patient had a crush injury to his foot. A competency based surgical skill training & evaluations system that is mobile, user-friendly, and improved technical training. The https:// ensures that you are connecting to the Diabetic Conditions. 12, Journal of Orthopaedic Surgery and Research, Vol. Figure 9a Left midfoot low-grade sprain in an 11-year-old boy after a fall. (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). This causes lots of swelling which can be seen in the picture of his foot. However, bone scintigraphy may be useful for diagnosis of low-grade injuries when other imaging modalities do not depict abnormalities. Figure 2b Diagrams show the normal three-column anatomy of the Lisfranc ligament complex in the left foot. - divergent: sharing sensitive information, make sure youre on a federal Again, a diastasis of more than 2 mm between the M1 and M2 bases is considered abnormal. 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. - metatarsalgia:may occur from displacement in the saggital plane; The authors divided Lisfranc fracture-displacements into three categories: homolateral, isolated, and divergent. (c) Long-axis fat-suppressed proton-densityweighted MR image of the left midfoot demonstrates the oblique course of the interosseous Lisfranc ligament (arrows). Figure 6a Left midfoot divergent Lisfranc fracture-dislocation in a 32-year-old woman who jumped from a 12-ft height. 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. (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). A healthy 28-year-old male presents to the trauma bay after being involved in an MVC. Outcomes of Lisfranc Injuries in the National Football League. Although Lisfranc sprains can be difficult to detect at physical examination and imaging, they can be a source of significant morbidity for athletes, with one series reporting that 18% of patients were unable to return to their sport after injury (9). The normal interosseous Lisfranc ligament has variable dimensions, with a length of 9 mm 1.5 and a width of 5 mm 1.3 seen on axial images that depict the ligament in the long axis (Fig 3) (21). Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. (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). 41, No. Lines 1 and 2 are assessed on the AP view. (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). (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). Open reduction internal fixation versus primary arthrodesis for lisfranc injuries: a prospective randomized study. On the x-ray of the side of the foot the blue lines should line up. Weight-bearing x-rays are an alternative to MRI to assess the integrity of the Lisfranc joint. Subtle radiographic changes can represent significant ligamentous Lisfranc injury. The ligament can either be uniformly low in signal intensity or striated with intermediate signal intensity, as shown. The plantar surface of the M1 base (black line) is superior to the plantar surface of the M5 base (solid white line). - ref: Arthrodesis versus ORIF for Lisfranc fractures. (f) Axial proton-densityweighted MR image of the left midfoot demonstrates the M3 bundle of the plantar Lisfranc ligament (pC1-M2M3; arrow). Forefoot-abduction injuries occur when the hindfoot position is fixed and the weight of the body rotates around the tarsometatarsal joint, resulting in ligament failure and consequently causing lateral displacement of the lesser metatarsals. - w/ symptomatic posttraumatic arthritis, consider arthrodesis; - Physical Exam: The articular surfaces of the second and first metatarsal are level in the transverse plane, indicating proximal migration of the first ray. NAV = navicular. (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). theYear=now.getFullYear() A widening of more than 2 mm between C1 and C2 suggests additional C1-C2 intercuneiform ligament injury. 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