Original articleLisfranc Injury: Imaging Findings for this Important but Often-Missed Diagnosis
Section snippets
Anatomy of the Tarsometatarsal Joint
Knowledge of the anatomy of the tarsometarsal (TMT) joint can be very helpful in making the diagnosis of a Lisfranc fracture–dislocation as well as understanding potential complications of this injury and evaluating posttreatment imaging for adequacy of repair. The TMT joint represents the junction of the midfoot and forefoot and the osseous structures include the five metatarsal bases, three cuneiforms (medial, intermediate, and lateral, respectively), and the cuboid.6 The cuneiforms are named
Mechanism of Injury
The most common mechanisms of the Lisfranc fracture–dislocation involve axial load or forced supination or pronation on a plantar flexed foot. This leads to fractures of the metatarsals and tarsal bones as well as ligamentous injuries.18 These indirect mechanisms are much more common than direct mechanisms (such as crush injuries) in causing Lisfranc fracture–dislocations.
Examples of the indirect mechanism of injury include the “bunk bed” fracture in which children leaping from the top bunk of
Classification of Injury
Classification of the displaced Lisfranc injury was described by Myerson and coworkers14 based on segmental patterns of injury. Type A describes a completely incongruent tarsometatarsal joint complex with medial or lateral dislocation of the forefoot. Type B characterizes a partially incongruent injury with further subclassifications of B1 and B2, describing medial dislocation of the first metatarsal and lateral dislocation of the second to fifth metatarsals, respectively. Divergent injuries
Radiographic Findings
As radiographic findings may be subtle and patients frequently present with polytrauma, a systematic approach should be utilized when interpreting conventional radiographs for possible Lisfranc injury. There are three key anatomic relationships to analyze when examining a dorsoplantar view of the foot. First, the medial margins of the second metatarsal and the middle cuneiform should be well aligned.24, 25 Second, the lateral margin of the first metatarsal should also be aligned with the
Role of CT and MRI
CT is useful in the diagnosis of subtle midfoot malalignments and fractures as it allows for imaging in various planes and allows for visualization of unobscured anatomy. Tarsometatarsal malalignment, subtle fractures, and joint space fracture fragments are better appreciated than with conventional radiography (FIG 6, FIG 7, FIG 8). CT also allows detection of interposed bone fragments and tendons, which may impede adequate reduction27 (Fig 9). CT is advantageous as patient positioning is not
Conclusions
Although relatively rare injuries, fractures and dislocations at the Lisfranc joint are important to recognize due to the potential for chronic morbidity with missed initial diagnosis or improper treatment. Multiple factors contribute to the relatively high initial miss rate including unfamiliarity with appropriate tarsometatarsal anatomy, difficulty in obtaining adequate radiographs of the midfoot due to suboptimal positioning and bony overlap, as well as low clinical suspicion, especially in
References (30)
Treatment of the missed Lisfranc injury
Foot Ankle Clin North Am
(2006)- et al.
Dislocations and fracture dislocations of the tarso-metatarsal joints
Orthop Clin North Am
(1987) - et al.
Complications of missed or untreated Lisfranc injuries
Foot Ankle Clin North Am
(2003) - et al.
Current concepts review: Lisfranc injuries
Foot Ankle Int
(2006) Lisfranc fracture-dislocations
Clin Orthop
(1963)- et al.
Dislocation of the tarsometatarsal joint
J Bone Joint Surg Am
(1963) Dislocations of the metatarsal bone and adjacent toe
J Bone Joint Surg Br
(1964)- et al.
Lisfranc injuries
Injury Int J Care Injured
(2004) - et al.
Lisfranc's fracture-dislocation: A review of the literature and case reports
J Am Podiatr Med Assoc
(1991) - et al.
Lisfranc's fracture-dislocations: Etiology, radiology, and results of treatment—A review of 20 cases
Clin Orthop
(1983)
Strategic approach fends off charges of malpractice: Program provides tips for avoiding litigation
Diagn Imaging
Effect of compensation claims on isolated Lisfranc injuries
Subtleties of Lisfranc fracture-dislocations
AJR
Tarsometatarsal joint: Anatomic details on MR images
AJR
Fracture dislocations of the tarsometatarsal joints: End results correlated with pathology and treatment
Foot Ankle Int
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