Your diagnosis? Midfoot sprain: Lisfranc ligament disruption

Imaging of Acute Ankle and Foot Sprains

Ankle and foot injuries are very common injuries in the general population, and more so in athletes. MR imaging is the optimal modality to evaluate for ligamentous injuries of the ankle and associated conditions after ankle sprain. In this article, the authors discuss the epidemiology, biomechanics, normal anatomy, and pathology of the ankle as well as injuries of the hindfoot and midfoot that are often associated with ankle injuries.

Undisplaced subtle ligamentous Lisfranc injuries, conservative or surgical treatment with percutaneous position screws?

PURPOSE

Undisplaced subtle ligamentous Lisfranc injuries are easy to miss or underestimate, and many cases are treated without surgical fixation. It has not yet widely known whether conservative treatment for undisplaced subtle ligamentous Lisfranc injuries may lead to a poor outcome. The purpose of this study is to compare the outcomes of conservative versus surgical management (percutaneous position screw) of undisplaced subtle ligamentous Lisfranc injury.

METHODS

We analysed 61 cases in this retrospective study, including 38 males and 23 females. Forty-one patients were managed conservatively, while 20 patients received surgical treatment involving minimal invasive percutaneous position screw. American orthopaedic foot &ankle society (AOFAS), foot function index (FFI, including FFI disability, FFI pain score and activity limitation scale) scores, Maryland foot score and short form-36 (SF-36) were recorded and compared after a follow-up of 10-16 months (average 12.3).

RESULTS

Patients in the surgical management group had higher scores in all evaluation methods (p < 0.05). The complications in the conservative management group had higher incidence, mainly including secondary diastasis (34.1% vs. 5.0%), joint stiffness after 3 months (82.9% vs. 0%), and secondary arthrodesis (12.2% vs. 0%). The highest rate of complication in surgical management group was temporary forefoot pain (55.0%).

CONCLUSION

The results of this study suggest that the outcomes of the surgical management with percutaneous position screw fixation are better than the conservative management to treat undisplaced subtle ligamentous Lisfranc injuries. This study can serve as a resource for orthopaedic surgeons in recognizing and managing such injuries.

The Role of Percutaneous Reduction and Fixation of Lisfranc Injuries

To be able to perform percutaneous fixation of Lisfranc injuries, this article emphasizes that an anatomic reduction must be mandatory. When uncertainty remains as to whether closed reduction is anatomic, formal open reduction is recommended because accuracy of reduction is correlated with long-term outcome. Closed injuries with minimal displacement, bony avulsions, and skeletally immature individuals seem the most appropriate indications for percutaneous fixation. Not all injuries are ideal for this method of treatment, and this is an area that needs to be more clearly defined in the future.

Lisfranc injury in a west point cadet

Background:

Lisfranc joint injuries are fairly uncommon; however, few injuries hold such an elevated potential for devastating chronic secondary pain and disability. It is imperative when evaluating an injury to the ankle or foot to have a high clinical index of suspicion for Lisfranc injury, as physical examination findings are often subtle.

Case Description:

An 18-year-old military cadet reported to a direct-access sports physical therapy clinic with foot pain. Despite negative radiographic findings, there was a high suspicion for Lisfranc injury based on the injury mechanism and physical examination. A computed tomography scan demonstrated an oblique fracture through the base of the third metatarsal, a small marginal fracture at the plantar base of the second metatarsal, and a subtle diastasis. Two days following his injury, he underwent an open reduction and internal fixation, completed subsequent rehabilitation, and returned to full activity approximately 1 year following injury.

Conclusion:

Early diagnosis of Lisfranc injuries is imperative for proper management and prevention of a poor functional outcome. If a strong clinical suspicion exists, negative radiographic findings are insufficient to rule out a Lisfranc injury, and therefore, advanced imaging is required.

Lisfranc injuries: an update

Lisfranc injuries are a spectrum of injuries to the tarsometatarsal joint complex of the midfoot. These range from subtle ligamentous sprains, often seen in athletes, to fracture dislocations seen in high-energy injuries. Accurate and early diagnosis is important to optimise treatment and minimise long-term disability, but unfortunately, this is a frequently missed injury. Undisplaced injuries have excellent outcomes with non-operative treatment. Displaced injuries have worse outcomes and require anatomical reduction and internal fixation for the best outcome. Although evidence to date supports the use of screw fixation, plate fixation may avoid further articular joint damage and may have benefits. Recent evidence supports the use of limited arthrodesis in more complex injuries.

Foot and ankle update

The purpose of this foot and ankle update is to educate the reader on important foot and ankle topics including current controversies, physical examination, diagnostics, and management. Quick-view lists are used to give easy access to the most significant knowledge points for providing patient care for these entities. These topics were chosen either because they are very common or because of the high morbidity involved should there be a misdiagnosis or mismanagement.

Epidemiology, imaging, and treatment of Lisfranc fracture-dislocations revisited

The purpose of this article is to discuss the features of Lisfranc injuries and identify their typical imaging findings on radiographs, CT, and MR imaging. Lisfranc injuries are most often caused by hyperplantarflexion of the foot, often during a sporting injury or in high-speed motor vehicle collisions. The most common radiographic findings include diastasis of the base of the first and second metatarsals and the "fleck" sign, though neither is necessarily present in every Lisfranc fracture-dislocation. Owing to their often subtle radiographic presentation, clinically suspected Lisfranc injuries warrant imaging with a more sensitive test for the detection of osseous and ligamentous Lisfranc injuries. 3D CT imaging provides a comprehensive evaluation of the injury for optimal treatment planning, with resultant decreased long-term patient morbidity. Furthermore, 3D volume-rendered CT and CT multiplanar reconstructions (MPRs) provide osseous and neurovascular anatomic detail that may be a considerable help with surgical planning for operative cases of Lisfranc injuries. Also, with 3D CT and MPRs, other occult fractures, which are common in patients with high-energy injury and multiple trauma, may become evident.

Treatment of Lisfranc joint injury: current concepts

Injuries to the tarsometatarsal joint complex, also known as the Lisfranc joint, are relatively uncommon. However, the importance of an accurate diagnosis cannot be overstated. These injuries, especially when missed, may result in considerable long-term disability as the result of posttraumatic arthritis. A high level of suspicion, recognition of the clinical signs of injury, and appropriate radiographic studies are needed for correct diagnosis. When surgery is indicated, closed reduction with percutaneous screw fixation should be attempted. If reduction is questionable, open reduction should be performed. Screw fixation remains the traditional fixation technique.