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doi: 10.3810/psm.2010.12.1834
The Physician and Sportsmedicine: Volume 38: No.4
The Midfoot Sprain:
A Review of Lisfranc Ligament Injuries
Jaymes D. Granata, MD And Terrence M. Philbin, DO
Copyright 2010 All rights reserved. Cover and contents may not be reproduced in whole or in part without prior written permission. The Physician and Sportsmedicine is a registered trademark of JTE Multimedia, LLC. Sending and distribution of any document from this site is strictly prohibited either for free and or a service fee, and will be sited as a violation of copyright under the laws of THE UNITED STATES OF AMERICA

Abstract: The subtle clinical and radiographic findings of an unstable Lisfranc ligament injury can be easily misdiagnosed as a stable midfoot sprain. Appropriate treatment ranges from conservative management to surgery, depending on the extent of ligament disruption and subsequent joint instability. Initial evaluation with non-weight bearing radiographs is often normal in unstable injuries. The results of missed or inappropriately treated Lisfranc injuries are poor. Chronic joint instability can lead to persistent pain, degenerative joint disease, and decreased functional capacity. Inability to return to previous levels of activity may result from painful midfoot arthritis. It is important to have a high index of suspicion for unstable Lisfranc injuries in patients who present with midfoot pain after low-energy injuries. Stress radiographs and magnetic resonance imaging can help differentiate between stable and unstable ligament sprains. Referral to an orthopedic surgeon is appropriate for injuries that result in joint diastasis. Long-term outcomes are optimized by early anatomic reduction.

Keywords: Lisfranc joint; Lisfranc ligament; tarsometatarsal; midfoot; sprain; athletes

Introduction

Jacques Lisfranc de St. Martin (1790–1847) was a surgeon in the French army from 1813 to 1814 during the final years of the Napoleonic wars. He lived in a pre-modern era of surgery that was defined by no formal anesthesia, no sterile technique or antibiotics, and no radiographs. Within these limitations, many surgical procedures involved quickly amputating limbs. From his military experience treating traumatic foot injuries, frostbite, and gangrene of the toes, he developed and published a technique for amputation through the tarsometatarsal (TMT) joint. His novel method of amputation was unique in that it promoted the preservation of limb length when others would amputate at a higher level.1 From this original publication in 1815, the term Lisfranc is now used to describe a variety of anatomic and pathologic conditions involving the TMT joints. The widespread use of the term Lisfranc to describe joints, ligaments, injuries, fractures, dislocations, and subluxations can be confusing.

The aim of this article is to provide an overview of a particular type of Lisfranc injury commonly referred to as a “midfoot sprain.” This injury pattern can be challenging to diagnose, and there is controversy regarding the best surgical treatment. A high index of suspicion and thorough evaluation is needed to make an accurate and timely diagnosis. The rate of missed or delayed diagnoses range from 13% to 24%, which are primarily due to subtle radiographic findings.2 Orthopedic injuries are a common cause of malpractice litigation, and delay of > 6 months in the treatment of Lisfranc injuries has been directly related to poor long-term outcomes.3,4

The historical incidence of Lisfranc fracture dislocations is 1 per 55 000 persons, accounting for 0.1% to 0.2% of fractures.5-7 The incidence of predominantly ligamentous Lisfranc injuries is higher, particularly within certain populations. In football players, the incidence of Lisfranc ligament injuries is estimated to be 4% per year, with nearly one-third of these injuries occurring in linemen.7,8 In the pediatric literature, Lisfranc injuries have been reported in children as young as 3 years. Buoncristiani et al9 reported on 8 children (aged 3–10 years) who were treated conservatively for acute midfoot injuries. Seven of the 8 patients were pain-free at 32-month follow-up. One patient had persistent pain, decreased function, and radiographic evidence of midfoot arthritis at 3-year follow-up, indicating nonanatomic healing and instablility.9,10

Anatomy and Biomechanics

The Lisfranc (TMT) joint is the articulation between the tarsals and metatarsals, representing the junction between the midfoot and the forefoot. The forefoot is composed of the 5 metatarsals and their phalanges. The midfoot consists of the 5 tarsal bones: 3 (medial, intermediate, and lateral) cuneiform (C) bones, the navicular, and cuboid (Figure 1A, B). Stability is provided by both the wedge-shaped (C) bones, organized in a Roman arch configuration, and their strong capsuloligamentous connections. These structures form the transverse arch of the foot.

View: (Figure 1 ) - Dorsal view of the foot. A) Three regions: forefoot and midfoot, separated by the tarsometatarsal (Lisfranc) joint; midfoot and hindfoot, separated by the transverse tarsal (Chopart’s) joint. B) Osseous anatomy, distracted view.

The anatomy of the ligaments between the first and second metatarsals (M1 and M2) at the TMT joint is unique. Metatarsals 2 to 5 are connected by proximal intermetatarsal ligaments; this intermetatarsal ligament is absent between M1 and M2. The result is an alternative connection between the midfoot medial C1 and the forefoot M2. This is the Lisfranc ligament complex, which is composed of dorsal, interosseous, and plantar ligamentous structures (Figure 2).

View: (Figure 2 ) - Lisfranc ligament complex. The first metatarsal is removed revealing the dorsal, interosseous, and plantar components of the Lisfranc ligament complex.

Recent orthopedic and radiology literature has expanded on the Lisfranc ligament complex, with an emphasis on clarifying the anatomy and determining the amount of disruption, which leads to an unstable injury pattern.11-19 The dorsal ligaments are the weakest in the complex and are the first to fail in the typical indirect injury mechanism associated with subtle Lisfranc injuries. The C1-M2 interosseous ligament is the largest and strongest ligament in the complex, and is referred to as “The” Lisfranc ligament. The plantar ligament attaches C1 to M2 and M3. This C1-M2/M3 ligament is considered by some to be the primary stabilizer of the Lisfranc joint. Figure 3 provides a basic schematic of the ligamentous anatomy.

View: (Figure 3 ) - Ligaments of the midfoot. A) Simplified ligaments; B) dorsal ligaments; C) interosseous ligaments; and D) plantar ligaments.
Mechanism of Injury

Disruption of the TMT joint complex can occur through various loading scenarios, which are categorized as either direct or indirect loads. The amount of energy involved in the injury is also important to consider, as higher-energy injuries with displaced fractures, dislocations, and compromised soft tissue may require immediate surgical attention. Crush injuries are an example of a direct loading mechanism that may result in severe soft tissue damage and compartment syndrome. These injuries may cause displacements in any direction depending on the applied force.

Indirect loading mechanisms typically result in dorsal or medial/lateral displacements. This is due to the typical injury mechanism of forced abduction/adduction or hyperplantarflexion with axial loading. The dorsal ligamentous and soft tissue restraints are much weaker than the plantar structures, resulting in the characteristic dorsal displacements. These injuries are more common in the athletic population and have been reported in all types of sporting and recreational activities, including football, basketball, baseball, soccer, hockey, ballet, mountain biking, and windsurfing.20-24 A classic mechanism is described in football linemen, wherein an axial load is applied to the heel of a fixed plantarflexed ankle with the toes in dorsiflexion. Depending on the severity of injury, the TMT joints can remain intact, subluxate, or present as an obvious dislocation.

Injury Classification

There is no universal classification system for Lisfranc injuries. Various classifications have been proposed, which have generally focused on either the mechanism of injury or the resultant displacement patterns. Tarsometatarsal joint injuries generally present in 1 of 2 ways: fracture dislocations with obvious displacement or primarily ligamentous injuries with subtle diastasis. Two classification systems are commonly used to address these categories: the Myerson classification for displaced injuries and the Nunley and Vertullo system for subtle diastasis.7,25

The Myerson classification is a modification of a system that evolved over the past century, beginning with an observational study by Quenu and Kuss in 1909.26 Three basic radiographic displacement patterns were described in their study: divergent, homolateral, and isolated. When all 5 metatarsals were involved, the injury was classified as either divergent or homolateral, depending on the direction of displacement. If only a portion of the TMT joint was injured, they referred to the injury as isolated. In 120212, Hardcastle et al27 published a retrospective case series of TMT joint fracture dislocations and proposed a classification system that could be used to guide treatment. Their system was a modification of the Quenu and Kuss classification with 3 types: Type A (total incongruity), Type B (partial incongruity), and Type C (divergent). This framework provided the basis for the Myerson classification system of Lisfranc fracture dislocations.

Primarily ligamentous injuries (midfoot sprains) do not typically present with obvious displacement. Nunley and Vertullo7 proposed a classification system for midfoot sprains with more subtle radiographic findings. Their classification system was based on a series of Lisfranc injuries in athletes, and provides a basis for surgical treatment. There are 3 stages, depending on the extent of injury: stage 1 injuries are Lisfranc ligament sprains with no diastasis or loss of arch height, as seen on weightbearing radiographs. These were diagnosed by an increased uptake on bone scan in their original series. Stage 2 injuries are Lisfranc ligament ruptures with 2 to 5 mm of diastasis between M1 and M2, but no loss of arch height on lateral weightbearing radiograph. Stage 3 injuries result in diastasis of 2 to 5 mm between M1 and M2 on anteroposterior radiographs and loss of arch height on lateral radiograph (Figure 4). For any injuries that result in obvious displacement, Nunley and Vertullo7 recommend using the Myerson classification to characterize the injury.

View: (Figure 4 ) - Nunley and Vertullo midfoot sprain classification. Stage 1: Lisfranc ligament sprain, no diastasis or loss of arch height. Stage 2: Ruptured Lisfranc ligament with 2–5 mm of diastasis between the first and second metatarsal, with no loss of arch height. Stage 3: Ruptured Lisfranc ligament with 2–5 mm of diastasis and loss of longitudinal arch height, represented by a decreased distance between the plantar aspect of the fifth metatarsal bone and the plantar aspect of the medial cuneiform bone on an erect lateral radiograph.
Diagnosis

A thorough history and physical examination should raise suspicion of a midfoot sprain in the majority of cases. There will be some variability in presentation depending on the extent of injury and patient-specific characteristics. Therefore, a high index of suspicion is required to make an accurate and timely diagnosis. Patients with diabetes and peripheral neuropathy may not report the high level of pain that would be expected with an acute Lisfranc injury. The reported mechanism of injury may also be trivial, such as stepping off of a curb or twisting the foot. Despite the potential wide variation in presentation, once a midfoot injury is suspected, the physician should attempt to exclude an unstable injury that requires surgical intervention.

The physical examination is critical for identifying the correct injury site. In the acute injury phase, patients will have difficulty bearing full weight on the injured extremity. A complete inspection of the foot and ankle complex should be noted, including the plantar aspect of the foot. The plantar ecchymosis sign is bruising noted on the plantar medial aspect of the foot and is often associated with Lisfranc injuries (Figure 5A, B).28 Palpation for areas of point tenderness and range of motion of the individual TMT joints can help identify which joints are affected within the foot. Provocative maneuvers, such as the piano key test and the pronation abduction test, will elicit pain when an injury is present, but may not be well tolerated by patients with acute injuries.29,30

View: (Figure 5 ) - A) Diffuse swelling across the foot after an acute injury. B) Plantar ecchymosis sign.

Imaging of the midfoot should begin with 3-view weightbearing plain radiographs of the foot. Non-weight bearing radiographs have been associated with a 50% missed diagnosis rate when an unstable injury was present.7 Many patients will have difficulty with weight bearing in the acute phase, which will make it difficult to obtain radiographs. Patients may require either an ankle block prior to weightbearing or manual stress radiographs, or an examination (under anesthesia) with manual stress views to determine stability. If non-weight bearing radiographs are obtained, any obvious fractures or dislocations will be noted, but the integrity of the Lisfranc joint cannot be determined if no displacement is seen. A fracture around an apparently reduced Lisfranc joint may also make the diagnosis difficult. Concomitant injuries are not uncommon, especially M2 fractures, even with low-energy mechanisms. Figure 6 shows a patient who presented with foot pain after stepping off of a curb. The patient was diagnosed with a spiral M2 fracture, and was treated with a hard-sole shoe, weight bearing as tolerated. The patient presented to the clinic 3 months after the initial injury with continued pain despite healing of the fracture. Close inspection of the follow-up radiographs revealed subtle diastasis between M1 and M2 with a small area of calcification. If an anatomic reduction is not obtained with surgical management, there will most likely be continued pain and limited physical activities because of TMT joint arthritis.

View: (Figure 6 ) - Standing anteroposterior radiograph of the left foot: spiral second metatarsal fracture and Lisfranc ligament injury.

Other imaging modalities, such as bone scan, ultrasound, computed tomography (CT) scans, and magnetic resonance imaging (MRI), have all been used to further evaluate suspected Lisfranc injuries. Bone scans can confirm the suspicion of an injury to the TMT joint complex but are not useful in determining if the injury is stable. Computed tomography scans are excellent for evaluating the osseous anatomy in the foot. Both plain radiographs and CT scan may reveal a small avulsion fracture (“fleck sign”) between M1 and M2, representing a primarily unstable Lisfranc ligament injury.30 Magnetic resonance imaging is a valuable tool for directly evaluating the integrity the ligament complex itself.

Raikin et al31 evaluated the utility of MRI in determining the stability of a midfoot sprain. Findings on MRI were compared with stress radiographs and intraoperative findings in 21 patients with Lisfranc injuries. The plantar C1-M2/M3 ligament was found to be the strongest predictor of joint instability, with 19 of 21 injuries correctly classified with MRI. Grade 2 sprains and complete ruptures of the C1-M2/M3 ligament were classified as unstable injuries in their study. The presence of a normal ligament on MRI was suggestive of a stable injury that could be treated conservatively. Using their protocol, a negative MRI may prevent some patients from undergoing an examination under anesthesia to determine stability.

Treatment

Stable grade 1 midfoot sprains (Nunley and Vertullo stage 1) should be treated conservatively. Rest, compression, and elevation in the acute period followed by immobilization and non-weight bearing with a cast or boot for ≥ 6 weeks is recommended. In patients who have continued pain at 6 weeks, an additional 4 weeks of protected weight bearing in a controlled ankle motion boot is recommended. Once pain has subsided, a gradual return to activity is initiated with proper shoe wear and arch supports.

Unstable midfoot sprains (Nunley and Vertullo grades 2 and 3) should be treated with anatomic reduction and internal fixation. The need for an anatomic reduction is no longer debated, but there is still controversy regarding the best surgical treatment.32-35 The 2 most common surgical procedures are open reduction and internal fixation or primary arthrodesis (fusion). The surgical procedure of choice depends on many factors, including injury type, patient age, activity level, and time from the original date of injury. We generally recommend open reduction and internal fixation as the primary treatment of choice in athletes, and plan for screw removal between 6 and 12 months postoperatively. Closed reduction and percutaneous screw fixation has been described, but we routinely make a dorsal incision to visualize anatomic reduction of the joint. Instability is evaluated intraoperatively and addressed with screw fixation as needed, beginning with the medial column of the foot and moving laterally. We use 3.5- or 4.5-mm fully threaded stainless steel screws (depending on the size of the patient) and the construct orientation depends on the injury pattern. Primary arthrodesis in young athletic patients is reserved for delayed or missed diagnosis with preexisting arthrosis. Regardless of the treatment method, the most important factors that predict outcome are early anatomic reduction of the joint surfaces, as well as early diagnosis and treatment.

Summary

Unstable Lisfranc ligament injuries can be easily dismissed as stable midfoot sprains and treated inappropriately with conservative treatment. We recommend that physicians exclude an unstable Lisfranc ligament injury in any patient presenting with acute onset midfoot pain due to a traumatic injury. Weightbearing anteroposterior and lateral radiographs can be used to classify the injury and determine the treatment plan. For patients who are unable to tolerate full weightbearing radiographs, stress radiographs can be obtained under regional anesthesia, or MRI can be used to directly visualize the Lisfranc ligament complex and the stability of the injury can be reliably predicted based on the plantar C1-M2/M3 ligament. All unstable injuries should be referred to an orthopedic surgeon for surgical consultation and rehabilitation. Delayed diagnosis and treatment adversely affects long-term outcomes of patients with unstable Lisfranc injuries.



Conflict of Interest Statement
Terrence M. Philbin, DO discloses conflicts of interest with Biomet, DonJoy, OrthoHelix, and Pfizer. Jaymes D. Granata, MD discloses no conflicts of interest.
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Jaymes D. Granata, MD 1
Terrence M. Philbin, DO 2

1Department of Orthopaedics, The Ohio State University Medical Center, Columbus, OH 2Orthopedic Foot and Ankle Center, Westerville, OH

Correspondence: Terrence M. Philbin, DO, Orthopedic Foot and Ankle Center, 300 Polaris Pkwy., Suite 2021, Westerville, OH 43082.
Tel: 614-895-8747
Fax: 614-895-2235
E-mail: [email protected]
Disclaimer
In an effort to provide information that is scientifically accurate and consistent with accepted standards of medical practice, the editors and publisher of The Physician and Sportsmedicine routinely consult sources believed to be reliable. However, readers are encouraged to confirm this information with other sources. For example and in particular, physicians are advised to consult the prescribing information in the manufacturer's package insert before prescribing any drug mentioned.




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