The Lisfranc's joint is comprised of the bases of the metatarsals (1st through the 5th) and components of the lesser tarsus( 1st cuneiform, 2nd cuneiform, and 3rd cuneiform and the cuboid). The architecture of the tarsometatarsal (Lisfranc's) joint has an arch with the "keystone" component of the second metatarsal base as a structural stabilizer at this joint. According to the literature, injuries to the Lisfranc's (tarsometatarsal) joint occur in less than 1% of all foot fractures. Perhaps this rare occurrence would explain the high incidental misdiagnosis which approximates 20% of the time.

Significant complications occur due to compromise to the vasculature (Dorsal Pedal and the Perforating Arteries). Severe edema (swelling) may lead to a compartment syndrome. The formation of a hematoma (blood clot) may further add to the difficultly in treatment. If, in a severe situation, significant compromise of blood flow from the above scenario occurs, amputation could result. Thus, proper diagnosis and quick reduction are paramount.

The osseous structures (bones) are firmly attached to each other by a complex and plantar transverse ligaments as well as the intermetatarsal ligaments. The first and second metatarsals, however, lack an intermetatarsal ligament. The Lisfranc's ligament binds the medial cuneiform to the base of the second metatarsal base on the plantar surface. The plantar ligaments are stronger than the dorsal ligaments. This helps to maintain the transverse arch.

The inherent stability of this joint is due to its convex shape from medial to lateral. The second metatarsal base is locked into the medial (first) cuneiform and the lateral (third) cuneiform. The transverse arch of the lesser tarsus has a "keystone" effect with the second (intermediate) cuneiform as the apex of the transverse arch. Therefore, the second metatarsal and the second (intermediate) cuneiform are the structural stabilizers of the Lisfranc's joint.

Hardcastle et. al. have proposed a comprehensive classification based upon the injury pattern at the Lisfranc's joint. Other classifications exist but are not as standard as the Hardcastle system. The Hardcastle system is based upon the radiographic (X-ray's) presentation and thus gives the surgeon a systematic approach in the reduction and realignment prior to surgical intervention.

Total incongruity is displacement of all metatarsals with fracture of the second metatarsal base (keystone) which either moves laterally or dorsoplantarly. This is known as Type A.

Partial incongruity has two variants. Medial displacements of the first metatarsal or a combination of the 2nd, 3rd, or 4th metatarsals which dislocates medially. Lateral displacement of the lesser metatarsals with the first metatarsal intact. Medial displacement is known as B1, Lateral displacement is B2.

Divergent displacement involves displacement of the first metatarsal medially and a combination of any of the lesser metatarsals laterally thus diverging the first from the lesser metatarsals. (This may occur in the sagittal or transverse planes or both.)

There are many scenarios that can cause these injuries. The prominent role is the locking of the forefoot in a plantar flexed or equinos position with the body and midfoot moving past the forefoot in a shearing force. An example would be locking in the foot on an automobile brake and upon impact of an accident, the human body moving forward onto or below the antatarsals (forefoot).

The key to proper diagnosis is clinical suspicion of this rare injury. The spontaneous relocation in some cases shows minimal or no radiographic findings. This is usually diagnosed as a sprain foot. A weight bearing x-ray may allow displacement of the disrupted component of the joint enough to reveal this injury. An MRI or CT Scan is of great value to assess other soft tissue and osseous damage that may not be seen on the radiographic exam.

The patient, more than likely, will recall a "pop" sensation as in misstepping a curb. There will exist gross swelling and tenderness at the tarsometatarsal joint. Primarily the first or the second metatarsal base. Looseness of this joint may be present and will be painful. If pulses are absent a doppler ultrasound should be performed to rule out vascular compromise. X-rays may show only a widening (diastasis) of the first cunieform to the second cunieform which would reveal a Lisfranc's ligament rupture or multiple fractures at the base of lesser metatarsals. The "fleck sign" reveals an avulsion fracture of the second metatarsal base in which the Lisfranc ligament has avulsed(a small bone chip) the second metatarsal base.

Accurate anatomical alignment is a must. The integrity or stability of this joint needs to be repaired. This is tantamount to avoid severe foot problems in later life. It is very common to manipulate or reduce this rare injury in the operatory setting. The author's preferred approach is the use of chinese fingertraps with counter traction upon the rearfoot (usually 15-20 pounds should suffice). Under flouriscopic visualation, the relocation with manipulation may occur. Only if soft tissue is trapped at the dislocation would an open surgical option be needed. Once alignment is achieved, then percutaneous K-wire fixation may stabilize this joint while it heals in a non weight bearing cast for six to eight weeks. Occasionally, an open procedure may have a better result. This is based upon the soft tissue disruption and/or interpositioning that will not allow relocation of the metatarsals.

The prognosis is more favorable when anatomical alignment and stability is achieved. It is important to note this injury can lead to amputation if the vasculature is disrupted. Should repair of the arteries or relief from a compartment syndrome be necessary, an open approach is mandated. The patient must be informed of arthritis and pain even with perfect execution of realignment of this joint. However, with perfect execution of realignment, function may be preserved.

Dr. Graham has been in private practice in Effingham since 1989 and is on staff at St. Anthony's Memorial Hospital and Effingham Ambulatory Surgical Treatment Center. He is Board Certified by the American Board of Podiatric Surgery and American Board of Podiatric Orthopaedics and Primary Podiatric Medicine. Dr. Graham is a Fellow of the American College of Foot and Ankle Surgeons, the American College of Foot and Ankle Orthopaedics and Medicine, and American Professional Wound Care Association. He is also a member of the American Podiatric Medical Association and the Illinois Podiatric Medical Association.

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