Lisfrancs Injury HUB 

GENERAL LISFRANCS INJURY INFORMATION FROM THE L.E.G. TEAM

Lisfrancs Injury - What is it


Lisfrancs injury refers to an injury of the midfoot joints. These injuris are theb results of broken bones and /or ligament tears in the midfoot region. The sverity of this injury can vary frmo simple to complex and they can be quite debilitatiing if left undiagnosed or untreated. Lisfrancs injury’s are uncommon but can be quite serious injuries. They usually involve any trauma (inclusive of fracture, dislocation/subluxation) to the Tarsometatarsal joints of the foot.




LISFRANCS injury - More


Historically referred to as the Lisfranc joint - this joint is essentially the tarsometatarsal articulation. (TMTJ) The midfoot is critical to stability of the arch during walking. Normally durign gait the midfoot will prvide shock absorption and allow adaptation to various cambers and tilts in the ground surface. Forces from the arch are transferred to the forefoot via this joint. As a result, injury to this joint can effect a persons ability to;

  • Balance
  • Walk
  • Push off on toes
  • Climb ladders/stairs
  • Change direction
  • Adjust to altered terrain
  • Hills and cambers are also very difficult




Lisfrancs Injury - Diagnosis


Lisfrancs diagnosis is extremely important and is often delayed due to a lack of a gold standard for care. At present the GOLD STANDARD in medicien is to order Weight bearing A-P foot Xray view This illuminates the spread that can occur in a true Lisfrrancs ligament disruption. Some of signs that may lead a clinician to a Lisfrac's diagnosis may include:

  • Bruising under the foot. This suggests a significant tear of the midfoot ligaments and /or possilbe a midfoot fracture.
  • Tenderness to pressure (palpation) along the Lisfrancs joints in the midfoot.
  • Pain with a stress rotation of the midfoot.
  • Pain with a "piano key" test. This is a sagital plane tarso-metatarsal jpint range of motion assessment, but if pain is elicited may be an indicator of potential injury to the TMTJ.
  • Balance test - Single Leg balance is very painful with significant Lisfrancs injuries
  • Single leg calf raise - In significant Lisfrancs injuries it is painful to stand on one foot and come up on "tip toes.".
Other scans and imaging: Magnetic resonance imaging (MRI) scan. An MRI creates images of soft tissues like the ligments / tendons. MRI is not required to diagnose a Lisfranc injury. It may be ordered in cases where the diagnosis may be unclear. Computerised tomography scan (CT ) scan. These scans are more detailed than x-rays and can create cross-section images of the foot.




Lisfrancs Injury - Mechanism of Injury


The mechanism by which a Lisfrancs injury can occur is normally a high velocity twisting movement of the forefoot combined with compression Immediately you may also be:

  • Unable to bear weight on foot

  • Unable to balance on one leg

  • Swelling over dorsum of foot

  • Plantar foot ecchymosis (bruising)

  • TMTJ ++ tender with palpation

  • TMTJ ++ tender during any inversion /eversion ++pain




Lisfrancs Injury - Classification






GOLD STANDARD LISFRANCS TREATMENT OPTIONS

Conservative treatment


All forms of Lisfrancs injuries must see a specialist foot and ankle therapist or surgeon and must be Xrayed. Xray must be the Gold standard Weightbearing AP view. If unsure most Surgeons will also request an MRI to see ligametnous damage If deemed stable then conservative treatment may begin under the care of and established therpaist who has considerable experience rehabilitating foot injury. If there are no fractures or dislocations in the joint and the ligaments are not completely torn, nonsurgical treatment may be all that is necessary for healing. You will require 6 weeks in a non weghtbeariing immobilisation boot - You must be very strict about not putting weight on your injured foot during this period. This then progresses to weightbearing in a removable cast boot or an orthotic LEG offers a 12 week Rehab plan for Lisfrancs injuries. Below is an example of week 1




Surgical


Surgical stabilisation is often required for these injuries. The aim of any Lisfrancs Surgical procedure is to stabilise the unstable Lisfrancs area and to realign the joints /fractures to a more anatomical position to enable healing and potential future function. This can be acheived by any number of methods at the discretion of the Surgoen and pertaining to the particular injury itself. Surgery is recommended for all injuries with a fracture in the joints of the midfoot or with a bnormal positioning (subluxation) of the joints Sometimes muliple surgical procedures are required. Surgical examples: Internal fixation. In this procedure, the bones are positioned correctly (reduced) and held in place with plates or screws. Because the plates or screws will be placed across joints that normally have some motion, some or all of this hardware may be removed at a later date. This can vary from 3 to 5 months after surgery, and is at the surgeon's discretion. Occasionally, the hardware may break before it is removed. This is not unusual when screws or plates span bones that have some movement. Metal can fatigue and fail under these conditions, just as a paperclip will fail if bent repeatedly.




L.E.G. - GOLD STANDARD TREATMENT FOR LISFRANCS INJURIES


The Lower Extremity Group offers to you the Gold Standard in Lower extremity injury rehabilitation. We utilise a World Class rehabilitation program for Lisfranc's injuries, and this is deilvered to you online in the comfort of your own home. All you have to do is follow our easy to use evidence based plan to treat and manage your Lisfranc's injury. This online program contains 12 complete weeks of revolutionary rehabilitation guides to help you manage and treat your Lisfranc's injury every single day. We deliver our evidence-based daily Lisfranc's injury management program via our amazing app, which is very easy for you to follow and includes;

  • Progressive neuromuscular exercises that will strengthen the muscles around the foot and ankle and help reduce the pain associated with Lisfranc's injuries.
  • 5 progressive levels of evidence based rehabilitation that do not require expensive equpiment
  • Passive and dynamic mobility exercises to increase range of motion and tissue extensibility of mucles and fascia
  • ​Myofascial massage exercises
  • Using the app will enable you to understand when to apply the various exercises to help manage Lisfranc's Injuries
  • Plus more
We offer online consultations as a part of the rehabiliation precess to help you rehabilitate and manage your Lisfranc's injury. ​Our experienced therapists have taken these aforementioned technical modalities and simplified them into easy to watch videos for you to follow and complete. These are delivered daily to your smart device within our Lisfranc's injury management program. Book in today - Online or in clinic





REHAB PROTOCOLS


RECOMMENDED MEDICAL LITERATURE ARTICLES

Lisfranc fracture-dislocations: current management Inmaculada Moracia-Ochagavía et al 2019


EFORT Open Rev. 2019 Jul 2;4(7):430-444.doi: 10.1302/2058-5241.4.180076. eCollection 2019 Jul. https://pubmed.ncbi.nlm.nih.gov/31423327/ Abstract It is essential to know and understand the anatomy of the tarsometatarsal (TMT) joint (Lisfranc joint) to achieve a correct diagnosis and proper treatment of the injuries that occur at that level.Up to 20% of Lisfranc fracture-dislocations go unnoticed or are diagnosed late, especially low-energy injuries or purely ligamentous injuries. Severe sequelae such as post-traumatic osteoarthritis and foot deformities can create serious disability.We must be attentive to the clinical and radiological signs of an injury to the Lisfranc joint and expand the study with weight-bearing radiographs or computed tomography (CT) scans.Only in stable lesions and in those without displacement is conservative treatment indicated, along with immobilisation and initial avoidance of weight-bearing.Through surgical treatment we seek to achieve two objectives: optimal anatomical reduction, a factor that directly influences the results; and the stability of the first, second and third cuneiform-metatarsal joints.There are three main controversies regarding the surgical treatment of Lisfranc injuries: osteosynthesis versus primary arthrodesis; transarticular screws versus dorsal plates; and the most appropriate surgical approach.The surgical treatment we prefer is open reduction and internal fixation (ORIF) with transarticular screws or with dorsal plates in cases of comminution of metatarsals or cuneiform bones.




Lisfranc injury: A review and simplified treatment algorithm Urpinder Singh Grewal et al. 2020


Foot (Edinb). 2020 Dec;45:101719. doi: 10.1016/j.foot.2020.101719. Epub 2020 Jul 6. https://pubmed.ncbi.nlm.nih.gov/33038662/ Abstract Background: Lisfranc injuries encompass large spectrum of injuries varying from low energy to high energy complex fracture dislocations. Whilst multiple complex classification systems exist; these do little to aid and direct the clinical management of patients. Therefore, this study aims to provide a simplified treatment algorithm allowing clinicians to standardise care of Lisfranc injuries. Methods: A comprehensive literature search was performed, and abstracts were reviewed to identify relevant literature. Results: Delay in diagnosis has a negative impact on outcome. If a Lisfranc injury is suspected and plain radiographs are inconclusive; computed tomography and if necessary magnetic resonance imaging are indicated if there is still an index of suspicion. In the absence of joint dislocation/subluxation management will be determined by stability which can be best assessed by weightbearing radiographs. If stable, injuries can be treated conservatively in a non-weight bearing cast for 6 weeks followed by a period of graduated weight bearing. Evidence is mounting that with regard to unstable purely ligamentous Lisfranc injuries primary arthrodesis (PA) has: better functional outcomes, increased cost effectiveness and reduced rates of return to theatre. With regard to bony unstable Lisfranc injuries more research is required before a single treatment modality - PA or open reduction internal fixation can be advocated, due to the lack of randomized control trials and limited patient follow-up periods in existing studies. Conclusion: A simplified treatment algorithm excluding the requirement for complex classifications is suggested. This may help with the diagnosis and management of these injuries. It is our believe that this algorithm will aid health professionals to standardize care for these injuries. Further prospective research trials are required to assess outcomes of different modalities of operative management, particularly with regards to open reduction and internal fixation versus primary arthrodesis for bony Lisfranc injuries.




Lisfranc fracture dislocation: a review of a commonly missed injury of the midfoot Simon Lau et al


Emerg Med J. 2017 Jan;34(1):52-56. doi: 10.1136/emermed-2015-205317. Epub 2016 Mar 24. https://pubmed.ncbi.nlm.nih.gov/27013521/ Abstract Musculoskeletal trauma to the foot is a common presentation to EDs. A Lisfranc fracture dislocation involves injury to the bony and soft tissue structures of the tarsometatarsal joint. While it is most commonly seen post high velocity trauma, it can also present post minor trauma. It is also misdiagnosed in approximately 20% of cases. These Lisfranc injuries typically present to EDs with pain particularly with weight bearing, swelling and post a characteristic mechanism of injury. Diagnosis is via clinical examination and radiological investigation-typically plain radiographs and CTs. Once diagnosed, Lisfranc injuries can be classified as stable or unstable. Stable injuries can be immobilised in EDs and discharged home. Unstable injuries require an orthopaedic referral for consideration of surgical fixation.




Fixation of isolated Lisfranc ligament injury with the TightRope™: A technical report Dong-Il Chun et al 2021


Orthop Traumatol Surg Res. 2021 Apr 22;102940. doi: 10.1016/j.otsr.2021.102940. Online ahead of print. https://pubmed.ncbi.nlm.nih.gov/33895381/ Abstract Treatment of Lisfranc ligament injury is still debatable. For this reason, we applied a standard suture button (TightRope™, Arthrex, Naples, FL), a device originally designed for syndesmosis fixation, in treating isolated Lisfranc ligament (ILL) injuries. Twelve patients diagnosed as having an ILL injury were recruited. All patients regained their previous activity level within 3 months after the surgery without any complications. We propose that standard suture button device in an ILL injury is an easy technique to perform with short learning curve, accompanied with satisfactory outcomes.




Suture Button vs Conventional Screw Fixation for Isolated Lisfranc Ligament Injuries Jaeho Cho 2021


Foot Ankle Int. 2021 May;42(5):598-608.doi: 10.1177/1071100720976074. Epub 2020 Dec 22. https://pubmed.ncbi.nlm.nih.gov/33349047/ Abstract Background: Suture buttons have been used for isolated Lisfranc ligament (ILL) fixation. However, no study has reported on its clinical and radiologic outcomes. Methods: In this retrospective comparative study, patients with ILL injuries were divided into 2 groups according to the treatment method: 32 conventional screw group and 31 suture button group. The clinical and radiologic outcomes at preoperation, 6 months and 1 year postoperation, and last follow-up period were measured. Plantar foot pressure was measured at postoperative month 6 months. Postoperative complications at the last follow-up were evaluated. Results: The suture button group showed better American Orthopaedic Foot & Ankle Society midfoot scale (P < .001) and visual analog scale (P < .001) scores compared with the conventional screw fixation group at the postoperative month 6 period before screw removal. However, no significant difference in clinical outcome between the 2 groups was found at postoperative year 1 or last follow-up. No differences in radiologic outcomes were found between the 2 groups. Plantar foot pressure was significantly elevated in the conventional screw group at the great toe and first metatarsal head area compared with the contralateral foot just before screw removal. Recurrent Lisfranc joint diastasis was found in a single case in the conventional screw group and 2 cases in the suture button group. Conclusion: Suture button fixation in the treatment of ILL injuries may provide comparable fixation stability and clinical outcome with conventional screw fixation in the early postoperative period. Level of evidence: Level III, retrospective case-control study, therapeutic.