- Email: [email protected]
Lisfranc's or tarsometatarsal fracture-dislocation
NAME THAT FRACTURE Section Editor: Miki Patterson, MS, RNCS, NP, ONC
Lisfranc’s or Tarsometatarsal Fracture-Dislocation Miki Patterson, MS, RNCS, NP, ONC he foot may sustain many types of injuries. One of the most commonly missed fractures in a multitrauma patient is the Lisfranc’s fracture or injury. A Lisfranc injury is a disruption of the tarsals-metatarsals joint, with or without an associated fracture. Figure 1 shows the bones in a normal foot in a radiograph and line drawing. The normal alignment of the tarsals to the metatarsals is demonstrated. The second metatarsal is keyed into position between the medial and lateral cuneiform bones, and the first metatarsal positioned higher than the others. The fracture was named after Napoleon’s army physician, Dr Jacques Lisfranc, who described a type of foot injury (actually an amputation through the tarsal-metatarsal joint) sustained by the horseback-riding soldiers. In the past, men were injured when their toes or forefoot was stuck in the stirrup and a force was applied to their leg. The force produced a hyperextension or hyperflexion injury of the ligaments between the tarsals and the metatarsals. Today, Lisfranc’s injuries are seen in football, occurring when the foot is braced in flexion and the leg sustains an axial load. Lisfranc’s injuries are also seen in motor vehicle crashes when the driver is applying pressure to the brake during a front-end impact. There are many forms of this injury, with or without accompanying fractures.
T
Miki Patterson is an orthopedic trauma coordinator at University of Massachusetts Memorial Medical Center, Worcester. Please write [email protected] with comments. Reprint requests: Miki Patterson, MS, RNCS, NP, ONC, University of Massachusetts Memorial Medical Center, 55 Lake Ave, North, Worcester, MA 01655. Int J Trauma Nurs 2000;6:133-6. Copyright © 2000 by the Emergency Nurses Association. 1075-4210/2000/$12.00 + 0 65/1/110466
A
B
Figure 1. Normal alignment of the foot bones as demonstrated in an anterior-posterior radiograph (A) and line drawing (B).
Table 1. Key points regarding Lisfranc’s injuries 1. Lisfranc’s injuries are commonly missed, and any foot swelling in a multitrauma patient should raise suspicion. 2. The neurovascular status of the foot should be assessed on admission and periodically; any changes in neurovascular function, especially pain out of proportion to the injury, should be recorded and reported to the physician because acute compartment syndromes of the foot have occurred with this type of injury. 3. If a Lisfranc’s injury is found, it may be treated with an open reduction, internal fixation, and the foot is treated with casting and immobilization. 4. Early arthritis and stiffness are not uncommon with Lisfranc’s injuries.
doi:10.1067/mtn.2000.110466 OCTOBER-DECEMBER 2000
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Name that Fracture 133
Figure 2. Radiographs of the ankle and foot reveal widening of the joint between the medial malleolus and talus of the right ankle.
INITIAL ASSESSMENT AND DIAGNOSIS The neurovascular status of all distal extremities should be assessed at admission. A Lisfranc’s injury can produce a compartment syndrome of the foot. Any changes in neurovascular status of the toes and pain out of proportion should be recorded and reported to the physician. The diagnosis of a Lisfranc’s injury can be difficult in that the metatarsals may return to nearly their normal position after the injury. The dislocation may not be apparent or may be subtle, even on a radiograph. The patient typically presents with swelling and ecchymosis on the dorsum, or top, of the midfoot, and if awake, he or she reports having severe pain. In a severe case, the forefoot may appear shortened compared with the other foot if the Lisfranc’s dislocation remains unreduced. To diagnose a Lisfranc’s injury, anterior-posterior, lateral, and oblique radiographs should be obtained. A fracture at the base of the second metatarsal or a chip fracture adjacent to the tarsalmetatarsal joints should raise suspicions of this type of injury. On the lateral and oblique views, the metatarsals may be misaligned from their respective tarsal bones. CASE STUDY A 28-year-old man was the driver in a motor vehicle crash and was transported to the emer134
gency department via stretcher. He was strapped to a backboard. The patient had sustained obvious injuries to his chest (sternal bruising), right forearm (laceration), and swelling was noted in the right ankle and foot. A computed tomography of the thorax and abdomen were completed and read as negative for hemorrhage or soft tissue injury. The patient was returned to the emergency department, and radiographs of the extremities were completed. The arm and ankle were splinted before films were taken because of the deformity, swelling, and ecchymosis seen there. There was a 4 cm laceration on the ulna side of the forearm and bone was visible through the wound. An open ulna fracture was suspected although none was seen on the radiograph. The ankle was extremely tender to palpation over the medial joint line, just below the malleolus. On examination, there was laxity with slight eversion of the heel. The patient did not tolerate this and complained mostly of pain on the dorsum of his foot where the foot was held for examination. Figure 2 shows the x-ray films of the ankle and foot. The films reveal widening of the joint between the medial malleolus and talus of the right ankle. No fractures were noted on the lateral view of the foot, but a Lisfranc’s dislocation and lateral displacement of the first
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Name That Fracture
VOLUME 6, NUMBER 4
A
B
Figure 3. Lateral (A) and anterior-posterior (B) views of foot with Lisfranc’s injury. Lateral view appears normal; anterior-posterior view shows Lisfranc’s fracture.
A
B
Figure 4. Postoperative radiographs of foot after open reduction and internal fixation of Lisfranc’s fracture. Note Kirschner wires used to hold bones in alignment. Oblique view of the right foot (A); lateral view of the right foot (B).
through fifth metatarsals, off the tarsals, of the right foot, are visible on the anterior-posterior view (Figure 3). The patient was taken to the operating room for inspection, debridement, and closure of the right forearm wound. The Lisfranc’s fracture OCTOBER-DECEMBER 2000
was anatomically reduced (closed procedure) and Kirschner wires were placed to maintain the reduced position (Figure 4). The ankle sprain did not require surgery and was immobilized along with the lower leg. The patient was placed in a short leg cast and kept non-weight bearing
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Name That Fracture 135
for 6 weeks. The pins were removed after 6 weeks, although the patient remained in a cast and was allowed protected weight bearing for a few weeks after that. One year after the injury, the patient was back to work at a computer, had occasional foot pain at the end of some days, and used aspirin analgesics to relieve the discomfort.
O
SUMMARY Lisfranc’s injuries are one of the most commonly missed fractures in a multitrauma patient. Failure to recognize and treat such an injury can lead to acute (eg, compartment syndrome of the foot) and chronic problems (eg, arthritis). A list of reminders is included to help with the recognition and treatment of Lisfranc’s injuries (Table 1).
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INTERNATIONAL JOURNAL OF TRAUMA NURSING/Name That Fracture
OR PHONE: 1-800-654-2452 Outside the U.S., call 407-345-4000
VOLUME 6, NUMBER 4
Lisfranc’s or Tarsometatarsal Fracture-Dislocation Miki Patterson, MS, RNCS, NP, ONC he foot may sustain many types of injuries. One of the most commonly missed fractures in a multitrauma patient is the Lisfranc’s fracture or injury. A Lisfranc injury is a disruption of the tarsals-metatarsals joint, with or without an associated fracture. Figure 1 shows the bones in a normal foot in a radiograph and line drawing. The normal alignment of the tarsals to the metatarsals is demonstrated. The second metatarsal is keyed into position between the medial and lateral cuneiform bones, and the first metatarsal positioned higher than the others. The fracture was named after Napoleon’s army physician, Dr Jacques Lisfranc, who described a type of foot injury (actually an amputation through the tarsal-metatarsal joint) sustained by the horseback-riding soldiers. In the past, men were injured when their toes or forefoot was stuck in the stirrup and a force was applied to their leg. The force produced a hyperextension or hyperflexion injury of the ligaments between the tarsals and the metatarsals. Today, Lisfranc’s injuries are seen in football, occurring when the foot is braced in flexion and the leg sustains an axial load. Lisfranc’s injuries are also seen in motor vehicle crashes when the driver is applying pressure to the brake during a front-end impact. There are many forms of this injury, with or without accompanying fractures.
T
Miki Patterson is an orthopedic trauma coordinator at University of Massachusetts Memorial Medical Center, Worcester. Please write [email protected] with comments. Reprint requests: Miki Patterson, MS, RNCS, NP, ONC, University of Massachusetts Memorial Medical Center, 55 Lake Ave, North, Worcester, MA 01655. Int J Trauma Nurs 2000;6:133-6. Copyright © 2000 by the Emergency Nurses Association. 1075-4210/2000/$12.00 + 0 65/1/110466
A
B
Figure 1. Normal alignment of the foot bones as demonstrated in an anterior-posterior radiograph (A) and line drawing (B).
Table 1. Key points regarding Lisfranc’s injuries 1. Lisfranc’s injuries are commonly missed, and any foot swelling in a multitrauma patient should raise suspicion. 2. The neurovascular status of the foot should be assessed on admission and periodically; any changes in neurovascular function, especially pain out of proportion to the injury, should be recorded and reported to the physician because acute compartment syndromes of the foot have occurred with this type of injury. 3. If a Lisfranc’s injury is found, it may be treated with an open reduction, internal fixation, and the foot is treated with casting and immobilization. 4. Early arthritis and stiffness are not uncommon with Lisfranc’s injuries.
doi:10.1067/mtn.2000.110466 OCTOBER-DECEMBER 2000
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Name that Fracture 133
Figure 2. Radiographs of the ankle and foot reveal widening of the joint between the medial malleolus and talus of the right ankle.
INITIAL ASSESSMENT AND DIAGNOSIS The neurovascular status of all distal extremities should be assessed at admission. A Lisfranc’s injury can produce a compartment syndrome of the foot. Any changes in neurovascular status of the toes and pain out of proportion should be recorded and reported to the physician. The diagnosis of a Lisfranc’s injury can be difficult in that the metatarsals may return to nearly their normal position after the injury. The dislocation may not be apparent or may be subtle, even on a radiograph. The patient typically presents with swelling and ecchymosis on the dorsum, or top, of the midfoot, and if awake, he or she reports having severe pain. In a severe case, the forefoot may appear shortened compared with the other foot if the Lisfranc’s dislocation remains unreduced. To diagnose a Lisfranc’s injury, anterior-posterior, lateral, and oblique radiographs should be obtained. A fracture at the base of the second metatarsal or a chip fracture adjacent to the tarsalmetatarsal joints should raise suspicions of this type of injury. On the lateral and oblique views, the metatarsals may be misaligned from their respective tarsal bones. CASE STUDY A 28-year-old man was the driver in a motor vehicle crash and was transported to the emer134
gency department via stretcher. He was strapped to a backboard. The patient had sustained obvious injuries to his chest (sternal bruising), right forearm (laceration), and swelling was noted in the right ankle and foot. A computed tomography of the thorax and abdomen were completed and read as negative for hemorrhage or soft tissue injury. The patient was returned to the emergency department, and radiographs of the extremities were completed. The arm and ankle were splinted before films were taken because of the deformity, swelling, and ecchymosis seen there. There was a 4 cm laceration on the ulna side of the forearm and bone was visible through the wound. An open ulna fracture was suspected although none was seen on the radiograph. The ankle was extremely tender to palpation over the medial joint line, just below the malleolus. On examination, there was laxity with slight eversion of the heel. The patient did not tolerate this and complained mostly of pain on the dorsum of his foot where the foot was held for examination. Figure 2 shows the x-ray films of the ankle and foot. The films reveal widening of the joint between the medial malleolus and talus of the right ankle. No fractures were noted on the lateral view of the foot, but a Lisfranc’s dislocation and lateral displacement of the first
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Name That Fracture
VOLUME 6, NUMBER 4
A
B
Figure 3. Lateral (A) and anterior-posterior (B) views of foot with Lisfranc’s injury. Lateral view appears normal; anterior-posterior view shows Lisfranc’s fracture.
A
B
Figure 4. Postoperative radiographs of foot after open reduction and internal fixation of Lisfranc’s fracture. Note Kirschner wires used to hold bones in alignment. Oblique view of the right foot (A); lateral view of the right foot (B).
through fifth metatarsals, off the tarsals, of the right foot, are visible on the anterior-posterior view (Figure 3). The patient was taken to the operating room for inspection, debridement, and closure of the right forearm wound. The Lisfranc’s fracture OCTOBER-DECEMBER 2000
was anatomically reduced (closed procedure) and Kirschner wires were placed to maintain the reduced position (Figure 4). The ankle sprain did not require surgery and was immobilized along with the lower leg. The patient was placed in a short leg cast and kept non-weight bearing
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Name That Fracture 135
for 6 weeks. The pins were removed after 6 weeks, although the patient remained in a cast and was allowed protected weight bearing for a few weeks after that. One year after the injury, the patient was back to work at a computer, had occasional foot pain at the end of some days, and used aspirin analgesics to relieve the discomfort.
O
SUMMARY Lisfranc’s injuries are one of the most commonly missed fractures in a multitrauma patient. Failure to recognize and treat such an injury can lead to acute (eg, compartment syndrome of the foot) and chronic problems (eg, arthritis). A list of reminders is included to help with the recognition and treatment of Lisfranc’s injuries (Table 1).
N THE MOVE? Send us your new address at least six weeks ahead
Don’t miss a single issue of the journal! To ensure prompt service when you change your address, please photocopy and complete the form below. Please send your change of address notification at least six weeks before your move to ensure continued service. We regret we cannot guarantee replacement of issues missed due to late notification. JOURNAL TITLE: Fill in the title of the journal here.
OLD ADDRESS: Affix the address label from a recent issue of the journal here.
NEW ADDRESS:
Clearly print your new address here. Name Address City/State/ZIP
COPY AND MAIL THIS FORM TO: Mosby Subscription Customer Service 6277 Sea Harbor Dr. Orlando, FL 32887 136
OR FAX TO: 407-363-9661
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Name That Fracture
OR PHONE: 1-800-654-2452 Outside the U.S., call 407-345-4000
VOLUME 6, NUMBER 4