Monday, November 9, 2009

Lisfranc Injury

Here is an article about Lisfranc Injuries, including notes on symptoms, diagnosis, and treatment of the problem.

Lisfranc Injury
History of Lisfranc Injury
by Terence Vanderheiden, D.P.M.

Lisfranc injuries are named after Jacques Lisfranc, a French surgeon in the early 1800s. In the army, a lot of the soldiers would get thrown from their horses, and their foot would get caught in the stirrup. This would cause an injury to the middle of the foot. Unfortunately, back then this injury sometimes ended up needing an amputation. Thankfully, today it is a different story, and amputation is usually not needed. Lisfranc injuries, though, can still cause a lot of problems. Learn more about Lisfranc injuries.

What is a Lisfranc Injury? Lisfranc injuries involve the midfoot area. The Lisfranc joints are between the first metatarsal, second metarsal, medial cuneiform and intermediate cuneiform. The Lisfranc complex involves all of the tarsometatarsal joints. There is also a Lisfranc ligament that runs on the bottom of the medial cuneiform to the second metatarsal base. Lisfranc injuries, to the midfoot, can include sprains, dislocations, fractures (broken bones) or all of the above. Two very serious complications can be seen with Lisfranc injuries: injuries to the dorsalis pedis artery and compartment syndrome. These are both medical emergencies and need surgery right away.

Causes. Lisfranc injuries are most often caused by some type of trauma, which can be either direct or indirect. An example of direct trauma would be dropping something on the foot. Indirect trauma usually involves a twisting of the foot after it gets caught on something. Lisfranc injuries account for about 1% of all fractures. They are not common, but sports medicine doctors tend to see the injury more frequently. Lisfranc injuries can occur in car accidents, military personnel, horse riders and in many sports (football, baseball and soccer, to name a few).

Signs and Symptoms
• Swelling of the foot and/or ankle
• Bruising of the foot and/or ankle
• Pain usually in the middle part of the foot
• Difficulty stepping on the foot (due to pain)
• Widening of the midfoot area (due to bone dislocation)
• Large bump on the top mid-foot area (due to bone dislocation)

Diagnosis. First, your doctor will do a thorough history and physical exam. He or she will be sure to check your pulse (dorsalis pedis artery) on the top of your foot, because sometimes this artery can be injured due to the trauma. Your doctor will also make sure you do not have a compartment syndrome, which is a build-up of pressure in the foot causing excruciating pain. The excessive pressure can cause damage to the soft tissues, nerves, arteries and muscles. Compartment syndrome is a medical emergency that requires surgery to relieve the pressure.
Next, you will probably get X-rays of your injured foot. The X-ray may be weight bearing (standing on the foot) or nonweight bearing. Sometimes your healthy foot is also X-rayed for comparison. Lisfranc injuries can be difficult to see on plain X-rays. If there is a question about it, your doctor may send you for a CT (computed tomography) scan. Since a CT scan has three-dimensional views, it will allow the doctor to see the bones in much better detail. An MRI (Magnetic Resonance Imaging) is also occasionally used to evaluate the soft tissues, especially the Lisfranc ligament. An MRI is not usually needed if there is dislocation or fracture, because this usually signifies that the Lisfranc ligament has already ruptured. If the dorsalis pedis artery is not felt by hand, then a Doppler ultrasound may be needed to assess the artery.

Treatment. The treatment for Lisfranc injuries varies, depending on if you had a sprain, dislocation, fracture or all of the above. Treatment also depends on when you were diagnosed with the injury. Generally speaking, if you have sustained a Lisfranc sprain, you will need to be nonweight bearing (no weight on the foot) in a cast or removable cast boot for four to six weeks. This will usually be followed by physical therapy and a gradual return to activity. Lisfranc dislocation and fracture injuries are usually treated with surgery. It is important to try and line up the bones and joints as much as possible. This is done with wires, screws or plates. After surgery you are usually nonweight bearing for six weeks and then you begin walking with a cast-walking boot for another four weeks. If the bones and joints are not lined up properly, there is an increased risk of degenerative changes, which can lead to arthritis and instability. If pain in the midfoot continues for a long time, sometimes a second surgery is needed to fuse (arthrodese) the midfoot bones together.

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