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Divergent Lisfranc injury with dislocation of great toe interphalangeal joint: A rare case report

Posted on September 30, 2017 | Comments Off on Divergent Lisfranc injury with dislocation of great toe interphalangeal joint: A rare case report

by Dr. Ganesh Singh Dharmshaktu1*, Dr. Binit Singh2

The Foot and Ankle Online Journal 10 (3): 3

Injury to the Lisfranc joint is an uncommon event and requires keen evaluation to diagnose it early for the optimal outcome following adequate treatment. Many classifications describe the divergent pattern of this injury as separate entity and even rarer in incidence. The associated ipsilateral great toe interphalangeal dislocation along with the rare divergent pattern of Lisfranc fracture dislocation makes our case unusual. The case was managed by reduction of the great toe interphalangeal dislocation with percutaneous reduction and fixation of Lisfranc injury with screws and multiple K-wires, resulting in a good clinical outcome on follow up.  No single case similar to ours is reported previously to the best knowledge of the authors.

Keywords: foot, injury, dislocation, Lisfranc joint, tarsometatarsal joint, interphalangeal, management, fixation

ISSN 1941-6806
doi: 10.3827/faoj.2017.1003.0006

1 – Assistant Professor, Department of Orthopaedics, Government Medical College, Haldwani , Uttarakhand. India.
2 – Assistant Professor, Department of Orthopaedics, Government Medical College, Haldwani , Uttarakhand. India.
* – Corresponding author: drganeshortho@gmail.com

IInjury to the Lisfranc joint (Tarsometatarsal joint) is a rare event with reported incidence of 0.1 to 0.4% of fracture cases [1]. Early identification and meticulous management, often surgical, is required for optimal outcome as the conservative approach has been linked to poor results [2]. Quenu and Kuss did instrumental work to highlight the anatomical and clinical understanding of Lisfranc joint along with description of the “Lisfranc ligament bundle” bridging second metatarsal and first cuneiform bone as key stabilizing structure of tarsometatarsal (TMT) joint [3]. The classification given by the same authors is widely used and it describes three types of the injury; homolateral, isolated and divergent. Divergent dislocation was described as a complete disruption of the TMT joint with first ray and lesser rays displaced in the opposite direction. Another classification by Hardcastle et al modified the abovementioned classification on the basis of radiological evaluation into three types – complete, partial and divergent [4]. Type C or divergent variant was noted with medialisation of first metatarsal and lateral translation of variable number of rest of the metatarsals. The literature is scant about this rare pattern of injury as compared to other types.

Case Report

A 28-year-old male patient was brought to us with a history of injury to his right foot a few hours earlier. There was swelling and pain after the patient sustained an injury to the foot by the jumping off a moving bus. He reported he lost his balance and his foot was twisted before he fell to hard ground. The exact position of the foot at the time of impact is not properly recalled by the patient. There was visible deformity over medial aspect of foot and great toe suggesting presence of underlying significant bony or soft tissue injury. The radiograph of the affected foot showed fracture dislocation of Lisfranc joint along with inter-phalangeal dislocation of ipsilateral first toe. The pattern of Lisfranc injury was divergent with medial dislocation of first TMT joint and lateral dislocation of the rest of the TMT joint (Figure 1). There was also a fracture of the fifth metatarsal base with minimal displacement. Following informed consent, the patient was planned for urgent reduction of aforementioned injury with internal fixation. The rarity of the injury pattern was explained to the patient with additional written consent for future publication.

Figure 1 Preoperative radiograph showing great toe interphalangeal dislocation with divergent Lisfranc fracture dislocation.

The closed reduction of the interphalangeal dislocation was easily achieved under anesthesia which was later confirmed under fluoroscopy and the closed reduction of Lisfranc injury was achieved under fluoroscopic guidance. Two K-wires (2.0 mm) were introduced, one along the second metatarsal into the tarsal bones transfixing the Lisfranc joint. The other K-wire (1.0 mm) was introduced along the lateral TMT joints for added stability. The additional cortical screw (3.5 mm) was used for added stability from medial aspect and fixing the Lisfranc joint (Figure 2). The small wounds were dressed and a well-padded below knee plaster protection splint was applied following the confirmation of satisfactory alignment and fixation of the injuries. Elevation and non-weight bearing protocols were advised. Active toe and knee joint range of motion exercises were encouraged throughout the follow up. Gradual healing of the injury was noted in the follow-up along with reduction of swelling, pain and discomfort. The hardware were sequentially removed between 18-26 months postoperatively (Figure 3). The plaster splint was removed after eight weeks as swelling and pain were minimal. The only complication noted was hardware prominence of the medial screw that loosened over time and later was managed by its removal. The removal of K-wires and screw was uneventful at four and six month follow up. There was no re-dislocation of great toe noted and the patient was performing activities of daily living.

Figure 2 Postoperative radiograph showing the fixation of the Lisfranc injury with K-wire and screw from medial aspect along with reduced interphalangeal dislocation.

Figure 3 The follow up radiograph showing healed Lisfranc injury at the time of final hardware removal.

Discussion

Meticulous clinical and radiological assessment is critical for the diagnosis of Lisfranc injuries as these are notoriously missed in emergency settings and may be the reason for later medico-legal issues [5]. The divergent dislocation, as in our case, have characteristic radiographic deformity that makes it hard to miss and the diagnosis is evident. The divergent Lisfranc fracture dislocation is stated to be associated with fractures of other bones in the foot like the cuneiforms and navicular [6].The subtle injuries, the doubtful diagnosis and the requirement of looking for interposed structure interfering with reduction calls for use of imaging like computerized tomogram (CT) or magnetic resonance imaging (MRI) [7,8]. Our patient refused further imaging due to financial issues and urgent operative intervention was initiated. Open reduction-internal fixation (ORIF) and primary arthrodesis are two common techniques. Our method with use of closed reduction and percutaneous fixation with wires and screws resulted in primary arthrodesis of Lisfranc joint. The reported incidence of secondary procedures for complications has been found to be minimal with primary arthrodesis [9]. Studies have also shown good outcome of primary arthrodesis in comparison with ORIF in the long term [9,10]. Primary arthrodesis also obviates need for secondary arthrodesis in case of arthritis following either modality of treatment. Our minimal invasive approach resulted in early discharge and avoided wound complications.

Acknowledgement None

References

  1. Court-Brown CM, Caesar B. Epidemiology of adult fractures. A review. Injury, 2006;37(8):691-697. PubMed  
  2. Myerson MS, Fisher RT, Burgess AR, et al. Fracture dislocations of the tarsometatarsal joints: End results correlated with pathology and treatment. Foot Ankle.1986;6(5):225-242. PubMed
  3. Quenu E, Kuss G. Etude sur les subluxations du metatarse (luxations metatarsotarsiennes) du diastasis entre le 1stet le 2nd metatarsien. Rev Chir(Paris).1909; 39:281-336,720-791,1093-1134.
  4. Hardcastle PH, Reschauer R, Kutscha-Lissberg E, et al. Injuries to the tarsometatarsal joint. Incidence, classification and treatment. J Bone Joint Surg Br.1982;64(3):349-346. PubMed
  5. Chesbrough RM. Strategic approach fends off charges of malpractice: Program provides tips for avoiding litigation. Diagn Imaging 2002;24(13):44-51.
  6. Berquist TH, editor. Trauma. Radiology of the Foot and Ankle. New York: Raven Press, 1989. p. 191-7.
  7. Philbin T, Rosenburg G, Sferra JJ. Complications of missed or untreated Lisfranc injuries. Foot Ankle Clin North Am 2003;8:61-71. PubMed
  8. Kiuru MJ, Niva M, Reponen A, Pihlajamaki HK. Bone stress injuries in asymptomatic elite recruits: a clinical and magnetic resonance imaging study. Am J Sports Med. Feb 2005;33(2):272-276.
  9. Henning JA, Jones CB, Sietsema DL, et al. Open reduction internal fixation versus primary arthrodesis for lisfranc injuries: A prospective randomized study. Foot Ankle Int. 2009;30(10):913-922. PubMed
  10. Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective randomized study. J Bone Joint Surg Am.2006;88(3):514-520. PubMed

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Lateral subtalar dislocation: A case report

Posted on September 30, 2014 | Comments Off on Lateral subtalar dislocation: A case report

by Vijaykumar Kulambi1, Gaurav M2pdflrg

The Foot and Ankle Online Journal 7 (3): 4

Subtalar dislocation refers to the simultaneous dislocation of the distal articulations of the talus at the talocalcaneal and talonavicular joints. Closed reduction and immobilization remains the treatment of choice. However, if closed reduction is unsuccessful in some patients, open reduction is required. Open reduction can be associated with higher energy subtalar dislocations. A variety of bone and soft tissue structures may become entrapped, resulting in obstruction of closed reduction.  This is a unique case report which presents an unsuccessful closed reduction of an open lateral subtalar dislocation that required open reduction.

Key words: Subtalar joint, dislocation, open reduction

ISSN 1941-6806
doi: 10.3827/faoj.2014.0703.0004

Address correspondence to: Dr. Gaurav M
E mail : movement.gaurav@gmail.com

1 Professor, Dept. of Orthopaedics, J.J.M. Medical College, Davangere, Karnataka State, India.
2 Post graduate student, Dept. of Orthopaedics, J.J.M. Medical College, Davangere, Karnataka State, India.

Subtalar dislocation is an uncommon injury accounting for 1-2% of all joint dislocations [1]. It involves the disruption of the talocalcaneal and talonavicular joints, while the calcaneocuboid joint remains intact [2,3,4,5]. Medial dislocations comprise up to 85% of subtalar dislocations, whereas lateral subtalar dislocations are less frequent occurring in 15% to 20% of dislocations. In medial subtalar dislocation, the head of the talus is found laterally and the rest of the foot is dislocated medially. However, in a lateral subtalar dislocation, the talus can remain fixed while the remaining structures of the foot are dislocated laterally along the talus. Subtalar dislocations present with an impressive amount of deformity. The medial dislocation has been referred to as an acquired clubfoot, while the lateral dislocation has previously been described as an acquired flatfoot [6]. Many of these injuries are open as well, particularly when associated with a high-energy mechanism. Up to 40% of subtalar dislocations may present with an open wound [7].

We present a unique case report of a 30 year old male patient presenting with an open lateral subtalar dislocation following a fall from a height, with posterior tibialis tendon interposition posing difficulty in closed reduction.

Case Report

A 30 year old male patient presented with a history of a fall from a height as he climbed a coconut tree. Initial examination revealed diffuse swelling of the left foot with a laceration of 4 cm over the medial aspect of the left foot, extending distally from below the medial malleolus. The left foot was fixed in a pronated position. Distal perfusion and neurological status of both lower limbs and bladder functions were intact.

Radiographs revealed dislocation of the left talocalcaneal and talonavicular joints, without any regional bony injury (Figure 1, 2, 3).

Initially, closed reduction was attempted which was unsuccessful. The patient was taken to the operating room for open reduction. The talus was explored through the medial wound, and the tendon of tibialis posterior was found to be interposed between the talus and calcaneum.

fig1

Figure 1 Preoperative lateral view, demonstrating subtalar joint dislocation without fracture.

fig2

Figure 2 Preoperative ankle AP view, demonstrating subtalar joint dislocation without fracture.

fig3

Figure 3 Preoperative oblique foot view, demonstrating talonavicular joint dislocation without fracture.

fig4

Figure 4 Postoperative lateral view, demonstrating Kirschner wire fixation.

The posterior tibial tendon was retracted, and the talus was levered into a more anatomical position with reduction achieved. Adequate reduction was confirmed using a computer assisted radio monitor (c-arm). A thick Kirschner wire was inserted from the calcaneum into the talus to hold the reduction (Figure 4). A below knee splint was applied after placing a sterile dressing on the operative site.

Discussion

Clinical reviews of subtalar dislocations are relatively infrequent and generally limited to a small numbers of patients. These injuries most commonly occur in young adult males, although Bibbo et al noted 36% of subtalar dislocations in their case series of 25 patients occurred in patients over 40 years of age [8].

The direction of subtalar dislocation has important effects with respect to management and outcome. The method of reduction is different for each type of injury. Lateral subtalar dislocations are often associated with a higher energy mechanism and a worse long-term prognosis compared to medial subtalar dislocations.

Subtalar dislocations can result from either high-energy or low-energy mechanisms. The distinction is important because outcome has been correlated with the severity of the initial injury. In the case series presented by Bibbo et al, high-energy mechanisms such as motor vehicle trauma and falls from a height accounted for 68% of subtalar dislocations [8]. Open subtalar dislocations and lateral subtalar dislocations are more common with a high-energy mechanism. Medial injuries are more common than lateral dislocations, suggesting that the forces required to produce it are less than those required to produce a lateral dislocation.

High-energy subtalar dislocations may be associated with other injuries, either regional or involving other body systems. Bibbo et al described associated foot and ankle injuries in 88% of patients with subtalar dislocations. In their series of subtalar dislocations from a major level 1 trauma center, other musculoskeletal injuries occurred in 48% of patients and 12% of patients had injuries to the head, abdomen, or chest [8]. Regional fractures include talus, ankle, calcaneus, navicular, cuboid, cuneiform, and metatarsal fractures [9]. Osteochondral shearing injuries to the articular surface of the talus, the calcaneus, or the navicular are common. These injuries occur in up to 45% of patients, and are difficult to detect on plain radiographs [3,10,11]. Injuries remote from the foot and ankle may occur as well.

All subtalar dislocations require a timely reduction. In most cases, closed reduction can be accomplished. Often times, the injury presents with skin tenting requiring a prompt reduction to reduce the possibility of skin necrosis. Open peritalar dislocations require a formal irrigation and debridement in addition to the reduction followed by wound closure [12].

In approximately 10% of medial subtalar dislocations and 15% to 20% of lateral dislocations, closed reduction cannot be achieved [13,14]. Soft tissue interposition and bony blocks have been identified as factors preventing closed reduction. With medial dislocations, the talar head can become trapped by the capsule of the talonavicular joint, the extensor retinaculum, the extensor tendons, or the extensor digitorum brevis muscle [13,14]. With a lateral dislocation, the posterior tibial tendon may become firmly entrapped and present as a barrier to closed reduction requiring open reduction [14,15].

In our case presentation, the patient had sustained a high-energy trauma leading to a lateral subtalar dislocation. Following the initial failed closed reduction attempt, open reduction was required. We identified the tibialis posterior tendon obstructing the possible closed reduction. This case report shows successful open reduction of a lateral subtalar dislocation with Kirschner wire fixation.

References

  1. Perugia D, Basile A, Massoni C, Gumina S, Rossi F, Ferretti A. Conservative treatment of subtalar dislocations.  Int Orthop 2002;26(1):56-60. – Pubmed citation
  2. Plewes LW, McKelvey KG. Subtalar dislocation.  J Bone Joint Surg Am 1944 Jul;26(3):585-8. – Online
  3. DeeLee JC, Curtis R. Subtalar dislocation of the foot. J Bone Joint Surg Am 1982 Mar;64(3):433-7. – Pubmed citation
  4. Bohay DR, Manoli A II. Subtalar joint dislocations.  Foot Ankle Int 1995 Dec;16(12):803-8. – Pubmed citation
  5. Smith H. Subastragalar dislocation: a report of seven cases.  J Bone Joint Surg Am 1937 Apr;19(2):373-80. – Online
  6. Straus DC. Subtalar dislocation of the foot.  Am J Surg 1935;30:427-34.
  7. Merchan EC. Subtalar dislocations: Long-term follow-up of 39 cases.  Injury 1992;23(2):97-100. – Pubmed citation
  8. Bibbo C, Anderson RB, Davis WH. Injury characteristics and the clinical outcome of subtalar dislocations: a clinical and radiographic analysis of 25 cases.  Foot Ankle Int 2003;24(2):158-63. – Pubmed citation
  9. Christensen SB, Lorentzen JE, Krogsoe O, Sneppen O. Subtalar dislocation.  Acta Orthop Scand 1977;48(6):707-11. – Pubmed citation
  10. Grantham SA. Medial subtalar dislocation: five cases with a common etiology.  J Trauma 1964 Nov;4:845-849. – Pubmed citation
  11. Heppenstall RB, Farahvar H, Balderston R, Lotke P. Evaluation and management of subtalar dislocations.  J Trauma 1980 Jun;20(6):494-7. – Pubmed citation
  12. Edmunds I, Elliott D, Nade S. Open subtalar dislocation.  Aust N Z J Surg 1991 Sep;61(9):681-6. – Pubmed citation
  13. Mulroy RD. The tibialis posterior tendon as an obstacle to reduction of a lateral anterior subtalar dislocation.  JBJS 1955 Jul;37-A(4):859-63. – Pubmed citation
  14. Leitner, B. Obstacles to reduction in subtalar dislocations.  JBJS 1954 Apr;36(A:2):299-306. – Pubmed citation
  15. Sanders DW. Fractures of the talus.  In: Bucholz RW, Heckman JD, Court-Brown C, editors.  Rockwood and Green’s Fractures in Adults.  Vol 1.  6th ed.  Philadelphia: Lippincott Williams & Wilkins; 2006.  2249-2292.

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