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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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Outcome after early open reduction and Kirschner wire fixation of Lisfranc joint injuries

Posted on March 31, 2014 | Comments Off on Outcome after early open reduction and Kirschner wire fixation of Lisfranc joint injuries

by Irfan Ahmad Latoo (MS)1, Reyaz Ahmad Dar (MS)1, Mubashir Maqbool Wani (MS)1, Iftikhar Hussain Wani (MS)1, Mohammad Shafi bhat1pdflrg

The Foot and Ankle Online Journal 7 (1): 1

The study was a consecutive study conducted over a period of four years commencing in 2008 on Lisfranc joint injuries of feet. We studied the outcome of early open reduction and internal fixation of 20 cases of Lisfranc injuries using AOFAS-M score (American Orthopaedic Foot and Ankle Society-Midfoot score). Most patients were in the age group of 18-35 years. In our series the cause of injury was road traffic accidents in 50% cases followed by fall from height in 40% of cases. Most of Lisfranc fractures were of type B (60%) followed by type A. Most common associated injuries were metatarsal fracture (30% cases). The follow-up was 1-3 years with an average of 2 years. The mean AOFAS-M score was 78.36 with patients losing points to pain and decreased recreational function. Ours was not a comparative study but we strongly feel that early open reduction and Kirschner wire fixation of Lisfranc fracture dislocations within 24 hours of injury considerably improves functional outcome in these cases.

Key words: Lisfranc fracture, Kirschner wire

ISSN 1941-6806
doi: 10.3827/faoj.2014.0701.0001

Address correspondence to: Mubashir Maqbool Wani, Hospital for Bone and Joint Surgery Barzulla, India 190005.
Email: mubashirmaqboolwani@yahoo.co.in

The Lisfranc joint has been an eponym of tarsometatarsal joint injuries since Jacques Lisfranc, a field surgeon in Napoleon’s army described an amputation through the joint for gangrenous injuries of the forefoot [1]. Fracture dislocations of the Lisfranc (tarsometatarsal) joints of foot are uncommon but serious injuries with high potential for chronic disability. These injuries can easily be missed in the emergency department as radiographs may show only subtle incongruity of the joint [2].

In the treatment of fracture dislocation of tarsometatarsal joints, early accurate diagnosis combined with prompt anatomic reduction and stable internal fixation provides optimal results [3]. Closed reduction and percutaneous Kirschner wire fixation has been advocated by some [4,5], but the trend is towards open reduction and screw/Kirschner wire fixation [6,7].

The purpose of this study was to evaluate the functional outcome of patients with Lisfranc joint injuries treated with open reduction and internal fixation with Kirschner wires within 24 hours of injury.

Lisfrcfig1

Figure 1 X-ray right foot AP view showing C2 injury.

Materials and Methods

We performed a consecutive study of 20 patients with tarsometatarsal joint injuries at our hospital commencing in 2008 after approval by hospital ethics committee. An informed consent was taken from all the patients. Only those patients were included who presented < 24 hours of injury and were aged between 16 years and 65 years, the patients who were excluded from study were patients with open injuries, patients presenting > 24 hours of injury and polytrauma patients. The injuries were classified by Myerson’s modification of Hardcastle classification [8].

Lisfrcfig2

Figure 2 X-ray right foot oblique view of same patient as Figure 1.

Surgical Technique

A dorsal longitudinal incision was made between the first and second metatarsal. The extensor hallucis longus tendon, deep peroneal nerve and dorsalis pedis artery were identified and retracted as a unit.

Small irreducible fragments were debrided from the joint. The first tarsometatarsal joint was aligned by reducing the medial border of medial cuneiform to the medial border of the first metatarsal. The planter medial aspect of the joint was directly visualized to ensure that there was no planter gap. The second metatarsal was then reduced to the medial border of middle cuneiform. The joints were fixed with Kirschner wires. In some cases a second longitudinal incision was made centered over the fourth metatarsal and the third metatarsocuneiform joint was reduced. The fourth and fifth metatarsals usually reduced once the above three reductions were achieved and were held with one or two transarticular K-wires from the base of 5th metatarsal to the cuboid.

Lisfrcfig3

Figure 3 X-ray foot AP View of same patient 8 weeks after fixation.

Results

Most patients (70%, n=14) were in age group of 18-35 years with a mean 33.2 years. Males (80%, n=16) outnumbered females (20% n=4). Both right and left foot were equally involved. Cause of injury were road traffic accidents in 50% cases (n=10), fall from height in 40% (n=8) and other causes in 10% (n=2).

Metatarsal fracture was the most common associated injury (30%, n=6). The injuries were classified by Myerson,s modification of Hardcastle classification [8]. The majority of injuries (60%, n=12) were type B followed by type A (20%, n=4). All the operations were done within 24 hours of injury.

Lisfrcfig4

Figure 4 X-ray foot AP view of same patient 1.5 years after fixation.

Following surgery a posterior splint was applied and left in place for 10-14 days. During this period alternate wound dressings were done. Stitches were removed at around 14 days and short leg cast was given at the time of removal of stitches. K-wires were removed at 8 weeks. Full weight bearing was allowed at 10-12 weeks. Anatomical reduction was obtained in 19 patients (95%).

There was one case of loss of reduction in our study. There were two cases of superficial wound infection in our series both of them responded to antibiotics. Primary closure of skin was done in 90% cases (n=18) while in two patients delayed primary closure was done. There was no case of compartment syndrome of foot in our series. Good to fair results were seen in 90% cases (n=18).

Lisfrcfig5

Figure 5 X-ray foot Lateral view of the same patient after 1.5 years of fixation.

The mean AOFAS-M score in our study was 78.36 with most patients losing points to pain and decreased recreational function. Eighty percent of patients were able to return to their original occupation, including 10 household or office workers and six laborers.

Discussion

Lisfranc injuries result from high-energy injuries. In our study, motor vehicular accidents were the most common cause of injury, a finding consistent with the already available literature. Anatomic reduction and internal fixation has become standard principle governing treatment of tarsometatarsal fracture dislocations. Most authors agree stable anatomic reduction leads to optimal results [9]. The advantage of open reduction is that it allows direct visualization of the fracture dislocation for debridement of comminuted fracture fragments and osteochondral defects.

There is controversy about which method of fixation is best. There are proponents of k-wire fixation [10,11], while others rely on screw fixation [9,12]. In our study the age group ranged from 16-65 years with mean of 33.2 years.

In Goossens et al study [13], age groups ranged from 10-52 years with mean of 34 while as reported in Pereira et al [14], age group ranged from 17-50 years with mean of 31.53. The mean age group in our study was close to the study of Goossens et al [13]. Males outnumbered females in our study with ratio of 4:1 while as in Hesp et al [15], the male to female ratio was 2.3:1. The reason for higher male to female ratio in our study may be due to the fact that most of females in our setup are household sedentary workers. Both right and left feet were equally involved in our study.

The mode of injury was road traffic accidents (RTA) in majority of patients (50%) followed by fall from height which was consistent with Hardcastle et al [8], 40.3% RTA and Kuo et.al. [16], with RTA 42%. In our study most of the Lisfranc injuries (60%) were type Hardcastle type B followed by type A (20%). In Enríquez et al [17] series type B injuries were most common Lisfranc injuries (50%). While as in Pereira et al series [14], type B Lisfranc joint injuries constituted 80.94 percent of Lisfranc fracture dislocations. Metatarsal fracture were the most common associated injury in our study in 30% cases. In Goossens et al, series [13] metatarsal injuries were also the most common associated injuries (40%).

The mean duration of hospital stay in our series was three days. K-wire were removed at mean of 8 weeks in our study while as in Kuo et al [16] K-wires were removed at 6-8 weeks. There was no case of compartment syndrome in our study and primary closure was done in 90% cases. While two cases delayed primary closure was done. Complication in our study included loss of reduction in one case and two cases of superficial wound infection. Both cases occurred within one week of surgery and responded well to antibiotics and daily dressings. In Kuo et al series [16], there was no case of postoperative wound infection and one patient in their series required fasciotomy with split-thickness skin graft. There was one case of loss of reduction in our series.

The percentage of loss of reduction with K-wires was less in our series as we immobilized the foot for longer duration in short leg cast (mean 8 weeks). Molded arch support was given to patients after three months, which was discarded at 6 months in 70% cases while as 30% cases felt its need up to one year. In our study good to fair results were seen in 90% cases as per scale used by Pereira et al [14], with mean AOFAS score 78.23. Our mean AOFAS score was higher than Kuo et al [16], while as in Pereira et al [14] it was 77.36. Like this study most of our patients lost points to pain and decreased recreational function.

We believe that early open reduction and K-wire fixation considerably improves the functional outcome in these injuries. There is an added advantage that no second surgery for removal of hardware is required. The disadvantage is that this method needs longer period of immobilization in a cast. The limitation of our study is that there was no control group so that we could compare our results.

References

1. Cain PR, Seligson D. Lisfranc’s fracture-dislocation with intercuneiform dislocation: presentation of two cases an a plan for treatment. Foot Ankle. 1981;2 (3): 156-60. – [Pubmed]
2. Norfray JF, Geline RA, Steinberg RI et-al. Subtleties of Lisfranc fracture-dislocations. AJR Am J Roentgenol. 1981;137 (6): 1151-6. – [Pubmed]
3. Kuo RS, Tejwani NC, Digiovanni CW et-al. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am. 2000;82-A (11): 1609-18. – [Pubmed]
4. Arntz CT, Veith RG, Hansen ST. Fractures and fracture-dislocations of the tarsometatarsal joint. J Bone Joint Surg Am. 1988;70 (2): 173-81. – [Pubmed]
5. Buzzard BM, Briggs PJ. Surgical management of acute tarsometatarsal fracture dislocation in the adult. Clin Orthop Relat Res. 1998;(353): 125-33. – [Pubmed]
6. Curtis MJ, Myerson M, Szura B. Tarsometatarsal joint injuries in the athlete. Am J Sports Med. 21 (4): 497-502. – [Pubmed]
7. Myerson M. The diagnosis and treatment of injuries to the Lisfranc joint complex. Orthop Clin North Am. 1989;20 (4): 655-64. – [Pubmed]
8. 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): 225-42. – [Pubmed]
9. Rosenberg GA, Patterson BM. Tarsometatarsal (Lisfranc’s) fracture-dislocation. Am J Orthop. 1995;Suppl : 7-16. – [Pubmed]
10. Pérez blanco R, Rodríguez merchán C, Canosa sevillano R et-al. Tarsometatarsal fractures and dislocations. J Orthop Trauma. 1988;2 (3): 188-94. – [Pubmed]
11. Tan YH, Chin TW, Mitra AK et-al. Tarsometatarsal (Lisfranc’s) injuries–results of open reduction and internal fixation. Ann Acad Med Singap. 1995;24 (6): 816-9. – [Pubmed]
12. Jeffreys TE. Lisfranc’s fracture-dislocation: a clinical and experimental study of tarso-metatarsal dislocations and fracture-dislocations. J Bone Joint Surg Br. 1963;45 : 546-51. – [Pubmed]
13. Goossens M, De stoop N. Lisfranc’s fracture-dislocations: etiology, radiology, and results of treatment. A review of 20 cases. Clin Orthop Relat Res. 1983;(176): 154-62. – [Pubmed]
14. Pereira CdJ, Espinosa EG, Miranda I, Pereira MB, Canto RSdT. Evaluation of the surgical treatment of Lisfranc joint fracture-dislocation. Acta ortop bras. 2008;16(2) – [Webpage]
15. Hesp WL, Van der werken C, Goris RJ. Lisfranc dislocations: fractures and/or dislocations through the tarso-metatarsal joints. Injury. 1984;15 (4): 261-6. – [Pubmed]
16. Kuo RS, Tejwani NC, Digiovanni CW et-al. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am. 2000;82-A (11): 1609-18. – [Pubmed]
17. Enríquez CJA, López VA, García HA, González TA, Ventura MA, Soto RV. Lisfranc’s fracture dislocation. Epidemiological study and results at the General Hospital in Mexico. Acta Ortop Mex 2005; 19 (s1). – [Webpage]

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