History
Jacques LisFranc De St-Martin (1790 - 1847)
General Surgeon in Napoleonic army
Epidemiology
0.2% of all orthopedic injuries
Mechanism
High energy - Lis Franc fracture dislocations
| Twisting / abduction injury of forefoot | Axial Loading | Direct Crush |
|---|---|---|
|
Original description is fall from horse with foot caught in stirrups MVA |
Fall from height |
Risk compartment syndrome Open fractures |
Low energy - Isolated Ligamentous Lis Franc injuries from sport
Classification
| Isolated | Homolateral | Divergent |
|---|---|---|
| Only 1st MT injured / displaced | All 5 metatarsals displaced in same direction |
1st metatarsal displaces medially Other 4 metatarsals displace laterally |
| Most common | Least common | |
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Myerson
A: Total incongruity (medial or lateral)
B: Partial incongruity
B1: Medial
B2: Lateral (most common)
C: Divergent displacement
C1: Partial
C2: Total
Anatomy
Bony Stability
| Alignment | Alignment | Roman arch | Keystone / Mortise |
|---|---|---|---|
|
1st - medial cuneiform 2nd - middle cuneiform 3rd - lateral cuneiform |
4th and 5th metatarsals articular with cuboid |
Bases of metatarsal wider dorsally than plantar Form half of Roman arch |
2nd metatarsal is keystone of transverse metatarsal arch - medial cuneiform is recessed proximally - mortise provided for base of second |
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Ligamentous stability
Lis Franc ligament
- plantar structure
- 1 cm long x 0.5 cm diameter
- base 2nd MT to medial cuneiform
- avulsion as 'fleck fracture'
Examination
Swelling and pain out of proportion
Brusing plantar aspect foot indicative of Lis Franc ligament rupture
Signs compartment syndrome
X-ray
AP / Assess medial column
Diastasis between 1st and 2nd metatarsal
Medial border 1st metatarsal should line up medial border medial cuneiform
Medial border of 2nd metatarsal should line up with medial border middle cuneiform
Internal Oblique 30o / Assess lateral column
Medial border 3rd metatarsal line up with medial border lateral cuneiform
Medial border of 4th metatarsal line up with medial border cuboid
CT scan
Dorsal displacement of metatarsals
Compression fractures / nutcracker of cuboid
Operative Management
Indications
Any displacement
Divergent / Homolateral
Timing
Wait for swelling to reduce
2 - 3 weeks
Two Incision Approach
First incision
- between 1st and 2nd metatarsal
- lateral to EHL
- protect branches of SPN
- dorsalis pedis and DPN are in this intermetatarsal space
2nd incision
- between 3rd and 4th metatarsal
Reduction + ORIF
AP view
- 1st metatarsal to medial cuneiform - screw
- 2nd metatarsal to intermediate cuneiform - screw
- medial cuneiform to base of second metatarsal - screw
+/- medial cuneiform to intermediate cuneiform - screw
Oblique view
- 3rd metarsal to lateral cuneiform - screw / K wire fixaiton
- 4th metatarsal to cuboid with K wires
- 5th metatarsal to cuboid with percutaneous K wire
Fusion
Post operative
Non weight bear for 8 weeks
Removal of K wires
Removal of Lis Franc screws
Complications
Compartment Syndrome
Midfoot Arthritis