Lisfranc

Scenario

A 45 year old female presented to A+E after her foot was run over by a car. Her radiograph is presented below.

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This is an AP and oblique plane film radiograph of an unknown skeletally mature individuals foot. The most obvious abnormality is that there is a widening of the first web space, the lateral border of the 2nd metatarsal does not line up with the lateral border of the middle cuneiform (on AP) and the medial border of the 4th metatarsal lines up with the medial border of the cuboid on the oblique view. This indicates a Lisfranc injury.

AP radiograph

  • Fleck sign + widening of the 1st web space
  • Lateral border of the 1st and 2nd ray does not line up with the lateral border of the medial and middle cuneiform repectively

Oblique view (internally rotated)

  • Medial border of the 4th metatarsal lines up with the medial border of the cuboid

Lateral view

  • Dorsal subluxation of the metatarsal relative to the respective tarsal bone.

A lisfranc injury is a tarsometatarsal fracture dislocation characterized by traumatic disruption between the articulation of the medial cuneiform and base of the 2nd metatarsal. 

Diagnosis may show widening of the interval between the 1st and 2nd ray.

In an appropriately marked and consented anaesthetised patient. I would complete a WHO checklist.

I would position the patient supine with a bolster beneath the ipsilateral hip. Torniquet on to 310mmHg.

Incision

– Dorsomedial incision – over the first tarsometatarsal joint between the EHL and EDL.

– Dorsolateral incision – EDL and EDB

Prepare the fracture site. Reduce using pointed reduction forceps. Hold with K wire. place a screw through the cortical shelf on the medial cuneiform 3.5mm screws.

Closure: 2-0 vicryl then 3-0 monocryl.