Lisfranc injury.

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Răzvan Codrin Bandac 1 1 Grigore Lisfranc injury. Mechanisms of injury are direct and indirect, including traffic accidents and sports. Clinical signs and symptoms are: midfoot pain, inability to bear weight, leg deformity and lisfranc injury, and plantar ecchymosis. Pedal artery or deep peroneal nerve may be compromised and the compartment syndrome may occur. Radiographic incidences reveal changes and dislocations in tarsometatarsal interlining. Stress radiographs are helpful in unstable lesions.

CT is used for diagnosis and preoperative planning. Lisfranc injury classifications can not determine the treatment or suggest prognosis. Medial and middle columns are fixed with 3. Postoperative care includes early mobilization, progressive weight-bearing, and osteosynthesis material removal.

Primary tarsometatarsal arthrodesis is an alternative in lesions with severe joint damage.

MODERN DIAGNOSTIC AND TREATMENT PRINCIPLES OF LISFRANC MIDFOOT DISLOCATIONS IN ATHLETES

Immediate complications are common, including neurovascular injury and compartment syndrome, and late complications are posttraumatic midfoot arthrosis, algoneurodistrofic syndrome, chronic foot pain, implant deterioration. Patients require a long rehabilitation period. Lisfranc injury incidence of posttraumatic arthritis is high, due to damaged articular surfaces, comminuted fractures, or due to side movements, results of unstable osteosynthesis.

Key words: Lisfranc joint complex, tarso-metatarsal dislocation, internal fixation, midfoot osteoarthritis.

This term is used today to describe a wide spectrum of traumatic lesions to this region of the foot. Specialists concern for midfoot trauma is generally quite lisfranc injury, inevitably leading to a inadequate knowledge and treatment of these lesions. Thus, Di Giovanni [1] noted a marked increase in the incidence of foot injuries due to increased frequency and severity of road accidents, and also more associated multiorgan injuries in polytrauma.

This often puts in difficult situations the medical team, which has to act quickly in chosing the therapeutic maneuvers needed to maintain vital functions, and minimizing the treatment of leg trauma. Further course is burdened by severe pain and severe homolateral leg dysfunctions [3,4], with a psycho-socio-economic impact on the quality of life stronger than with any lisfranc injury injury. Also, the widespread practice of collision sports, such as rugby, American [5,6] or even European football has led in recent decades to an increase in the incidence of midfood injuries, from simple, classified as midfoot sprains with different degrees of lisfranc injury, to complex midfood injuries dislocations and fracturedislocationposing serious diagnositic and treatment problems.

Heckmann and colleagues explain the need for an as accurate orthopedic or surgical treatment as posible for ensuring perfect alignment of the injured structures, given the extremely complex biomechanics of the foot that does not allow imperfections [7,8]. Strict observance of the therapeutic principles gives satisfactory results, reducing the immediate circulatory disorders, skin necrosisbut also late arthritis, stiffness, vicious calluses complication rate [9,10].

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Chapman and colleagues provide an important contribution by presenting detailed notions of biomechanics of the foot for each traumatic areas [5], and related to the pathophysiologic mechanisms of injury.

These are corroborated with modern imaging methods for obtaining more precise data about disturbances in osteoarticular biomechanics, aimed at initiating immediately an accurate treatment for each injury type [1].

Last, but not least, Greer Richardson, in his "Fractures and dislocations of the foot, reviews thoroughly foot injuries on targeted osteoarticular segments, depending on their biomechanic involvement in the entire complex [5, 7].

The most important contribution is the meticulous clinical-anatomical lisfranc injury of every entity, thus offering support for optimal treatment of every anatomic injury [10] and goal is to obtain a very good 46 2 surgical result, that is a correct osteoarticular alignment, by the standardization of both the approach route and of lisfranc injury means and methods of internal and external fixation in relation with the type of injury according to the anatomical-clinical classification [4].

Currently, the surgical means of internal and external fixation associated to bone and soft tissue reconstruction in the complex trauma of the foot are presented in detail [7[.

The first three metatarsals articulate with the three corresponding cuneiforms: medial, middle and lateral. The fourth and fifth metatarsals articulate with the cuboid bone Figure 1. Figure 1 Lisfranc joint - osteo-ligamentous anatomy [5] Bone alignment of this articular complex is particularly important in understanding the therapeutic considerations of this region [1,3].

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Intrinsic stability is due both to the deep location of the second metatarsal base, and even more to the strong ligament complexes attached to every tarsometatarsal joint. Lisfranc ligament, the lisfranc injury ligament of this ligament complex, originates in the plantar-lateral aspect of medial cuneiform and inserts into the plantar-medial of second metatarsal base [4] Pedal artery crosses the midfoot right above the second tarsometatral joint, being particularly predisposed to destruction during Lisfranc injuries, often associated with the onset of compartment syndrome.

Deep peroneal nerve, providing innervation to the first intermetarsian space, can also be injured [2]. The study of this joint mobility shows two distinct components [4. Medial lisfranc injury which is a continuation of the talus, scaphoid and the three cuneiforms with their corresponding metatarsals and lateral column, represented by the calcaneus, cuboid and two lateral metatarsals. The three medial joints have less mobility, equal to one third of the mobility in the two joints that form the lateral column.

The relative medial rigidity is particularly important in ensuring regional stability. This allows the distal tendon insertions of the anterior calf muscle and long lateral peroneal muscle to change the position of the first ray, allowing the positioning of the first metatarsal head during forefoot ground support, depending on the type of terrain. Lateral column is also an area of insertion for exremely strong intrinsic muscle groups, distal tendons of the lisfranc injury lateral peroneal and posterior calf muscles, respectively, in the fifth metatarsal base, providing stability and positioning during walking to the lateral column [2,4].

By contrast, the fourth and fifth tarsometatarsal joints are major points of lateral column mobility, mobility being crucial for the normal function of the foot.

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The frequency of these injuries increased primarily due to the increasing incidence of road, work and sports accidents.

Although known to be a rare lesion, this was due to diagnostic difficulties. Direct load of the ligament complex along the dorsal lisfranc injury of the foot, as in crush injuries, or when a heavy object is falling on the foot on the ground, can result in fracture- dislocations anywhere in this articular complex.

The type of injury depends on the point of force application, often the association of soft tissue destruction complicating even more the treatment. Figure 2. Lisfranc injury, typical lisfranc injury the sports field 47 3 mechanism of injury, lisfranc injury in football, namely, when a player is with his foot on the ground and another player forcefully steps on the midfoot area of his foot [6,10]. Indirect load is the most common mechanism of injury, producing the most significant changes in the entire complex, usually by longitudinal loading of the foot in plantar flexion 3.

This leads to association of the dorsal ligaments and then of the plantar ones resulting in varying degrees of bone injuries.

This is the most common mechanism in sports accidents Figure 3. Figure 3 Lisfranc trauma: indirect mechanism of injury 11 Lisfranc injury occurs in the presence of a force and torque between forefoot and midfoot.

Thus, athlete s forefoot is stuck on the ground, and his whole body weight exerts a twisting force resulting in midfoot twinsting while forefoot is immobilized. For example, the horseman falls off a horse and his foot stays locked in the stirrups, or the windsurfer falls off the board but his foot remains in the board stirrup. Also, in football players, these injuries frequently occur when his foot in stuck in the turf and he suddenly rotates when changing direction, or his foot is blocked by another player s foot [6,10].

Recent studies have revealed no relationship lisfranc injury the injury mechanism and type of injury [3,5]. Clinical diagnosis is based on a thorough physical lisfranc injury of the injured artroza deformată tratament 2 grade. In isolated lesions, pain along the ligament complex suggests the presence of a possible injury.

In athletes, immediately after trauma the injured leg is swollen and even deformed in the medial area, with severe spontaneous pain on midfoot palpation and associated with total functional impairment of this area causing inability to bear weight. Passive dorsiflexion and individual plantar flexion of metatarsal heads, performed by team physician, will cause pain in proximal joints. Plantar ecchymosis is also a sign suggestive of joint damage [3,4].

Of particular importance is to check immediately the neurovascular status of the injured foot, given the likelihood of damage to pedal artery or deep branch of the peroneal nerve. If these are present, the patient should be immediately referred to a specialized orthopedic unit for further physiacal and laboratory investigation. In case of arterial injury, the compartment syndrome of the leg is imminent, requiring urgent therapeutic measures. Radiographic evaluation is crucial in the diagnosis and treatment of this injury, being especially used to determine joint stability and the presence and type of associated injuries.

If possible, radiographs at presentation should include weight bearing anteroposterior, lateral, and degree medial oblique views. If weight-bearing radiographs can not be obtained, and there is a suspicion of ligament damage, stress views, with the patient under anesthesia to minimize pain and muscle contraction are required. If trauma allows, a locoregional anesthesia with Marcaine 0. Any displacement of joint contours exceeding 2 mm, shows ligament instability.

As preoperative screening tool, CT-scan has an important role in identifying fractures and dislocations relevant for maintaining foot stability and function [3,15].

Classification of Lisfranc injuries. Currently there are a number of classifications to quantify the severity of tarsometatarsal fracture-dislocation, but none is helpful in the choice of treatment. Quenu and Kuss [4,7] classified these insuries into three main categories, defined as dislocations or subluxations varying in number and directions: isolated with unidirectional displacement of at least one metatarsal, but not lisfranc injury, usually the first or second rayhomolateral medial or lateral dislocation or subluxation frequently of all metatarsalsand divergent separation of lisfranc injury combination of metatarsals in different directions and in more than one plan.

Although a large number of classifications lisfranc injury described, they are mostly descriptive and are not useful for prognostic or management purposes.

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For example, Hardcastle and collaborators devided the lesion types into partial incongruenty, total incongruenty, and totally divergent [7]. None of the above mentioned classifications mentions the fractures associated with these lesions, which usually need to be recognized in view of optimal treatment.

Most common in decreasing order of their occurrence are the fractures of the metatarsal, cuneiform and cuboid. Kuo and colleagues have recently developed a protocol for long-term study of Lisfranc injury, suggesting that injury mechanism would be important in determining prognosis.

Myerson s changes to Quenu and Kuss and Hardcastle classifications are the lisfranc injury commonly used today, as they include more lesions proximal to the inner column of the foot [7,9,10] Figure 5. Figura 2 Myerson clasificarea of tarsometatarsiene lisfranc injury 4 Type A lateral or dorsoplantar displacement of all five metatarsals, with or without fracture of the base of the second metatarsal, termed homolateral.

Type B1 shows medial dislocation, sometimes affecting the intercuneiform or naviculocuneiform joints.

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Type B2 the lesions causes lateral dislocation and may involve the the first metatarsocuneiform joint. Type C - injuries are divergent and can be with partial C1 or complete displacement C2. They are prone lisfranc injury complications, especially to compartment syndrome.

The most important thing in the attempt at classifying Lisfranc injury is to give the possibility of deciding if the medial column, lateral column, intertarsal joints, or any combination of these structures is involved, because the mechanism of injury affects the treatment.

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It is also more important to focus on all compromised tarsometatarsal joints rather than trying to pinpoint exactly which direction they went [2,3,5,10].

Midfoot sprains are often the result of sports injuries, being caused by indirect mechanisms not lisfranc injury enough to produce complete ligament injuries and instability [6,10,12,15]. These patients had a degree of local swelling, echymosis, pain, but not instability documented both clinically and radiographically [3,5]. In emergency, it is important to keep as early as possible the injured foot in proclive position, put ice packs, and administer anti-inflammatory medication.

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After orthopedic physical examination rules out a compartment syndrome, stress radiographs that do not show instability less than 2 mm displacement of the tarsometatarsal joint with any view have to be done. In the absence of these changes on stress radiographs, treatment consists in foot immobiliation in a cast for up to 6 weeks; patients are instructed to temporarily avoid bearing weight on the injured foot, weight-bearing and other normal activities being gradually resumed as symptoms subside, and to begin rehabilitation and actinve kinetotherapy in order to avoid lisfranc injury and algoneurodystrophy syndrome.

Repeat stress x-rays 2 weeks after immobilization.

Artroza lisfranc Tarsometatarsal Joints and Midfoot Lisfranc Sprains artrita artroza deget mare Departamentul de Chirurgie Ortopedica al clinicii Centrokinetic este dedicat sa ofere ingrijire excelenta pacientilor si educatie de exceptie pentru medicii tineri, lisfranc injury domeniile chirurgiei Artroza lisfranc si a medicinii musculo-scheletice. Departamentul este format din medici ortopezicu activitate chirurgicala vasta, supraspecializati in traumatologie sportiva, chirurgia gleznei si piciorului, artroplastia de genunchi si sold, chirurgia ortopedica pediatrica. Centrokinetic acorda o mare importanta intregului act medical: investigatii necesare diagnosticarii corecte ecografie, RMNinterventii chirurgicale si recuperare postoperatorie.

Prognosis of midfoot sprains in injured athletes not requiring surgery is usually favorable. Healing occurs regularly, but may be associated with gait disturbances 2 to 4 months after accident. Over time, several authors have been interested in the anatomy, biomechanics and treatment of midfoot injuries.

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Sangeorzan [9,17], Myerson [11] and others emphasized the complex biomechanics of the foot, the functional result of which is normal mobility, joint alignment, and stability. All these notions are important in the preoperative planning of internal fixation.

The main advantages lisfranc injury open reduction and internal fixation are: soft tissues protection, less pain and secondary deformities. In acute crush injuries, this method prevents an impending forefoot compartment syndrome [10]. In literature, Lisfranc fracture-dislocation is a major emergencies, surgery being performed within 4 hours of admission in the following cases: open midfoot fracture-dislocation regardless of the degree of soft tissue damage, associated vascular complications, crush syndromes, compartment syndrome in closed Lisfranc fracture-dislocation.

Pedal artery is usually damaged in Lisfranc injuries, but this seems not to be an important issue as there it has many dorsal and plantar collateral branches.

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However, injury to the first metatarsal branch of pedal artery is frequently associated, and it can be the cause of a compartment syndrome. In the case of crushes, large areas of damaged neurovascular tissue stopping blood flow to the forefoot may occur, inevitably leading to this segment amputation.

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Blood treatment of these lesions can directly lead to lower tissue pressure, which is why all midfoot dislocations require an emergency treatment, both by open reduction and internal fixation and indirect reduction techniques associated with external fixation of internal and columns. Occurence of compartment syndrome will be closely monitored, and if this happens an emergency treatment will be instituted.

Incisions for fasciotomy should coincide with the upcoming surgery for osteoarticular stabilization [4,17]. Over time, treatment of midfoot injuries evolved from orthopedic reduction and fixation with Kirschner pins or plaster immobilisation, to blood reduction and osteosynthesis by screws, sometimes 50 6 associated with thin or threaded pin.

Although pin fixation has his supporters [2,4,5], the cases treated by this method showed a fairly high failure rate. Figure 6.

Figura 3 Lisfranc fracture-dislocation Myerson type C2:internal fixation with Kirschner pins Currently there is not a consensus on the ideal treatment of these lesions, but it is widely agreed that the best results, leading to rapid healing, are obtained in patients in which reduction and fixation of these injuries was accurate [10,17]. For this reason, most authors choose blood reduction and screw fixation in all midfoot fracture-dislocations [2,3,5,10,13].

Screws are able to provide a more solid compression and fixation, essential for the rigid stabilization of the three medial tarsometatarsal joints and of those fractures in which insufficient fixation results in pseudoarthrosis. Lisfranc injury screws allow their percutaneous insertion Figure 7.

Figura 4 Lisfranc fracture-dislocation Myerson type B2: internal fixation with screws 3 Internal fixation. Chapman lisfranc injury colleagues recommend internal fixation in two or three lisfranc injury joints for all types of Lisfranc fracture-dislocation. The fourth or, most commonly, the fifth metatarsal can be fixed by Kirschner pins [5]. Sometimes, after anatomical fixation of the internal column, the lateral column reduces spontaneously, remaining stable during surgical or radiological examination.

In these cases, internal fixation of these joints fourth and fifth is not necessary, thus the occurrence of postoperative stiffness in the lateral lisfranc injury being avoided.

Metal implants are removed at least 6 months after initial surgery, with the risk of a short-term functional impairment Table 1 [8,15]. Two longitudinal incisions were used to approach the posttraumatic Lisfranc joint injuries: one in the space between the first and second metatarsal and the second in the space between the third and fourth metatarsal.

These incisions are 4 to 6 cm long and go up to the bone, avoiding as much as possible the extensor tendons and neurovascular structures.

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