Lisfranc Injury Current Concepts PDF

Lisfranc Injury Current Concepts Hyojeong Mulcahy, MD* KEYWORDS  Lisfranc injury  Midfoot sprain  Midfoot fracture  Midfoot dislocation KEY POINTS  Prompt diagnosis and appropriate treatment of Lisfranc injury is the key to preventing osteoarthritis and chronic deformity.  Radiograph...

Lisfranc Injury Current Concepts Hyojeong Mulcahy, MD* KEYWORDS  Lisfranc injury  Midfoot sprain  Midfoot fracture  Midfoot dislocation KEY POINTS  Prompt diagnosis and appropriate treatment of Lisfranc injury is the key to preventing osteoarthritis and chronic deformity.  Radiographic evaluation of the Lisfranc joint requires a thorough search for subtle fractures and ma- lalignment on all views.  Computed tomography and MR imaging are primarily important for the diagnosis and management of low-energy Lisfranc injury. INTRODUCTION trauma or during a misstep.5 Lisfranc fracture- dislocation can also occur as part of the spec- Lisfranc injury is named after Jacques Lisfranc trum of neuropathic arthropathy.6 Motor vehicle de Saint-Martin, a French field surgeon accidents are the most frequently cited mecha- during the Napoleonic wars, and refers to an nism, accounting for approximately 40% to injury to the tarsometatarsal (TMT) joints of the 45% of injuries, and low-energy mechanisms ac- midfoot.1 Lisfranc injuries include a broad spec- count for approximately 30%.7 Lisfranc injuries trum of injuries ranging from sprain or subluxa- account for more than 15% of all athletic in- tion to a grossly displaced fracture or fracture- juries.8 Although the overall incidence is low, Lis- dislocation of the TMT joints.2 To avoid confu- franc injuries have become the second most sion, fractures of the tarsals or metatarsals common athletic foot injury, following metatarso- without TMT joint subluxation should not be phalangeal joint injury.6 The incidence of Lisfranc labeled as Lisfranc injuries. injuries is rising because of widespread high- Lisfranc injuries are uncommon and account for performance athletic training.9 They have been approximately 0.2% of all fractures.3 They often reported in various sports, including football, coexist with tarsal or metatarsal fractures.4 In the gymnastics, horse riding, and running.10 Lisfranc United States, the incidence has been reported injuries occur in 4% of football players and to be 1 per 55,000 every year in the general popu- 29.2% of offensive linemen per year.11 The lation, although this can be an underestimation, as “bunk bed” fracture is the pediatric equivalent up to one-third of injuries can be missed during the of the TMT fracture-dislocation in adults.12 Male initial assessment.3 individuals are 2 to 4 times more likely to sustain Acute injuries can be separated into 2 major a Lisfranc joint injury, possibly due to a higher types. The more common high-energy injuries rate of participation in high-speed activities. are secondary to crush injuries, falls, and motor The injury can occur at any age, but more vehicle accidents, whereas the low-energy in- commonly in the third decade of life.3 juries are often acquired in professional athletic radiologic.theclinics.com Disclosure: The author has nothing to disclose. Department of Radiology, University of Washington, Seattle, WA, USA * UWMC-Roosevelt Radiology, Box 354755, 4245 Roosevelt Way Northeast, Seattle, WA 98105. E-mail address: [email protected] Radiol Clin N Am 56 (2018) 859–876 https://doi.org/10.1016/j.rcl.2018.06.003 0033-8389/18/Ó 2018 Elsevier Inc. All rights reserved. Downloaded for Anonymous User (n/a) at Des Moines University from ClinicalKey.com by Elsevier on October 24, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved. 860 Mulcahy ANATOMY the first metatarsal.10 The middle column is the Osseous Structures most rigid, made up of the second and third metatarsals and their respective TMT articula- The midfoot is made up of 5 bones: navicular, tions (Fig. 2).15 The relative stiffness on the cuboid, and 3 cuneiform bones. The Lisfranc joint in- cludes the articulations between the 3 cuneiform bones and cuboid with the 5 metatarsals.6 The 5 metatarsal bones contribute to the long plantar arch in the sagittal plane. The TMT articulations tran- sition more proximally in the transverse plane from medial to lateral.10 The second metatarsal base is recessed proximally relative to the remainder of the TMT articulations. Its design is a mortise config- uration that provides resistance to medial or lateral shear forces across the joint complex. The trape- zoidal shape of the metatarsal bases and their cor- responding cuneiforms form a Roman arch, with the second metatarsal acting as the keystone, conferring coronal plane stability (Fig. 1).13 Biomechanically, the Lisfranc joint represents the transition from midfoot to forefoot and is, therefore, crucial for a normal gait pattern. Mobility within the joints of the TMT joint is, therefore, very important, particularly during weight bearing (WB) over uneven ground.14 These joints also are classified into columns in the foot. The lateral column is the most mobile and made up of the articulation between the fourth and fifth metatarsals and the cuboid. Therefore, posttraumatic symptomatic arthritis is rare in this column. The medial column con- sists of the navicular, the medial cuneiform, and Fig. 1. Roman arch. Short-axis CT image through the level of proximal metatarsals demonstrates asymmetric Roman arch of the TMT joint. The middle cuneiform and Fig. 2. Three columns. A diagram shows the normal second metatarsal base (M2) are shaped like a keystone 3-column anatomy of the midfoot. C1, medial cunei- in the coronal plane. M2 represents the ‘‘keystone’’ form; C2, middle cuneiform; C3, lateral cuneiform; because of its dorsal-most position and trapezoidal Cu, cuboid; M1–M5, metatarsals. The medial (black), articular surface, broad base dorsally, and apex at its middle (blue), and lateral (red) columns are shown. plantar surface. This transverse arch is an inherently sta- The stiff middle column acts as a rigid lever arm, ble configuration mechanically, but predisposes to with the medial and lateral columns providing appro- dorsal displacement (red arrows; shear force vectors). priate adjustment as WB gait. Downloaded for Anonymous User (n/a) at Des Moines University from ClinicalKey.com by Elsevier on October 24, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.  Lisfranc Injury: Current Concepts 861 medial side is possible because the center of mobility on the medial side of the foot is at the talonavicular joint. The stiff middle column acts as a rigid lever arm during WB, with the medial and lateral columns providing appropriate adjustment as WB forces pass through the mid- foot.14 The Lisfranc ligament rigidly links the medial and middle columns while still allowing mobility between the first 2 metatarsals.3 Ligamentous Complex The Lisfranc joint complex includes not only the TMT articular surfaces but also the intermetatarsal and anterior intertarsal surfaces. These ligaments reinforce and stabilize the articular capsules and skeletal elements. The ligamentous anatomy is complex and its complexity is reflected in the orthopedic and radiologic literature, which is inconsistent with respect to nomenclature and description.16,17 De Palma and colleagues18 described Lisfranc ligament complex in terms of dorsal, plantar, and interosseous ligaments on the basis of location. Each set consists of longitudinal, oblique, and transverse fibers. The longitudinal fibers connect the TMT joint of the same rays. The oblique fibers connect the contiguous rays, and the Fig. 3. Dorsal ligament system. Schematic representa- transverse fibers connect the tarsals or the tion of dorsal ligaments along the TMT joints. The metatarsals.18 Generally, the plantar ligaments dorsal ligament system of the Lisfranc joint complex are stronger than the dorsal ligaments, lies on the dorsal aspect of the foot. There are 7 which may account for the dorsal direction of TMT ligaments. Black lines, TMT ligaments; blue lines, dislocations.10 intertarsal ligaments; C, cuneiform; Cu, cuboid; green The dorsal ligament system of the Lisfranc joint lines, intermetatarsal ligaments; M, metatarsal; red complex lies on the dorsal aspect of the foot. lines, Lisfranc ligament. There are 7 TMT ligaments.17 The dorsal ligament metatarsals, and they are uniquely absent be- system includes also the intertarsal dorsal liga- tween the first and second metatarsals.18 ments uniting the cuneiforms and the cuboid, The plantar ligaments vary considerably in num- and the intermetatarsal dorsal ligaments connect- ber and arrangement. The plantar TMT ligaments ing the metatarsals (Fig. 3). are located in the plantar region of the foot. The Interosseous TMT ligaments include the Lis- medial ligaments are stronger than the lateral. franc (medial), the central, and the lateral longitudi- The plantar ligaments also include the intertarsal nal ligaments. The Lisfranc ligament arises from and intermetatarsal plantar ligaments, which are the lateral surface of medial cuneiform. It extends stronger than the corresponding dorsal ligaments. distally, laterally, and slightly downward, inserting The second plantar ligament is called plantar Lis- on the lower half of the medial aspect of second franc ligament and is the strongest of the plantar metatarsal. It is the largest ligament of the TMT ligaments. It arises inferolaterally from the medial joint and is 8 to 10 mm long and 5 to 6 mm thick. cuneiform and separates into 2 bands inserting Although multiple ligamentous and capsular con- onto the second and third metatarsals. It is consid- straints exist to stabilize these complexes, isolated ered the keystone of the TMT arch (Fig. 4).18 injury to the Lisfranc ligament has been shown to result in instability.19 There are 2 more sets of inter- MECHANISM OF INJURY AND osseous ligaments. The intertarsal interosseous CLASSIFICATIONS ligaments unite the cuneiforms and the cuboid Mechanism of Injury and are the most powerful attachments of these bones. The 3 intermetatarsal interosseous liga- Injuries to the TMT joints can be caused by direct ments unite from the second to the fifth or indirect forces. Direct injuries, most commonly Downloaded for Anonymous User (n/a) at Des Moines University from ClinicalKey.com by Elsevier on October 24, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved. 862 Mulcahy longitudinal force applied to a plantar-flexed foot at the time of impact. Forefoot hyper-plantar flexion ruptures the weaker dorsal TMT ligaments, and the involved metatarsals assume a pathologic position in plantar flexion.15 High-energy indirect injuries commonly occur in motor vehicle acci- dents when injury to the plantar-flexed foot occurs with a combination of deceleration and floorboard intrusion. Low-energy, indirect injuries are typically secondary to forced plantar flexion or forefoot abduction, and they account for most athletic in- juries (a.k.a., midfoot sprain). This type of injury most commonly occurs in American football, when one player falls onto the heel of another whose foot is in equinus and planted.21 Approxi- mately 4% of professional football players sustain Lisfranc injuries each year.22 This injury also can occur during running and jumping sports, fall- ing from a horse with the foot fixed on the stirrup, or rolling the foot when stepping off a curb or step.16,23 Classifications Several classification systems have been devel- oped for Lisfranc injuries. The earliest was pub- lished by Quenu and Kuss24 in 1909 and subsequently modified by Hardcastle and col- leagues25 in 1982 and Myerson and colleagues15 Fig. 4. Plantar ligament system. Schematic representa- in 1986. These classifications are all based on tion of plantar ligaments along the TMT joints. The TMT joint congruency and displacement of the plantar TMT ligaments are located in the plantar re- metatarsal bases. These classification systems gion of the foot. The second plantar ligament is called are effective in standardizing terminology of plantar Lisfranc ligament and is the strongest of the plantar ligaments. Black lines, TMT ligaments; blue Lisfranc injuries, and can be applied to high- lines, intertarsal ligaments; C, cuneiform; Cu, cuboid; energy and low-energy injuries; however, these green lines, intermetatarsal ligaments; M, metatarsal; classifications have not been found to be helpful red lines, plantar Lisfranc ligament. in determining management and predicting outcomes.7,15 These fracture-dislocation classifi- cation systems, however, are not useful for crush injuries, are due to high-energy direct, blunt low-energy injuries without fractures. These low- force applied to the dorsum of the foot. Direct in- energy Lisfranc injuries or midfoot sprains may juries produce plantar or dorsal dislocation of involve the intercuneiform or the naviculocunei- metatarsals depending on the exact point of appli- form joints, and can be easily undiagnosed cation of the force.15 These injuries often are asso- because of their subtle clinical and radiologic find- ciated with multiple atypical tarsal fractures, and ings.26 In 2002, Nunley and Vertullo27 classified extensive surrounding soft tissue injuries, athletic midfoot injuries into 3 groups based on including vascular compromise and compartment clinical findings, WB radiographs, and bone syndrome. Direct injuries usually result in worse scintigraphy. clinical outcome as compared with indirect Quenu and Kuss24 classified Lisfranc fracture- injuries.16 dislocations into 3 types, according to the direc- Indirect injuries can occur due to either high- tion of the metatarsal displacement: homolateral, energy or low-energy force. High-energy indirect isolated, and divergent. Homolateral type is the mechanism is usually related to motor vehicle most common, and isolated type is the least com- accidents or falls from a height, whereas low- mon.24 Because of its simplicity, this system energy trauma typically occurs during sports.20 formed the basis of many subsequent classifica- These indirect mechanisms are much more com- tion systems used in current clinical practice mon than direct mechanisms, and occur due to a (Fig. 5).28 Downloaded for Anonymous User (n/a) at Des Moines University from ClinicalKey.com by Elsevier on October 24, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.  Lisfranc Injury: Current Concepts 863 Fig. 5. Quenu classification. Lisfranc dislocations and fracture-dislocations as described by Quenu and Kuss.24 (A) Isolated; unidirectional displacement of at least one but not all the metatarsals, typically the first or second rays. (B) Homolateral; uniform medial or more typically lateral subluxation or dislocation of all the metatarsals. (C) Divergent; separation of any combination of metatarsals in different directions or in more than one plane. The Myerson classification system is the most (AP) WB radiography. Stage III implies disruption common classification system currently used, of the dorsal Lisfranc and plantar ligament, with and it divides Lisfranc fracture-dislocations into 3 greater than 5-mm diastasis and loss of arch large categories: types A, B, and C. In type A height on lateral WB radiography. Stage I injuries injury, all the TMT joints are disrupted with total in- are treated conservatively. Stage III requires congruity (lateral or dorsoplantar). Type B injury in- surgical treatment. Treatment of stage II is debat- volves 1 or more metatarsals being displaced with able, although the tendency is toward surgery partial incongruity (B1, medial displacement of the (Fig. 7).27,29 first metatarsal, and B2, lateral displacement of the lesser metatarsals). Type C injury involves DIAGNOSIS divergent displacement of metatarsals in opposite Clinical Findings directions (partial or complete) (Fig. 6).15 Nunley and Vertullo27 combined clinical, radio- Clinical findings in Lisfranc injury can be varied and graphic, and bone scintigraphy findings into a high clinical suspicion is critical to diagnose subtle classification system to describe low-energy Lis- Lisfranc injury. In patients with high-energy in- franc injuries with management implications. juries, such as crush injuries, the diagnosis is They categorized Lisfranc injuries into 3 stages: straightforward. Patients present with severe mid- stage I, II, and III. Stage I is a low-grade sprain of foot swelling, deformity, and a flat foot arch. Soft the Lisfranc ligament complex and a dorsal tissue injury, such as open fracture with skin capsular tear. The plain films are normal, but defect, injury to the dorsalis pedis, and injury to bone scans show uptake. Stage II is due to elon- the deep peroneal nerve, also may be present. gation or disruption of the Lisfranc ligament com- Compartment syndrome can occur as a complica- plex, with intact plantar capsular structures. Plain tion; it should be considered when severe pain and films show 1-mm to 5-mm diastasis between the swelling are present. When clinically suspected, first and second metatarsals on an anteroposterior pressure measurements should be performed. Downloaded for Anonymous User (n/a) at Des Moines University from ClinicalKey.com by Elsevier on October 24, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved. 864 Mulcahy Fig. 6. Meyerson Classification. Type A: Total incongruity of the TMT joint in any plane or direction. Type B1: Par- tial incongruity in which the displacement affects the first ray in relative isolation (partial-medial incongruity). Type B2: Partial incongruity in which the displacement affects 1 or more of the lateral 4 metatarsals in any plane (partial-lateral incongruity). Type C1: Divergent pattern, with the first metatarsal displaced medially and the lateral 4 in any other concomitant pattern of displacement with partial incongruity. Type C2: Divergent pattern with total incongruity. Occasionally in the setting of multitrauma, Lisfranc ligamentous strain or minor fracture (Fig. 9).32 In fractures can reduce spontaneously. In those patients with subtle Lisfranc injuries, a provocative cases in which there is no gross deformity, clinical test can be used to elicit midfoot pain, described diagnosis is more difficult.14,26 by Curtis and colleagues.33 Passive abduction Patients with low-energy Lisfranc injuries pre- and pronation of the forefoot is maneuvered with sent with inability to bear weight and with variable one hand while holding the hindfoot fixed with degrees of swelling in the midfoot.30 Pain with the other hand. palpation or manipulation of the TMT joints is char- acteristic for Lisfranc injury.3 The “piano key” test Radiographs assesses TMT joint pain. In this test, the midfoot and hindfoot are manually secured and a plantar At our institution, the initial imaging evaluation of force is applied to the individual metatarsal head patients with a suspected Lisfranc injury consists (as if one were striking a piano key). A positive of non-WB (NWB) AP, 30 internal oblique, and test will produce localized pain at the involved lateral radiographs of the injured foot. Although ra- metatarsal base (Fig. 8).31 Plantar arch ecchy- diographs may readily demonstrate fracture or mosis at the midfoot level is considered pathogno- dislocation, Lisfranc injuries may be initially over- monic for Lisfranc injury, and should trigger a looked because of subtle findings in low-energy in- thorough clinical and radiographic evaluation; juries, osseous overlap at TMT joint on traditional however, it may be absent in patients with radiographs, and possible spontaneous reduction Downloaded for Anonymous User (n/a) at Des Moines University from ClinicalKey.com by Elsevier on October 24, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.  Lisfranc Injury: Current Concepts 865 Fig. 7. Nunley classification. Stage I: Sprain of Lisfranc ligament with no diastasis or arch height loss on WB AP and lateral radiographs, but increased uptake on bone scan. Stage II: Intermetatarsal diastasis of 1 to 5 mm but no arch height loss. Stage III: Diastasis greater than 5 mm and loss of arch height (decreased distance between the plantar aspect of fifth metatarsal and plantar aspect of medial cuneiform). C1, medial cuneiform; M5, fifth metatarsal. after trauma. In patients who had equivocal find- ings on NWB radiographs, or in patients who had normal findings on NWB radiographs with a high clinical suspicion, WB radiographs are recommen- ded, including AP radiographs of both feet, and a lateral radiograph of the injured foot. WB radio- graphs are useful to better depict small fractures, and visualize malalignment of the Lisfranc joint.26 Comparison radiographs of the uninjured foot in- crease detection of subtle malalignment when asymmetry of the Lisfranc joint becomes appre- ciable (Fig. 10). WB examinations could be difficult to obtain, however, due to pain and discomfort of Fig. 8. “Piano key” test to assesses TMT joint pain. In this test, the midfoot and hindfoot are manually secured and plantar force is applied to the individual metatarsal head (as if one were striking a piano key). Fig. 9. Plantar bruise. Plantar arch ecchymosis at the A positive test will produce localized pain at the midfoot level is considered pathognomonic for Lis- involved metatarsal base. franc injury. Downloaded for Anonymous User (n/a) at Des Moines University from ClinicalKey.com by Elsevier on October 24, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved. 866 Mulcahy Fig. 10. Right-sided Lisfranc injury. Bilateral WB AP ra- diographs demonstrate normal alignment of C2-M2 on the comparison left foot (dotted white line), and malalignment of C2-M2 on the injured right foot (dotted black line). patients. If patients cannot cooperate owing to pain, WB radiographs could be performed after administration of intra-articular local anesthetic, or after allowing the foot to rest for a week.30 On the AP view, the following relationships should be analyzed: (1) medial borders of the second metatarsal and middle cuneiform as well as third metatarsal and lateral cuneiform should align; (2) lateral borders of the first meta- Fig. 11. Normal midfoot alignment on AP radiograph. On the AP view, the medial borders of M2-C2 (dotted tarsal and the medial cuneiform should align; and blue line) as well as M3-C3 (dotted green line) should (3) gap between the medial cuneiform and align. The lateral borders of M1-C1 (dotted red line) second metatarsal should be less than 2 mm should align. The gap between C1 and M2 should (Fig. 11).28,34–36 be less than 2 mm. On the oblique view, the lateral borders of the middle cuneiform and second metatarsal as well as lateral cuneiform and the third metatarsal the Lisfranc joint requires a thorough search for should align. The fourth and fifth metatarsals subtle fractures and malalignment on all views, should align with the cuboid.16 Occasionally, the as associated fractures occur in 39% of patients second metatarsal base articulates with the with Lisfranc injuries.38 On NWB AP radiographs, lateral cuneiform, which should not be misinter- small chip fragment between the second meta- preted as a step-off. Another common variation tarsal and medial cuneiform may be the only indi- is at the medial border of the M4 and cuboid, cator of an underlying Lisfranc injury (“fleck” where a few millimeters of step-off is permitted sign).15 Fractures are present in approximately (Fig. 12).6 90% of these injuries,3 are 3 times more common On the WB lateral radiograph, the following rela- in patients with polytrauma than athletes,15,33 and tionships should be analyzed: (1) there should be must be differentiated from the normal accessory no step-off at the dorsal margins of the tarsometa- ossicle (os intermetatarseum), which is typically tarsal joints34; (2) the talometatarsal angle (an smoothly corticated (Fig. 14).16 Fractures associ- angle formed by the long axes of the talus and ated with Lisfranc fracture-dislocation include M2) is less than 10 15; and (3) the plantar cortex those at the bases of the metatarsals, cuneiforms, of the medial cuneiform should project dorsal to cuboid, and, occasionally, navicular.6 The the plantar cortex of the fifth metatarsal (Fig. 13).37 nutcracker fracture, whereby the cuboid is frac- Diagnosis of Lisfranc fractures and Lisfranc in- tured between the fourth and fifth metatarsals juries is challenging. Radiographic evaluation of and the calcaneus, is critical to recognize, as Downloaded for Anonymous User (n/a) at Des Moines University from ClinicalKey.com by Elsevier on October 24, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.  Lisfranc Injury: Current Concepts 867 Fig. 14. Os intermetatarseum. AP radiograph shows well corticated ossicle between the first and second metatarsal bases with normal alignment of C2-M2 (ar- row). The os intermetatarseum is well corticated and should be differentiated from fracture fragments Fig. 12. Normal midfoot alignment on oblique radio- seen in patients with Lisfranc injuries. Fracture frag- graph. On the oblique view, the lateral borders of ments usually show irregular margins and indistinct C2-M2 (blue line) as well as C3-M3 should align (green cortices. line). The M4 and M5 should align with the cuboid (yellow line). operative fixation is required and best performed for the lateral column first to restore length and aid in reduction of the middle and medial columns (Fig. 15).39 Radiographic findings indicative of Lisfranc injury on AP radiographs include (1) greater than 1 mm of widening between the first and second metatarsal bases or between the medial and mid- dle cuneiforms; (2) greater than 2 mm widening be- tween the medial cuneiform (C2) and second metatarsal base (M2) (along the Lisfranc ligament); and (3) any malalignment of the longitudinal line across C2-M2 and between the lateral cuneiform and third metatarsal (see Fig. 15).6 On lateral WB radiographs, findings indicative of Lisfranc injury include (1) reduced distance between the plantar Fig. 13. Normal foot alignment on lateral radiograph. fifth metatarsal and medial cuneiform; (2) dorsal On the WB lateral radiograph, there should be no step-off at the dorsal margins of the TMT joints (red subluxation of the metatarsals at the TMT joints; dotted line). The talometatarsal angle (angle between and (3) talometatarsal angle greater than 15 the 2 black lines) is less than 10. Also, the plantar cor- (Fig. 16).15,37 Generally, lateral step-off at the tex of C1 should project dorsal to the plantar cortex of medial margin of the second TMT joint is accepted M5 (double arrowed white line). as the most common finding in Lisfranc injuries,23 Downloaded for Anonymous User (n/a) at Des Moines University from ClinicalKey.com by Elsevier on October 24, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved. 868 Mulcahy Table 1 Radiographic findings of Lisfranc injury Anteroposterior Radiograph Lateral Radiograph >1 mm of widening of Dorsal subluxations M1-M2 or C1-C2 of metatarsals at >2 mm widening of TMT joint C1-M2 Reduced distance Lateral step-off of of plantar cortex medial cortex of M2 between C1 with respect of C2 and M5 Bone fragment at >15 of talometatarsal C1-M2 angle Abbreviations: C1, medial cuneiform; C2, middle cunei- form; C3, lateral cuneiform; M1-M5, first to fifth metatar- sals; TMT, tarsometatarsal. Computed Tomography Computed tomography (CT) has several advan- tages over radiography, including visualization Fig. 15. “Fleck” sign. NWB AP radiograph shows ma- of unobscured osseous anatomy, and ability lalignment of the longitudinal line across C2-M2 to demonstrate subtle fractures and malalign- (dotted red line), widening of M1-2 (double headed ment in low-energy Lisfranc injuries.9 A study arrow), and a small bone chip (“fleck” sign) between the M1-C2 (white arrow.) Also, there is a nutcracker type fracture of cuboid (black arrow). with diastasis of 2 mm or more indicating instability (Table 1).15,27 When findings on WB radiographs are normal or equivocal but clinical suspicion remains high, stress radiographs (usually obtained under anesthesia) can be obtained to reveal dynamic instability. Abduction stress radiographs are per- formed by immobilizing the hindfoot and applying passive pronation and abduction to the forefoot (Fig.17). Again, a diastasis of more than 2 mm be- tween the first and second metatarsal bases is considered abnormal.15,30,33 Fig. 16. Lisfranc injury. Lateral NWB radiograph shows reduced distance between the plantar fifth metatarsal Fig. 17. Stress radiograph. Abduction stress radio- (white line) and medial cuneiform (dotted white line), graph is performed by immobilizing the hindfoot and dorsal subluxation of the metatarsals at the TMT and applying passive pronation and abduction to joints (white arrow). the forefoot. Operator is wearing leaded gloves. Downloaded for Anonymous User (n/a) at Des Moines University from ClinicalKey.com by Elsevier on October 24, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.  Lisfranc Injury: Current Concepts 869 by Preidler and colleagues40 showed that 50% and it is recommended when radiographic findings more metatarsal and twice as many tarsal frac- are normal or equivocal in the context of high clin- tures were seen at CT than at radiography. ical suspicion of Lisfranc injury. Similar to CT, the Also, CT is an important tool for the assessment multiplanar capabilities of MR imaging allow of fracture pattern, including their degree of optimal evaluation of malalignment at the midfoot, comminution, intra-articular extension, displace- but unlike CT, MR is superior to other imaging mo- ment, and any interposed soft tissues, typically dalities regarding direct visualization of soft tendons, that could preclude reduction.41,42 Mul- tissue structures. Although MR imaging is sensi- tiplanar reformatted CT data are superior to MR tive for detecting subtle marrow edema, it may imaging in detection of fractures or subtle misdiagnose small avulsion fractures as bone displacement (Fig.18). Three-dimensional (3D) bruise. Also, when tarsometatarsal malalignment volume rendering (VR) images are especially is seen on MR imaging in the absence of ligamen- beneficial for preoperative surgical planning in tous or osseous abnormality, its significance is patients with complex fractures after high- uncertain.44 energy trauma (Fig.19).26 Therefore, CT is partic- Imaging should be obtained with a small field ularly recommended in patients who have high- of view, and a small surface coil centered in the energy midfoot injuries or when fractures other midfoot. Sagittal, long axial (parallel to the meta- than simple fleck signs are identified on initial tarsals), and coronal planes (perpendicular to the radiographs.16 metatarsals) are performed to visualize the liga- The ideal imaging plane of the injured foot is with ment complex. Non–fat-saturated T1-weighted the CT beam angle oriented along the metatarsals sequence is helpful to assess for fractures that as they meet with their corresponding tarsal might be difficult to identify, and the fluid- bones. This can be accomplished by angling the sensitive sequences (T2-weighted or proton- CT gantry or performing multiplanar reconstruc- density fat saturation or short tau inversion re- tions from acquired data.34 CT is also useful in covery) are useful for detecting marrow and soft evaluating arthritis and bony deformities in the un- tissue signal abnormalities. Three-dimensional diagnosed injury.43 fast spin-echo volumetric SPACE (sampling perfection with application optimized contrasts using different flip-angle evolution) images can MR Imaging be helpful to assess the ligament complex by MR imaging is primarily important for the diagnosis providing thin slices for multiplanar reformatted and management of low-energy Lisfranc injuries, images.45 Fig. 18. Lisfranc injury. (A) NWB AP radiograph of foot demonstrates borderline widening of C1-M2 (red lines) and questionable lucency at the lateral cortex of C1 (arrow). (B) Axial CT image demonstrates fracture of the lateral, proximal aspect of C1 (arrow). N, navicula. Downloaded for Anonymous User (n/a) at Des Moines University from ClinicalKey.com by Elsevier on October 24, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved. 870 Mulcahy Discrete dorsal, interosseous, and plantar bands should be identified as distinct structures on MR imaging. The normal Lisfranc ligament complex can be demonstrated in all 3 planes using MR imaging, and they appear as striated or homo- geneous bands, with low to intermediate signal in- tensity on all sequences (Fig. 20).17 The dorsal ligament is the first to tear in midfoot sprain, fol- lowed sequentially by the interosseous and plantar ligaments.23 The dorsal intermetatarsal ligaments are best visualized in the coronal plane using thin slices, as they are thinner than the plantar ligaments.34 Lisfranc ligament injuries manifest as periliga- mentous fluid signal, waviness, irregularity, or disruption of the ligament. The presence of fluid surrounding the ligament, or isolated bone marrow edema can sometimes be the only clue to the presence of Lisfranc injury (Fig. 21).26 Interruption of any one of the dorsal or plantar bands repre- sents a partial tear, whereas disruption of both in- dicates a complete tear. Usually complete tears of the ligament are associated with diastasis of the articulation between the medial cuneiform and second metatarsal base to more than 2 mm.26 In the chronic phase, diagnosis is more difficult because there may be thickening and signal het- erogeneity of the injured ligament due to the fibrotic healing response.46 MR is also useful for assessment of commonly associated injuries such as the intermetatarsal and intertarsal liga- ments, as well as capsular tears. Other soft tissue injuries also may be encountered, including ante- Fig. 19. Lisfranc injury. Three-dimensional VR image rior tibialis tendon or deep peroneal nerve injuries.6 shows lateral total incongruity fracture-dislocation In a study of American football players with sus- (Meyerson type A), with lateral dislocation of all pected Lisfranc injury, Raikin and colleagues47 metatarsals at the TMT joints. noted that the plantar Lisfranc ligament was the most commonly injured. They compared MR imaging findings with intraoperative stress Fig. 20. Normal Lisfranc ligament. Anatomic diagram (A), short-axis T2-weighted FS (B), and long axis T2-weighted FS MR (C) images at the level of the second metatarsal (M2) demonstrate the 3 components of Lisfranc ligaments: interosseous or Lisfranc ligament proper (graded black bands in A, and thick arrows in B), dorsal component (black line in A, and arrowhead in B), and plantar component (graded gray bands in A, and thin arrow in B). Axial T2- weighted FS MR image shows the Lisfranc ligament as a thick band from the C1 to M2 (arrows in C). FS, fat saturated. Downloaded for Anonymous User (n/a) at Des Moines University from ClinicalKey.com by Elsevier on October 24, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.  Lisfranc Injury: Current Concepts 871 Fig. 21. Lisfranc injury. (A) WB AP radiograph shows normal alignment of TMT joint. (B) Short-axis T2-weighted FS MR image at the level of TMT joint demonstrates a partial tear of dorsal component (arrowhead) with increased signal, waviness, and indistinctness along the interosseous component (arrows). There is bone marrow edema at C1 and M2. radiographs and surgical findings and concluded result. Other factors, such as energy of the injury, that normal appearance of plantar Lisfranc cartilage damage, and associated soft tissue in- ligament on MR imaging is suggestive of a stable juries, can compromise the final outcome.22 midfoot. Initial management of Lisfranc injuries varies depending on the nature of the injury. Patients Diagnostic Imaging Decision Tree with high-energy injuries should receive thorough evaluations for compartment syndrome with The initial imaging evaluation of patients with a advanced imaging to assess for concomitant in- suspected Lisfranc injury consists of NWB radio- juries and surgical planning. Open injuries should graphs of the injured foot. In patients with high- be managed with urgent irrigation, débridement, energy injuries, such as crush injuries with fracture and stabilization. Dislocations of the TMT joints or dislocation, the diagnosis is straightforward. should undergo immediate closed reduction to Mostly patients will undergo CT for surgical plan- protect the soft tissues from sustained tension.13 ning. In patients who have equivocal findings on Patients with low-energy injuries are managed NWB radiographs, or in patients who have normal based on the severity of the injury. Those with sta- findings on NWB radiographs with a high clinical ble injuries (Nunley and Vertullo stage I) are treated suspicion, WB radiographs are recommended. conservatively, and those with unstable injuries WB radiographs should be carefully scrutinized (Nunley and Vertullo stages II and III) should be for subtle malalignment or asymmetries. Further- treated with open reduction and internal fixation more, initial normal radiographs do not exclude (ORIF).27 significant Lisfranc injury when there is high clinical concern for injury or symptoms persist. In those Nonoperative Treatment cases, further assessment should be performed with MR imaging. When MR imaging findings are Nonoperative treatment is limited to stable Lis- equivocal, stress radiographs under anesthesia franc joint complex injuries (Nunley and Vertullo, could play a role for the diagnose Lisfranc injury stage I), and includes those that are nondisplaced, (Fig. 22). and stable under radiographic stress examina- tion.27 Also, the patient with minimal ambulatory MANAGEMENT ability, an insensate foot, or preexisting inflamma- tory arthritis may be best treated nonsurgically.22 The key to successful management of Lisfranc Treatment involves protected WB in a controlled injury is to determine whether to use surgical sta- ankle motion walking boot. Serial physical exami- bilization. Regardless of the severity of injury, the nations and repeat WB radiographs should be per- goal of treatment is to attain a painless, stable formed 2 weeks from initial presentation to rule out foot. Maintenance of anatomic alignment is the occult instability. If the injury is stable, WB can be most important factor in achieving a satisfactory progressed and immobilization discontinued with Downloaded for Anonymous User (n/a) at Des Moines University from ClinicalKey.com by Elsevier on October 24, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved. 872 Mulcahy Fig. 22. Diagnostic imaging decision tree for foot injuries. gradual return to regular activity. If symptoms Operative treatment can take many forms, persist, occult foot injuries should be assessed including ORIF and open reduction with hybrid for, and further imaging modalities may be indi- internal and external fixation, closed reduction cated. It takes approximately 4 months to recover with percutaneous internal or external fixation, or from a nonoperative Lisfranc injury.3,21 open arthrodesis. Under fluoroscopic visualiza- tion, closed reduction should be attempted for all patients with dislocations regardless of the type Operative Treatment of fixation that is to be used (Fig. 23). When closed Surgery is indicated for displaced fractures reduction fails, the failure is usually due to a bone and dislocations as well as unstable ligamentous fragment or soft tissue interposed at the base of injuries. Unstable injuries, even subtle ones, the second metatarsal.39 Several studies have re- are managed surgically. Subtle Lisfranc injuries ported that restoration of anatomic reduction is are occurring with increasing frequency, likely best achieved via open reduction.48,49 because of greater participation in high-demand Several different methods of internal fixation of sports. Obvious injuries in patients with multiple Lisfranc injuries have been described. The 3 basic trauma are not often missed, but more subtle implements include Kirschner wires (K-wires), injuries are a common source of continued screws, or small plates. Recently, the use of suture disability.22 button devices has been examined (Fig. 24).50,51 The timing of surgery should be determined Because of the higher rate of complications of based on several factors. In open injuries, impend- K-wire fixation, including pin migration, and ing compartment syndrome, and a threatened soft pin site infection, current recommendations tissue envelope, are considered surgical emergen- are for more rigid fixation with transarticular cies. Dislocations always should be reduced ur- screws.20,52,53 The medial column is fixed first, gently by either closed or open means because then the middle column is reduced while the lateral they may occlude distal perfusion. In closed in- column may be pinned with K-wires.21,22 One juries, the status of the soft tissue guides the exception to the order of reduction is in the pres- timing of surgical intervention. The timing of sur- ence of a fractured and shortened cuboid. The gery is predicated on resolution of swelling, when length of the cuboid and the lateral column of the the skin begins to wrinkle.13 foot must be restored first to avoid a permanent Downloaded for Anonymous User (n/a) at Des Moines University from ClinicalKey.com by Elsevier on October 24, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.  Lisfranc Injury: Current Concepts 873 Fig. 23. Closed reduction of Lisfranc fracture-dislocation. (A) Initial radio- graph demonstrates Meyerson Type C2 total divergent type Lisfranc fracture-dislocation. Also, there is fracture subluxation of navicular. (B) AP radiograph after closed reduc- tion demonstrates near anatomic alignment. abduction deformity of the forefoot.39 Disadvan- percutaneously and require longer operating time tages of transarticular screw fixation include the to insert.50,54 Primary arthrodesis has recently need to remove the screws, articular damage to been advocated for some Lisfranc injuries, and it involved joints, and the potential for screw may be an alternative treatment for severely breakage.3 Another operative treatment option is comminuted intra-articular fractures.48,55 How- dorsal plating, and dorsal plating has ability to ever, when a primary arthrodesis is performed, reduce the joints and resist joint displacement more dissection is required, more bone is similar to intra-articular screws. Also, it minimizes removed, larger defects may require bone graft- additional soft tissue damage and intra-articular ing, and it is more difficult to achieve fixation. Pri- wear that occurs with transarticular screw mary arthrodesis is rarely performed in an placement. However, plates cannot be inserted athlete.39 Internal fixation is maintained for a Fig. 24. Different surgical techniques for Lisfranc injury fixation. AP radiographs shown after K-wire (A), screw (B), and tightrope (C) fixation of medial and middle columns in patients with Lisfranc injury. Downloaded for Anonymous User (n/a) at Des Moines University from ClinicalKey.com by Elsevier on October 24, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved. 874 Mulcahy Fig. 25. Surgical fixation of a patient with Lisfranc fracture-dislocation. (A) Initial injury was temporarily stabi- lized by an external fixator placement. (B) Postoperative radiograph 1 month after original injury demonstrates ORIF using a bridging plate, screws, and K-wire. minimum of 4 months to allow ligamentous heal- REFERENCES ing. The hardware can be left in permanently if the patient is asymptomatic. If there is any concern 1. Fischer LP. Jacques Lisfranc de Saint-Martin (1787- about the midfoot stability, then the patient should 1847). Hist Sci Med 2005;39(1):17–34 [in French]. start wearing the boot again and the rehabilitation 2. Welck MJ, Zinchenko R, Rudge B. Lisfranc injuries. should be decreased until the symptoms fully Injury 2015;46(4):536–41. resolve.15 External fixation can be used for severe 3. Desmond EA, Chou LB. Current concepts review: soft tissue injury precluding internal fixation, pre- Lisfranc injuries. Foot Ankle Int 2006;27(8):653–60. liminary alignment of a grossly unstable injury, 4. Wright MP, Michelson JD. Lisfranc injuries. BMJ and as an adjunct to internal fixation when the 2013;347:f4561. bone is comminuted or osteopenic (Fig. 25).13 5. Richter M, Wippermann B, Krettek C, et al. Fractures and fracture dislocations of the midfoot: occurrence, causes and long-term results. Foot Ankle Int 2001; SUMMARY 22(5):392–8. Although Lisfranc injuries are relatively uncom- 6. Cheung Y. Soft tissue injury to the ankle: ligament in- mon, they encompass a wide spectrum of injury, juries. In: Pope TL, Bloem HL, Beltran J, et al, edi- ranging from sprain to fracture-dislocation. Mis- tors. Musculoskeletal imaging. 2nd edition. diagnosed or undertreated Lisfranc injuries Philadelphia: WB Saunders; 2015. p. 455–73. commonly result in instability, which leads to early 7. Thompson MC, Mormino MA. Injury to the tarsome- osteoarthritis and chronic deformity. It is impor- tatarsal joint complex. J Am Acad Orthop Surg tant, therefore, for radiologists to have thorough 2003;11(4):260–7. understanding of anatomy, and mechanisms and 8. Garrick JG, Requa RK. The epidemiology of foot and patterns of these injuries to diagnose and to help ankle injuries in sports. Clin Sports Med 1988;7(1): clinicians to assess treatment options and prog- 29–36. nosis. Imaging modalities, such as conventional, 9. Kalia V, Fishman EK, Carrino JA, et al. Epidemiology, WB, and stress radiographs, as well as CT and imaging, and treatment of Lisfranc fracture- MR imaging can allow detection of these injuries dislocations revisited. Skeletal Radiol 2012;41(2): and assess the degree of injury. Stable injuries 129–36. may be treated conservatively, whereas all other 10. DeOrio M, Erickson M, Usuelli FG, et al. Lisfranc in- injuries require surgical interventions. juries in sport. Foot Ankle Clin 2009;14(2):169–86. Downloaded for Anonymous User (n/a) at Des Moines University from ClinicalKey.com by Elsevier on October 24, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.  Lisfranc Injury: Current Concepts 875 11. Meyer SA, Callaghan JJ, Albright JP, et al. Midfoot 28. Siddiqui NA, Galizia MS, Almusa E, et al. Evaluation sprains in collegiate football players. Am J Sports of the tarsometatarsal joint using conventional radi- Med 1994;22(3):392–401. ography, CT, and MR imaging. Radiographics 12. Johnson GF. Pediatric Lisfranc injury: “bunk bed” 2014;34(2):514–31. fracture. AJR Am J Roentgenol 1981;137(5): 29. Sandlin MI, Taghavi CE, Charlton TP, et al. Lisfranc 1041–4. injuries in the elite athlete. Instr Course Lect 2017; 13. Richter M, Kwon JY, Digiovanni CW. Foot injuries. In: 66:275–80. Browner B, Jupiter J, Krettek C, et al, editors. Skel- 30. Seybold JD, Coetzee JC. Lisfranc injuries: when to etal trauma: basic science, management, and observe, fix, or fuse. Clin Sports Med 2015;34(4): reconstruction, vol. 2, 5th edition. Philadelphia: WB 705–23. Saunders; 2015. p. 2251–387. 31. Keiserman LS, Cassandra J, Amis JA. The piano key 14. Lau S, Bozin M, Thillainadesan T. Lisfranc fracture test: a clinical sign for the identification of subtle tar- dislocation: a review of a commonly missed injury sometatarsal pathology. Foot Ankle Int 2003;24(5): of the midfoot. Emerg Med J 2017;34(1):52–6. 437–8. 15. Myerson MS, Fisher RT, Burgess AR, et al. Fracture 32. Ross G, Cronin R, Hauzenblas J, et al. Plantar dislocations of the tarsometatarsal joints: end results ecchymosis sign: a clinical aid to diagnosis of occult correlated with pathology and treatment. Foot Ankle Lisfranc tarsometatarsal injuries. J Orthop Trauma 1986;6(5):225–42. 1996;10(2):119–22. 16. Hatem SF. Imaging of Lisfranc injury and midfoot 33. Curtis MJ, Myerson M, Szura B. Tarsometatarsal joint sprain. Radiol Clin North Am 2008;46(6):1045–60. injuries in the athlete. Am J Sports Med 1993;21(4): 17. Castro M, Melao L, Canella C, et al. Lisfranc joint 497–502. ligamentous complex: MRI with anatomic correlation 34. Gupta RT, Wadhwa RP, Learch TJ, et al. Lisfranc in cadavers. AJR Am J Roentgenol 2010;195(6): injury: imaging findings for this important but often- W447–55. missed diagnosis. Curr Probl Diagn Radiol 2008; 18. De Palma L, Santucci A, Sabetta SP, et al. Anatomy 37(3):115–26. of the Lisfranc joint complex. Foot Ankle Int 1997; 35. Chiodo CP, Myerson MS. Developments and ad- 18(6):356–64. vances in the diagnosis and treatment of injuries to 19. Panchbhavi VK, Andersen CR, Vallurupalli S, et al. the tarsometatarsal joint. Orthop Clin North Am A minimally disruptive model and three- 2001;32(1):11–20. dimensional evaluation of Lisfranc joint diastasis. 36. Foster SC, Foster RR. Lisfranc’s tarsometatarsal J Bone Joint Surg Am 2008;90(12):2707–13. fracture-dislocation. Radiology 1976;120(1):79–83. 20. Stavlas P, Roberts CS, Xypnitos FN, et al. The role of 37. Faciszewski T, Burks RT, Manaster BJ. Subtle in- reduction and internal fixation of Lisfranc fracture- juries of the Lisfranc joint. J Bone Joint Surg Am dislocations: a systematic review of the literature. 1990;72(10):1519–22. Int Orthop 2010;34(8):1083–91. 38. Vuori JP, Aro HT. Lisfranc joint injuries: trauma mech- 21. Rosenbaum A, Dellenbaugh S, Dipreta J, et al. Sub- anisms and associated injuries. J Trauma 1993; tle injuries to the Lisfranc joint. Orthopedics 2011; 35(1):40–5. 34(11):882–7. 39. Myerson MS, Cerrato RA. Current management of 22. Watson TS, Shurnas PS, Denker J. Treatment of Lis- tarsometatarsal injuries in the athlete. J Bone Joint franc joint injury: current concepts. J Am Acad Or- Surg Am 2008;90(11):2522–33. thop Surg 2010;18(12):718–28. 40. Preidler KW, Peicha G, Lajtai G, et al. Conven- 23. Crim J. MR imaging evaluation of subtle Lisfranc in- tional radiography, CT, and MR imaging in patients juries: the midfoot sprain. Magn Reson Imaging Clin with hyperflexion injuries of the foot: diagnostic ac- N Am 2008;16(1):19–27, v. curacy in the detection of bony and ligamentous 24. Quenu E, Kuss G. Etude sur les luxations du meta- changes. AJR Am J Roentgenol 1999;173(6): tarse. Rev Chir Paris 1909;39:281. 1673–7. 25. Hardcastle PH, Reschauer R, Kutscha-Lissberg E, 41. Thordarsen DB. Fractures of the midfoot and et al. Injuries to the tarsometatarsal joint: incidence, forefoot. In: Myerson MS, editor. Foot and ankle classification and treatment. J Bone Joint Surg Br disorders, vol. 2. Toronto: WB Saunders; 1999. p. 1982;64(3):349–56. 1265–96. 26. Llopis E, Carrascoso J, Iriarte I, et al. Lisfranc injury 42. Philbin T, Rosenberg G, Sferra JJ. Complications of imaging and surgical management. Semin Muscu- missed or untreated Lisfranc injuries. Foot Ankle Clin loskelet Radiol 2016;20(2):139–53. 2003;8(1):61–71. 27. Nunley JA, Vertullo CJ. Classification, investigation, 43. Kaplan JD, Karlin JM, Scurran BL, et al. Lisfranc’s and management of midfoot sprains: Lisfranc in- fracture-dislocation. A review of the literature and juries in the athlete. Am J Sports Med 2002;30(6): case reports. J Am Podiatr Med Assoc 1991; 871–8. 81(10):531–9. Downloaded for Anonymous User (n/a) at Des Moines University from ClinicalKey.com by Elsevier on October 24, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved. 876 Mulcahy 44. Delfaut EM, Rosenberg ZS, Demondion X. Malalign- 49. Perez Blanco R, Rodriguez Merchan C, Canosa ment at the Lisfranc joint: MR features in asymptom- Sevillano R, et al. Tarsometatarsal fractures and dis- atic patients and cadaveric specimens. Skeletal locations. J Orthop Trauma 1988;2(3):188–94. Radiol 2002;31(9):499–504. 50. Pelt CE, Bachus KN, Vance RE, et al. 45. Ulbrich EJ, Zubler V, Sutter R, et al. Ligaments of the A biomechanical analysis of a tensioned suture de- Lisfranc joint in MRI: 3D-SPACE (sampling perfec- vice in the fixation of the ligamentous Lisfranc injury. tion with application optimized contrasts using Foot Ankle Int 2011;32(4):422–31. different flip-angle evolution) sequence compared 51. Brin YS, Nyska M, Kish B. Lisfranc injury repair with to three orthogonal proton-density fat-saturated the TightRope device: a short-term case series. Foot (PD fs) sequences. Skeletal Radiol 2013;42(3): Ankle Int 2010;31(7):624–7. 399–409. 52. Kuo RS, Tejwani NC, Digiovanni CW, et al. Outcome 46. Kitsukawa K, Hirano T, Niki H, et al. MR imaging after open reduction and internal fixation of Lisfranc evaluation of the Lisfranc ligament in cadaveric joint injuries. J Bone Joint Surg Am 2000;82-A(11): feet and patients with acute to chronic Lisfranc 1609–18. injury. Foot Ankle Int 2015;36(12):1483–92. 53. Ly TV, Coetzee JC. Treatment of primarily ligamen- 47. Raikin SM, Elias I, Dheer S, et al. Prediction of tous Lisfranc joint injuries: primary arthrodesis midfoot instability in the subtle Lisfranc injury. Com- compared with open reduction and internal fixation. parison of magnetic resonance imaging with intrao- A prospective, randomized study. J Bone Joint Surg perative findings. J Bone Joint Surg Am 2009;91(4): Am 2006;88(3):514–20. 892–9. 54. Alberta FG, Aronow MS, Barrero M, et al. Ligamen- 48. Rammelt S, Schneiders W, Schikore H, et al. tous Lisfranc joint injuries: a biomechanical compar- Primary open reduction and fixation compared ison of dorsal plate and transarticular screw fixation. with delayed corrective arthrodesis in the Foot Ankle Int 2005;26(6):462–73. treatment of tarsometatarsal (Lisfranc) fracture 55. Sheibani-Rad S, Coetzee JC, Giveans MR, et al. dislocation. J Bone Joint Surg Br 2008;90(11): Arthrodesis versus ORIF for Lisfranc fractures. Or- 1499–506. thopedics 2012;35(6):e868–73. Downloaded for Anonymous User (n/a) at Des Moines University from ClinicalKey.com by Elsevier on October 24, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.