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LISFRANC’S A Clinical FRACTURE-DISLOCATION and Experimental Study and T. E. From the Tarso-metatarsal reviewed Oswestry, cases studied LONDON, Department, dislocations twenty-two and have and factors considered. by plantar capsule ligaments. Hospital, fracture-dislocations are London uncommon treated at the Robert Jones and Agnes Hunt the mechanism ofthe injury in experiments maintaining The ENGLAND St Bartholomew’s MECHANISM The Dislocations Fracture-dislocations JEFFREYS, Orthopaedic of Tarso-metatarsal On stability of the first the medial of OF the added tarso-metatarsal joint support joints is provided interosseous developed and must is reinforced anterior into the base of the first metatarsal bone and the medial no interosseous ligament between the bases of the first and second may be an intervening bursa. The base of the second metatarsal cuneiforms. Bony stability is increased by the medial cuneiform and the metatarsal being well I have Hospital, of cadavers. INJURY normal metatarso-cuneiform side injuries. Orthopaedic on the feet by first by the insertion and of tibialis cuneiform bone. metatarsal bones, bone is dovetailed ligaments, known be dorsal There is but there into the the one between the as Lisfranc’s ligament. The bases of the lateral four metatarsal bones are united by strong dorsal, plantar and interosseous ligaments. The capsules of the lateral tarso-metatarsal joints are strengthened by collateral and interosseous ligaments and by the long plantar ligament. In the past, tarso-metatarsal dislocation was thought to be caused by a variety of forces (Bohler 1935), but fracture-dislocations Experiments of injury, each the picture was clarified by Gissane EXPERIMENTAL Four dissection, normal cadaveric the joint capsules dissection created displacement The forefoot The following of the of the first that artificial instability, occurs rather metatarsal all five produced bone being but than was fixed and attempts results were observed. metatarsus, hind foot four metatarsals first but dislocation extension, adduction These experiments The ligaments the imitate metatarsal dislocation experiments the forces bones being of the first displaced occurred 546 fracture of the second tarso-metatarsal being left medially (Fig. 3). suggested cause downwards. are two severe mechanisms (Fig. joints meant were exposed by It is doubtful if the to dislocation show the type in theliving of foot. joints. dislocation (Fig. I). 2) Supination joint, the base of the The lateral four metatarsal of the hind foot did not increase the remained intact. When the shaft of the dorsal displacement of the bases of the foot the lateral until the second metatarsal strains failed to produce patterns of injury : simple bone most the foot at the tarso-metatarsal hind foot produced lateral (Fig. 4), and medial dislocation ofthe hind foot (Fig. 5), which metatarsal that intact. displaced together metatarso-cuneiform and In one were which were made to dislocate 1) Pronation ofthe did not occur and abduction show two pronation of the hind foot joint produced by supination after who STUDIES feet were examined. and periarticular bones did not move (Fig. 2). 3) Further supination displacement as long as the second metatarsal bone second metatarsal bone fractured then medial and lateral (1951) were produced by forced pronation of the foot. carried out on cadaveric feet have convinced me that there responsible for a characteristic displacement. metatarsals fractured bone gave way. any dislocation. lateral dislocation three 4) Flexion, produced of the first metatarso-cuneiform is followed by complete dislocation 6). THE JOURNAL OF BONE AND JOINT SURGERY by LISFRANC’S 547 FRACTURE-DISLOCATION FIG. Dissected 1 footshowing lateral dislocation of all the metatarsal bones on pronationof the hind foot. (i FIG. Dissected foot medial first dislocation metatarsal supination VOL. 45 B, NO. 3, AUGUST 1963 2 showing of bone the on of the hind foot. 548 T. E. JEFFREYS In practice metatarsus pivot. and This, it is unlikely that the the are twisted however, hind does foot not alter mechanism in opposite the concepts is so simple directions outlined and it is probable around above. the A crush FIG. that the tarso-metatarsal injury of the foot 3 Dissected foot showing medial dislocation of all the metatarsal bones after fracture of the second metatarsal shaft. will produce a crushing will produce disorganisation of the tarso-metatarsal joints without force which fixes the forefoot and allows the hind foot conditions similar to those in the experiments. THE JOURNAL the effects of rotation, to twist as the patient OF BONE AND JOINT but falls SURGERY LISFRANC’S The injuries experiments. “en sustained There lateral bloc” in were the five displacement 549 FRACTURE-DISLOCATION twenty-two cases of cases simple reviewed of the pronation injury two (Fig. 7); FIG. 7 Figure 7-Radiograph in a case of lateral tarso-metatarsal Radiograph in a case of medial dislocation of first of the first metatarso-cuneiform available for varying severity, the mechanics combination the fifth nine joint case. The ofwhich (Fig. 8), remaining were of injury in these, but of direct and rotational but OF ACCIDENT Causes Road traffic accident twisted Gunshot Nohistory OF of the characteristic dislocation 8 Figure 8joint. reduction were not fracture-dislocations accidents. the dislocations of the injuries INJURY It is difficult of to analyse were produced by a are shown in Table I. SUSTAINED dislocation dislocation 9 - in falling 1 6 3 1 - . . medial before Fracture- . wound showed showed Simple . . findings the I TYPE of injury Crushinjury Foot AND traffic that causes TABLE NATURE FIG. the showed dislocation. metatarso-cuneiform cases in road it is probable force. The two radiographs seventeen sustained support dislocation; I . - TREATMENT Opinions about treatment without skeletal traction, after (1951) VOL. recommended 45 B, NO. 3, open AUGUST 1963 vary. Bohler (1935) preliminary elevation reduction even when advised manipulative of the foot to decrease displacement is slight. reduction oedema. A method with or Gissane of open T. E. JEFFREYS 550 reduction (Del and temporary Sel 1955). (Lisfranc The 1840, internal dangers Gissane fixation with of ischaemia 1951, percutaneous of the forefoot Watson-Jones 1955). TABLE SUMMARY Method Closed reduction. . in decompression compound reduction Open reduction Wound toilet and case be irreducible and because . Reduction medial ischaemia Fracture- dislocation dislocation 5 . . 1 - . . . 1 - . . . 2 - accepted gangrenous - 4 - 3 . toes had but seven oftreatment dislocation by manipulation, bones. Medial dislocation the review Simple ofdisplacement in any case, ofthe methods under I . Displacement two described authorities in . fixation closure. not necessary A summary impossible to reduce simple tissue between the displaced may . internal and closure. one series been by many II immobilisation . . and toilet was injuries. . No Wound only . also TREATMENT Immobilisation . manipulation. Open the has stressed in plaster-of-Paris manipulation. Unsuccessful In been of treatment Immobilisation Unsuccessful plaster-of-Paris occurred OF wires have to amputated. Operative were It may be because of the interposition of the first metatarso-cuneiform of soft joint acts as a bony cuneiform be of the fracture-dislocations is shown in Table II. block to reduction. ILLUSTRATIVE Case 1-A heavily and fell on a parquet lateral tarso-metatarsal CASES built man of fifty-five slipped floor. Radiographs showed a dislocation. Manipulation was unsuccessful tibialis anterior and at operation was found between first metatarsal and had to be lifted tion could Case 2-A the out first of the be reduced cuneiform way (Fig. middle-aged the tendon of the base of the bones, before the 9). woman fell and dislocation of the first metatarso-cuneiform After an unsuccessful attempt at closed open operation was carried out. The until screwed to The and “ medial tarsal bone. to provide Case 1-Lateral tendon of tibialis medial cuneiform tarso-metatarsal dislocation. The anterior is interposed between the and the base of the first metatarsal bone. a staple and as the an the base that key THE the of the first metatarsal displacement “ Internal stability JOURNAL in both is that was ofthe lateral first meta- fixation may be necessary after open reduction, and the base cuneiform and a joint. reduction, second. dislocations between first easy of sustained first cuneireduction of reduction was form bone was found to be blocking the base of the first metatarsal. The unstable and disloca- of the first metatarsal bone is suggested adequate OF method. BONE AND Unstable JOINT SURGERY LISFRANC’S reduction has is more been severed fixation there foot can though healing exercised weight bearing in medial immediately should has occurred. In the more severe and accurate If, after dislocation after may operation until This but of the been of the first metatarsal obtained by internal foot in plaster. The a!- open to secure may produce it is doubtful such anatomical reduction has reduction of gross displacement base has soft-tissue be necessary realignment. appearance, as the If a stable reduction need for immobilisation offracture-dislocation fixation radiographic effect in lateral be deferred types internal maintain normal than all its attachments. not seem to be any would be reduction and likely from 551 FRACTURE-DISLOCATION a what on the final result. and dislocation, the foot is moulded into a good shape, a satisfactory result is obtained. Five ofthe twenty-two cases developed late tarso-metatarsal arthritis been accurately reduced, and allowed to would bear small series, osteoarthritis the weight be wrong in plaster to draw firm but it would is determined articular cartilage Tarso-metatarsal (Fig. 10). three ofthem eight conclusions time FIG. 10 occurring reduction. had been weeks. from seem that the by the damage at the arthritis for All these had not It such onset of sustained a late by of injury. after accurate and stable SUMMARY I. The mechanism investigated 2. Five dislocation 3. of injury in tarso-metatarsal by experimental cases of simple are The dislocation studies in the cadaver. Two tarso-metatarsal dislocation and fracture-dislocation distinct and has been types ofinjury were observed. seventeen cases of fracture- reviewed. treatment 1 wish to thank of the injury is discussed. Mr Robert Roaf for his advice, Orthopaedic Hospital, Oswestry, for allowing Mr D. Tredennick for the photographs. and the surgeons me to study their of the Robert cases. Jones I am indebted Agnes Hunt to Mr B. Southern and and REFERENCES L. (1935) BOHLER, DEL SEL, J. M. (1955): Joint GISSANE, LISFRANC, : The Treatmeizt Surgery, The Surgical 37-B, Gazette des Sir R. (1955): E. & S. Livingstone Ltd. WATSON-JONES, 45 B, NO. 3, AUGUST Treatment p. 487. Bristol : John of Tarso-metatarsal Wright and Sons. Fracture-dislocations. JournalofBone and 203. W. (195 1) : A Dangerous J. (1840): Fractures l’appareil. VOL. of Fractures, Type of Fracture compliqu#{233}es. h#{243}pitaux civils Fractures 1963 of the Foot. R#{233}flexions sur et militaires, and Joint Journal of Bone l’#{233}poque Ia plus and opportune Joint Surgery, pour 33-B, 535. application Deuxi#{232}mes#{233}rie 2, 205. Injuries. Fourth edition, p. 902. Edinburgh and London: de