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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