Fractures and Dislocations of the Mid

Midfoot Fractures and
Anna N. Miller, MD, and Bruce Sangeorzan, MD
University of Washington
Harborview Medical Center
Revised October 2011
Based on the work of Drs. A. Walling and C. Jones
Midfoot Anatomy
• Lisfranc Joint Injury
– Diagnosis
Mechanisms of Injury
– Treatment
Foot Function and Shape
– Outcomes
Treatment Principles
• Midfoot Crush
Midfoot Crush
– External Fixation
• Cuboid Injury
– Internal Fixation
• Cuneiform Injury
Forefoot Crush
Midfoot Anatomy
Four Major Units
1. 1st Metatarsal (MT) <> Medial
Cuneiform: 6° of mobility
2. 2nd MT <> Middle Cuneiform:
Firmly Fixed
3. 3rd MT <> Lateral Cuneiform:
Firmly Fixed
4. 4th – 5th MT <> Cuboid: Mobile
Midfoot Anatomy
Osseous stability is provided
by the “Roman arch” of the
metatarsals and the recessed
keystone of the second
metatarsal base
Midfoot Anatomy
Associated Structures
– Dorsalis pedis artery*:
between 1st and 2nd MT bases
– Deep peroneal nerve:
runs alongside the artery
Midfoot Anatomy
“Column” Anatomy
– Medial column includes
talonavicular joint, cuneiforms,
and medial three rays of the
– Lateral column includes
calcaneocuboid joint and fourth
and fifth metatarsals.
Midfoot Anatomy
Medial column joints (tarsometatarsals
(TMT) 1-3) are qualitatively different from
lateral column joints (TMT 4-5)
Medial column joints more similar to intertarsal joints
Medial column joints need to be aligned and
Lateral column joints need to be mobile
Midfoot Anatomy
Lisfranc’s Joint
– articulation between the
cuneifoms + cuboid (aka tarsus)
and the bases of the five
Midfoot Anatomy
Dorsal Capsule
Plantar Ligaments
Midfoot Anatomy
Lisfranc’s ligament:
– large oblique ligament that
extends from the plantar aspect
of the medial cuneiform to the
base of the second metatarsal
– **there is no transverse
metatarsal ligament between the
first and second metatarsals)
Midfoot Anatomy
Interosseous ligaments:
– Connect the metatarsal
– ONLY 2-5, not 1-2
– Dorsal and plantar
– Plantar are stronger and
Secondary stabilizers:
– Plantar fascia
– Peroneus longus
– Intrinsincs
Mechanisms of Injury
Motor vehicle accidents 1/3-2/3 of cases
– Incidence of lower extremity foot trauma has
increased with the use of air bags
Crush injuries
Sports-related injuries are also occurring with
increasing frequency
Mechanisms of Injury
54 cadaver Limbs
Foot on the brake pedal
2 groups: with and without plantarflexion.
Impacted at rate up to 16 meters/second
3/13 of those in neutral position had injury-all at
high rates
65% of those in plantar flexion had injury including
those at moderate speeds
– Smith BR, Begeman PC, Leland R, Meehan R, Levine RS, Yang KH, King AI. A
mechanism of injury to the forefoot in car crashes. Traffic Inj Prev. 2005
Mechanisms of Injury: Direct
Force applied
directly to the TMT
articulation on the
dorsum of the foot.
Mechanisms of Injury: Indirect
Axial loading or
twisting  hyperplantarflexion and
ligament rupture.
More common
than direct.
Mechanisms of Injury
– More common (typical
athletic injury)
– Rarely associated with
open injury or vascular
– Less common (crush)
– Compartment syndrome
more common than with
Mechanisms of Injury:
Associated Fractures
Forceful abduction of the
forefoot may result in:
– 2nd metatarsal base
– Compression fracture
of the cuboid (“nut
Mechanisms of Injury:
Associated Fractures
Forceful abduction of the
forefoot may result in:
– Avulsion of navicular
– Isolated medial
cuneiform fracture
Foot Function and Shape
Plantigrade metatarsal heads
On heel rise, the [body weight] x
2.5 is supported by the
metatarsal planes
Dense plantar ligaments prevent
upward migration of metatarsals
Foot Function and Shape
Lateral column
– Includes calcaneocuboid and 4,5 metatarsals
– Shortening = abducto planus deformity
Foot Function and Shape
Medial column
– Talonavicular joint, cuneiforms, medial 3 rays
– Shortening = cavus foot
Treatment Principles
– Restore alignment
– Protect talonavicular motion
– Protect 4,5 TMT motion
Motion of other joints not important
Arthrodesis OK for most small joints
Treatment Principles
Hindfoot: Protect ankle, subtalar, and
talonavicular joints
Midfoot: restore length and alignment of
medial and lateral “columns”
Forefoot: Even weight distribution
Midfoot Crush
Midfoot Crush
External Fixation
– 4 mm Schanz pins in hindfoot
– 2.5 mm terminally threaded
Schanz pins in forefoot
– Maintain length and alignment
until swelling resolves
Midfoot Crush
Internal Fixation (Bridging)
– Restore medial and lateral
– Restore anatomy of key joints
– Span joints with 2.7 recon plate
– Remove plate at 6 months
Midfoot Crush
“Internal Fixator”
– Used as temporary fixation as in
previous slide
– When mobile joints involved, can
place multiple internal fixators
Midfoot Crush
Staged implant removal at six months
Midfoot Crush: Outcomes
25% of poly trauma patients do not return to work at
1 year
Lower extremity fractures cause more disability than
Those with foot injuries score worse in physical
function, social function, pain, and physical and
emotional role
– Turchin JOT 1999; MacKenzie Am J Pub Health 1998.
Forefoot Crush
Forefoot Crush
• Maintain alignment
• Even weight distribution
Lisfranc Joint Injuries
Bony or ligamentous injury
involving the tarsometatarsal
joint complex
Named after the Napoleonic-era
surgeon who described
amputations at this level
without ever defining a specific
Lisfranc Joint Injuries
Generally considered rare
– 1 per 55,000 people per year
– 15/5500 fractures
As index of suspicion increases, so does
~20% of these injuries overlooked
– Especially in polytraumatized patients!!
Lisfranc Joint Injuries: Diagnosis
Requires a high degree of clinical suspicion
– 20% misdiagnosed
– 40% no treatment in the 1st week
Be wary of the diagnosis of “midfoot sprain”
Lisfranc Joint Injuries: Diagnosis
Appropriate mechanism
Midfoot pain and difficulty weight bearing
Swelling across dorsum of foot & plantar ecchymosis
Deformity variable due to possible spontaneous
Lisfranc Joint Injuries: Diagnosis
Ecchymosis may appear late
Local tenderness at
tarsometatarsal joints
OR edematous foot with poorly
localized pain
Gentle stressing
plantar/dorsiflexion and rotation
will reveal instability
Lisfranc Joint Injuries: Diagnosis
Check neurovascular status
– Possible compromise of dorsalis
pedis artery
– Deep peroneal nerve injury
Lisfranc Joint Injuries:
AP, Lateral and Oblique
Stress views
– 2 plane instability
– Standing views provide “stress” and may
demonstrate subtle diastasis
Comparison views are very
Lisfranc Joint Injuries:
Oblique radiograph:
– Medial base of the 4th
metatarsal and medial
margin of the cuboid
should be aligned
Lisfranc Joint Injuries:
– More Radiology Income $$$$$$
– Confusion, Total
Suspicious Signs
Step off at 2nd, gap between 1 and 2
Fleck Sign
On the lateral view, the metatarsal should not be
dorsal to the cuneiform.
Suspicious Signs: Mills Line
Medial column line no longer intersects first metatarsal
Lisfranc Joint Injuries:
Absolutely nobody cares
Simply determine:
– Is this a fracture that enters the joint?
– Or is this a disruption of the supportive
– Is there adequate resistance to dorsal translation
of the metatarsals?
Lisfranc Joint Injuries: Treatment
Early recognition is the key to preventing long term
Anatomic reduction is necessary for best results:
– Displacement >1mm or gross instability of
tarsometatarsal, intercuneiform, or naviculocuneiform
joints is unacceptable
Goal: obtain and/or maintain anatomic reduction
Lisfranc Joint Injuries: Treatment
Stiff joints: RIGID
Flexible joints:
FLEXIBLE fixation
Lisfranc Joint Injuries: Treatment
1,2,3 TM joints have limited motion
– Rigid fixation
4,5 TM joints need mobility
– Flexible or temporary fixation
Metatarsal heads need to meet the floor
Bones heal, ligaments scar!
Lisfranc Joint Injuries: Treatment
Plantar tarsometatarsal ligaments intact: short
leg walking cast
Unstable in 2 planes due to fracture at base: Kwire fixation
Unstable in 2 planes due to ligament rupture:
rigid fixation or arthrodesis
Lisfranc Joint Injuries: Treatment
Naviculo-cuneiform not a mobile joint
Watch rotation of N-C joints
Primary fusion of immobile joints
Lisfranc Joint Injuries:
Nonoperative Treatment
For nondisplaced injuries with normal
weightbearing or stress x-rays
– Short leg cast
– 4 to 6 weeks NON weight bearing
– Repeat x-rays to rule out displacement as
swelling decreases
– Total treatment 2-3 months
Lisfranc Joint Injuries:
Operative Treatment
Surgical emergencies:
1. Open fractures
2. Vascular
compromise (dorsalis pedis)
3. Compartment
Lisfranc Joint Injuries:
Operative Treatment
1–3 dorsal incisions
– 1st incision centered at TMT joint and along
axis of 2nd ray, lateral to EHL tendon
– Identify and protect NV bundle
Lisfranc Joint Injuries:
Operative Treatment
First reduce and provisionally stabilize 2nd TMT joint
Then reduce and provisionally stabilize 1st TMT joint
If lateral TMT joints remain displaced, proceed with 2nd
or 3rd incision(s)
2nd MT base
Lisfranc Joint Injuries:
Operative Treatment
If reductions are anatomic, then proceed with
permanent fixation:
– Screw fixation for the medial column
– Countersink to prevent dorsal cortex fracture
Lisfranc Joint Injuries:
Operative Treatment
• Screws are POSITIONAL, not lag
• 3.5 or 4.0 mm screws
Lisfranc Joint Injuries:
joints fixed
Operative Treatment Stiff
with screws.
Fractures fixed with K wires
3.5 mm or 4.0 mm
Mobile joints fixed with K-wires (lateral MT often reduce w/medial column)
Lisfranc Joint Injuries:
Operative Treatment
• If intercuneiform
instability exists, use
intercuneiform screw
Lisfranc Joint Injuries:
Operative Treatment
• Intercuneiform joints
treated rigidly
3.5 or 4.0 mm fully threaded screws
Inserted without lag technique
Cannulated screws?
– Why is a cannulated screw like a rental car?
• Underpowered
• Overpriced
• Driven by someone who doesn’t know where he is going
» Sigvard T. Hansen, MD
Postoperative Management
Splint 10 –14 days, nonweight bearing
Short leg REMOVABLE boot 4 weeks,
nonweight bearing
Continue short leg removable boot while
graduating weight bearing over 6 weeks
Hardware Removal
Lateral column stabilization can be removed
at 6 to 12 weeks
Medial fixation should NOT be removed
before 4 months
Some advocate leaving screws indefinitely
unless symptomatic
Post traumatic arthritis
– Present in most, but may not be symptomatic
– Related to initial injury and adequacy of reduction
– Treated with arthrodesis for medial column
– Interpositional arthroplasty may be considered for
lateral column
Compartment syndrome
Complex regional pain syndrome
Neurovascular injury
Hardware failure
Long rehabilitation (> 1 year)
Incomplete reduction leads to increased
incidence of deformity and chronic foot
– Loss of rigidity:
Incidence of traumatic arthritis (0-58%)
related to intraarticular surface damage and
Late collapse:
Late Collapse
Primary Arthrodesis: Yes or No?
• Yes
– Prospective trial 41 patients, 2
– ‘primarily ligamentous’ injury
– Fused only medial rays (1,2,3)
– Significantly better outcomes in
arthrodesis group using AOFAS
scale at 42 months
– Pre injury function 92% and 65%
– 5 patients in ORIF group went on to
Ly TV, Coetzee JC. Treatment of primarily
ligamentous Lisfranc joint injuries: primary
arthrodesis compared with open reduction
and internal fixation. A prospective,
randomized study. JBJS-A 2006.
Prospective trial 32 patients, 2 groups
‘primarily ligamentous’ injury
Fused only medial rays (1,2,3)
Arthrodesis signif improved bother &
dysfunction than ORIF at 2 years
– PA & ORIF both satisfied with surg
– 12/14 patients in ORIF revision
– 1/14 arthrodesis
– 11/14 HWR
Henning JA, Jones CB, Sietsema DL,
Anderson JG, Bohay DR. Open
Reduction Internal Fixation vs. Primary
Arthrodesis for Lisfranc Injuries: A
Prospective Randomized Study. Foot
Ankle Int. 2009:30;913-922
Primary Arthrodesis: Yes or No?
– Retrospective comparison of 28 patients, 3
groups, ‘severe’ injury
– 12 ORIF; 5 partial and 6 complete arthrodesis
– Higher pain in arthrodesis group (Baltimore
– Complications higher in complete arthrodesis
• Mulier T, Reynders P, Dereymaeker G, Broos P. Severe Lisfrancs injuries:
primary arthrodesis or ORIF? Foot Ankle Int 2002.
48 patients followed 52 months (13-114)
AOFAS midfoot score 77 (90/100=normal)
Musculoskeletal Function Assessment (MFA)
score 19 (0/100=perfect)
12 with arthrosis, 6 required arthrodesis
Ligamentous injuries did worse
– Kuo RS, Tejwani NC, Digiovanni CW, Holt SK, Benirschke SK, Hansen ST Jr,
Sangeorzan BJ. Outcome after open reduction and internal fixation of Lisfranc joint
injuries. JBJS-A 2000.
11 patients, 41 months after ORIF
AOFAS midfoot Score 71 (90=normal)
8/11 had radiographic arthritis
In-shoe pressures similar to uninjured side (Tekscan)
– Teng AL, Pinzur MS, Lomasney L, Mahoney L, Havey R. Functional outcome following
anatomic restoration of tarsal-metatarsal fracture dislocation. Foot Ankle Int 2002.
46 patients, followed for 2 years
13 had poor outcomes and needed
employment change
The presence of a compensation claim was
associated with a poor outcome (p = 0.02)
– Calder JD, Whitehouse SL, Saxby TS. Results of isolated Lisfranc injuries and the
effect of compensation claims. JBJS-B 2004.
Navicular Fractures
– Horseshoe-shaped bone between
talus and cuneiforms
– Numerous short ligaments attach
dorsally, plantarly, and laterally
– Deltoid attaches medially
Navicular Fractures
Blood supply: because of the large articular surfaces, vessels can
only enter dorsally, plantarly, and thru tuberosity
Medial and lateral thirds have good blood supply
Central third is largely avascular
# of vessels decreases with age
Navicular Fractures
Avulsion fractures: usually
dorsal lip (essentially severe
– Immobilization & progressive
weight bearing
– Excision of fragment only if
Navicular Fractures
Tuberosity fractures: avulsion by
posterior tibial tendon and spring
Usually minimally displaced
May have associated
calcaneocuboid impaction
ORIF depending on degree of
displacement (>5mm)
Navicular Fractures
Body Fractures:
– High energy trauma with axial foot loading
– Frequently associated with talonavicular
– CT scans helpful for preop planning
– Anatomic reduction essential
Navicular Body Fractures
ORIF if any displacement
Anteromedial incision along medial aspect of
tibialis anterior
Second anterolateral incision as needed to help
reduce lateral fragment
Navicular Body Fractures
Courtesy of David P. Barei, MD
Navicular Body Fractures
Courtesy of David P. Barei, MD
Navicular Body Fractures
May require stabilization or
fusion to cuneiforms
Avoid fusion of essential
talonavicular joint if at all
Missed navicular fx required ORIF
and primary fusion due to arthritis
Navicular Body Fractures
– With adequate reduction most have good result,
but few are “normal”
Type 3 worst prognosis:
– Only ½ adequately reduced (60% of joint
– 6 of 21 developed ostonecrosis with one
• Sangeorzan BJ, Benirschke SK, Mosca V, Mayo KA, Hansen ST Jr. Displaced
intra-articular fractures of the tarsal navicular. JBJS-A 1989.
Navicular Stress Fractures
Uncommon; delay in diagnosis common
Usually due to repetitive stress and poor blood supply
– Running most common
Diagnosis: vague arch pain with midfoot tenderness
– X-Rays: AP, lateral, and oblique
– CT, bone scan, or MRI if uncertain
Navicular Stress Fractures:
Incomplete fracture
– Non-weightbearing cast until healed (variable
– Complete fracture or nonunion: ORIF with
screws perpendicular to fracture plane +/- bone
– Complications: nonunion or persistent pain
Cuboid Fractures
Isolated fractures are rare
Most often associated with other
Two types of fractures usually
– Avulsion
– Nutcracker (axial loading with
plantar flexion and forefoot
Cuboid Fractures:
Surgical indicated for:
– 2 mm displacement of articular surface
– Cuboid subluxation with weight bearing or
stress x-rays
– Loss of bony length
Cuboid Fractures: Treatment
Nondisplaced: immobilization 6-8 weeks
Displaced: ORIF
– Often requires bone graft and small
– Can use small external fixator for
– May have to bridge
joint to stabilize
Cuneiform Fractures
Isolated fractures quite rare
Displacement is unusual
Mechanisms of injury:
– Direct trauma
• Most common
• Heal rapidly with nonoperative treatment
– Indirect trauma (Lisfranc variants)
• May occur in any direction including axial shortening
• Instability requires ORIF
Midfoot: restore length and alignment
relationships of the medial and lateral
Forefoot: plantigrade metatarsal heads
Rigid fixation for unstable joints
Screws for dislocations of ‘stiff’ syndesmotic joints
– TMT 1-3
K-wires for dislocations of mobile joints
– TMT 4-5
Bone regenerates, ligaments scar
– Primary arthrodesis for primarily ligamentous injuries
K-wires adequate for metaphyseal fractures
ORIF for displaced cuboid and navicular fractures
– Otherwise non-operative management
Crushing injuries: temporize with combined
internal/external fixation or bulky splint
Small plates, 2.7 and 3.5 reconstruction plates
may be used as ‘internal fixators’ to restore
shape and alignment.
Summary: AGAIN
If it is designed to be stiff when functional, you must screw it
If it has motion when functional, use K-wires
Bone regenerates, ligaments scar
Outcome is fairly good when anatomically reduced and not
related to workplace compensation.
•Alberta FG, Aronow MS, Barrero M, Diaz-Doran V, Sullivan RJ, Adams DJ: Ligamentous Lisfranc joint injuries: A biomechanical comparison of dorsal plate
and transarticular screw fixation. Foot Ankle Int 2005; 26(6):462-473.
•Calder JD, Whitehouse SL, Saxby TS. Results of isolated Lisfranc injuries and the effect of compensation claims. J Bone Joint Surg Br. 2004 May; 86(4):52730.
•Coss HS, Manos RE, Buoncristiani A, Mills WJ. Abduction stress and AP weightbearing radiography of purely ligamentous injury in the tarsometatarsal
joint. Foot Ankle Int. 1998 Aug; 19(8):537-41.
•Henning JA, Jones CB, Sietsema DL, Bohay DR, Anderson JG. Open reduction internal fixation versus primary arthrodesis for lisfranc injuries: a prospective
randomized study. Foot Ankle Int. 2009 Oct; 30(10):913-22.
•Hunter JC, Sangeorzan BJ. A nutcracker fracture: cuboid fracture with an associated avulsion fracture of the tarsal navicular. AJR Am J Roentgenol. 1996Apr;
•Kuo RS, Tejwani NC, Digiovanni CW, Holt SK, Benirschke SK, Hansen ST Jr, Mulier T, Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint
injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg Am. 2006 Mar; 88(3):51420.
•MacKenzie EJ, Morris JA Jr, Jurkovich GJ, Yasui Y, Cushing BM, Burgess AR, DeLateur BJ, McAndrew MP, Swiontkowski MF. Return to work following
injury: the role of economic, social, and job-related factors. Am J Public Health. 1998 Nov; 88(11):1630-7.
•Reynders P, Dereymaeker G, Broos P. Severe Lisfrancs injuries: primary arthrodesis or ORIF? Foot Ankle Int. 2002 Oct; 23(10):902-5.
•Ross G, Cronin R, Hauzenblas J, Juliano P: Plantar ecchymosis sign: A clinical aid to diagnosis of occult Lisfranc tarsometatarsal injuries. J Orthop Trauma
1996; 10(2):119-122.
•Sangeorzan BJ. Fractures of the tarsal bones. Orthop Clin NorthAm. 2001 Jan; 32(1):21-33.
•Sangeorzan BJ. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am. 2000 Nov; 82-A(11):1609-18.
•Sangeorzan BJ, Benirschke SK, Mosca V, Mayo KA, Hansen ST Jr. Displaced intra-articular fractures of the tarsal navicular. J Bone Joint Surg Am. 1989 Dec;
•Sangeorzan BJ, Mayo KA, Hansen ST. Intraarticular fractures of the foot. Talus and lesser tarsals. Clin Orthop Relat Res. 1993 Jul; (292):135-41.
•Sangeorzan BJ, Swiontkowski MF. Displaced fractures of the cuboid. J Bone Joint Surg Br. 1990 May; 72(3):376-8.
•Sangeorzan BJ, Veith RG, Hansen ST Jr. Salvage of Lisfranc's tarsometatarsal joint by arthrodesis. Foot Ankle. 1990 Feb;10(4):193-200.
•Schepers T, Kieboom B, van Diggele P, Patka P, Van Lieshout EM. Pedobarographic analysis and quality of life after Lisfranc fracture dislocation. Foot Ankle
Int. 2010 Oct; 31(10):857-64.
•Schildhauer TA, Nork SE, Sangeorzan BJ. Temporary bridge plating of the medial column in severe midfoot injuries. J Orthop Trauma. 2003 Aug; 17(7):51320.
•Teng AL, Pinzur MS, Lomasney L, Mahoney L, Havey R . Functional outcome following anatomic restoration of tarsal-metatarsal fracture dislocation. Foot
Ankle Int. 2002 Oct; 23(10): 922-6.
•Turchin DC, Schemitsch EH, McKee MD, Waddell JP. Do foot injuries significantly affect the functional outcome of multiply injured patients? J Orthop
Trauma. 1999 Jan; 13(1):1-4.
•Vuori JP, Aro HT: Lisfranc joint injuries: Trauma mechanisms and associated injuries. J Trauma 1993; 35(1):40-45.
•Watson TS, Shurnas PS, Denker J. Treatment of Lisfranc joint injury: current concepts. J Am Acad Orthop Surg. 2010 Dec;18(12):718-28.
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