fractured cuniform and lisfranc's dislocation

[tomc90]

hi,

this is my first post and its a toughy...

has anyone rehab'd anyone following a fractured mid cuniform and a lisfranc's dislocation.

i have one who is 4/12 post injujry, had int. fixation and pop for 2/12 and is very stiff to fore-foot supination and pronation.

cheers,

tom

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[Physiobase]

I haven't had such a client exactly but one would take a very graded approach to treatment. Much like the repair of a fractured scaphoid. Did they repair with simple fixation or did they need a graft from somewhere.

It might be useful to have a bone scan to see how active the healing process is right now. Think of the bone as something that has been unloaded whilst in the cast. It will take a good 12 weeks to continue to ossify and so the fracture right now is only being help together by the fixation. Add to that the fact that the fixation is best at day one and if anything loosens over time.

Mobilisation of the subtalar joint in AP/PA and lateral directions would assist and be no problem. I imagine they need some deep tissue massage to the soleus and gastroc. as well.

Look forward to hearing some more info on the client, history of the trauma etc 8o

[tomc90]

cheers for the reply, i suppose this is quite an early stage in the rehabilitation of this condition. do you think the repair would accomodate a return to normal activity?

the fixation was with k-wires and no bone graft was undertaken and the patient is 21 years old and a keen rugby player.

from literature searches and speaking with a collegue who has treated one it apppears that OA of the intertaral bones is a common complication, and many athletes are unable to continue playing after such an injury. i've also been advised not to mobilise around the fracture site (i did actually do this for one session!) and to use cupping to facilitate movement of the scars.

aside from this i am advising on strengthening the affected leg, pelvis and trunk which are all very wasted in addition to measuing functional activities such as distance walked without pain etc.

i think the scan is a good idea, though as he has had no rehabilitation or advise up to now i think i will try reactivation initially and take up this option if/when he reaches a plateaux.

thanks again...

tomc90

[Physiobase]

here's bit more general info that I found interesting:


Frontal film of the foot shows fracture dislocation in the tarsometatarsal joint (Lisfranc's joint) with homolateral dislocation of first through fifth metatarsals and dorsolateral total incongruity (Myerson Type A).

Jacques Lisfranc (1790-1847) was a field surgeon in Napoleon's army serving on the Russian front. He wrote about a new amputation technique to treat forefoot gangrene from frostbite. This technique involved a route following a series of joints to avoid having to take the time to cut through bone. This route became known as the Lisfranc joint. However, Lisfranc did not actually describe the injury pattern well known by this eponym.

A Lisfranc injury encompasses everything from a sprain to a complete disruption of normal anatomy through these joints. Early recognition and treatment of this injury are important to preserve normal foot function.

The Lisfranc joint line describes the anatomic boundary between the rigid midfoot and the suppler weightbearing forefoot. Instability or disruption of normal support can lead to significant pain and disability for normal ambulation.

The incidence of this uncommon injury is approximately 1 per 55,000 persons per year.

Indirect trauma is more common than direct. Violent abduction of the forefoot can lead to lateral displacement of the four lateral metatarsal bones with or without a fracture at the base of the second metatarsal bone and the cuboid.

Dorsal displacement is more common than plantar. First metatarsal bone may dislocate in the same or opposite direction of other metatarsals. The result is damage to the tight ligamentous structure of this joint complex, which creates an unstable foot for weightbearing

Additionally this was an interesting comment on another surgical approach to this condition:

J Foot Surg. 1985 Jan-Feb;24(1):44-50. Related Articles, Links

Reduction of a fracture-dislocation of Lisfranc's joint by endoprosthetic implantation.

Sharon SM, Knudsen HA, Lowhorn M.

The medical literature demonstrates numerous documented cases of post-traumatic arthrosis following comminuted fracture-dislocations at the tarsometatarsal joint(s). Conventionally described reductions and methods of fixation, therefore, lend themselves to less than acceptable results. A newly devised, alternative method of approach to this disabling injury was indicated, and is presented by the authors in the hope of preventing the long-term sequelae commonly seen with this type of injury. After open reduction and remodeling of a severely comminuted fracture-dislocation at the second metatarsal-cuneiform articulation, a modified, double-stemmed Swanson Silastic implant was utilized in order to maintain second ray length and attempt prevention of the usual postinjury osseous consequences, i.e., fusion and arthritic changes. The case presented demonstrates that, after her last clinical evaluation 19 months postoperatively, the patient returned to her normal occupation, and at that time her foot was normal in appearance with no sign of traumatic arthritic change. This procedure thus far has proved to be very rewarding to the patient, and the authors believe it should be considered as an alternative approach in patients who present with injuries of this magnitude.

[arkesh_physio]

hi
i hope mobilisation of ST jt is a good idea.
also start some intrinsic foot muscles exs or faradic foot bath,
regards.

[tomc90]

hey arkeshphysio and physiodude,

thanks for the props, my faith in the physiobase system is being built up.

my patient is doing ok, still limited with p/f and inv and i am starting on the ST mobs. will also start on intrisic muscle work.

there is no sign of complications at present, and the condition is currently improving, so my fingers are firmly crossed.

if either of you would like an info sheet i've collected on the condition give me your e-mail and i'll forward it on.

thanks again.

tomc90

[Physiobase]

Thanks for the offer Tom. Please feel free to post it here so everyone might share the information. "A great many read, only a few post" 8o

[arkesh_physio]

thanx tom,
pls post it here so that all can refer,
regards,
ark.

[tomc90]

i would, but its not my own work and has been passed to me from a collegue. i am happy to pass on directly though.

sorry bout that...

tom

[Physiobase]

OK, ask them if you might post it and give them credit

[tomc90]

here it is, thanks to Ian Horsley for the permission to use.

tomc90

LISFRANC INJURY OF THE FOOT

The Lisfranc injury to the forefoot is thought to have originated with Napoleon’s surgeon named Jaques Lisfranc (1790 – 1847) who whilst serving on the Russian front, described a new amputation technique to treat forefoot gangrene from frost bite, which developed after riders fell from their horses with their foot caught in the stirrup. (Englanoff et al., 1995, Vuori and Are, 1993). This technique involved following a series of joints in order to avoid having to take the time to cut through bone.

A Lisfranc injury encompasses everything from a sprain to a complete disruption of the normal anatomy of the joints of the forefoot. (Hesp et al., 1984)

With the Lisfranc joint line describing the anatomic boundary between the rigid mid foot and the more mobile forefoot (Burroughs et al., 1998) .

Injuries to the tarso-metatarsal joint (also known as Lisfranc injuries) are uncommon and can be difficult to diagnose. (Ref. Harwood and Raikin, 2003). The report incidence of Lisfranc joint fracture dislocations is approximately 1 per 55,000 person per year. (Mantar and Burtis, 1994 Englanoff et al., 1995). They are commonly misdiagnosed during the initial examination, with as many as 20 percent of Lisfranc joint injuries being missed on the initial antero-posterior and oblique radiographs (Englanoff et al, 1995; Trevine and Kodros, 1995; Burroughs et al., 1998; Perron et al 2001 .

In a retrospective review of x-rays of 750 patients treated for tarso-metatarsal joint injuries or metatarsal fractures (Vuori and Are, 1993) found Lisfranc joint injuries in 9% (66) of patients. Nineteen percent (12) patients had a total dislocation, 71 percent (47) had a partial dislocation, and 11% (7) a substantial injury of the Lisfranc joint. Although they are classically described in the trauma literature (Burroughs et al., 1998) , they have rarely been described as a result of sports participation, and there was no apparent relationship between the mechanism of injury and the type of Lisfranc joint dislocation.

Due to the fact that 20% of tarso-metatarsal fracture – dislocations are overlooked, in the presence of suggestive clinical findings and negative routine x-rays, stress films in eversion-pronation and inversion-supination should be obtained under general anaesthetic (Goossons and De Stoop, 1983).

* Anatomy
The Lisfranc joint is composed of the articulations between the five tarso-metatarsal joints (Hesp et al., 1984; Mantas and Burks, 1994), although Myerson (1989) suggests that to avoid confusion, the term “Lisfranc joint complex” should be used to refer to tarso-metatarsal articulations and the term “Lisfranc joint” should be applied to the medial articulation involving the first and second metatarsals with the medial and middle cuneiforms.

Transverse ligaments join the bases of all the metatarsals with the exception of the articulation between the first and second metatarsals (Hesp et al., 1984; Mantas and Burks, 1994).

The Lisfranc ligament spans the medial cuneiform and the base of the second metatarsal, originating from the lateral plantar aspect of the medial cuneiform. It is the thickest of the ligaments in the region providing the only soft-tissue link between the medial ray and metatarsals, affording the area its stability ( Shapiro et al., 1994). The joint capsule and dorsal ligaments provide only minimal support on the dorsal aspect of the Lisfranc joint (Wiley, 1971; Heckman, 1991; Mantas and Burke, 1994)

A transverse line through the tars-metatarsal joints is not straight but highlights a recess formed by the second metatarsal, which lies within a mortise created by the three surrounding cuneiform bones (Englanoff et al., 1995). The osseous architecture of the joint, with its “keystone” wedging of the second metatarsal into the cuneiform, confers stability to the joint in the absence of ligamentous connections between the first and second metatarsal heads (Englanoff et al., 1995).

The joints are bound by thick plantar ligaments arranged in an interlocking pattern between the tarsal and second to fifth metatarsals, and are reinforced by attachments from the tibialis posterior tendon (Shapiro et al., 1994).

Due to this anatomical configuration, the second metatarsal is prone to dorsal dislocation when an axial load is applied, when the foot is positioned in extreme plantar flexion.

Anatomy Clinical Presentation
Midfoot swelling and the inability of the patient to weightbear on the affected foot, either immediately after the injury or when examined at a later date ( Burroughs et al., 1980). Palpation, with pain, along the tarso-metatarsal joints
Indicates a midfoot sprain. (Trevino and Kodros, 1995). In addition, stress should be applied to the tarso-metatarsal joints with passive pronatory and supinatory movements (Harwood and Rakin, 2003).

Pain can localize to the medial or lateral aspect of the foot in the tarso-metatarsal region with digital palpation, or it can be produced by abduction and pronation of the forefoot whilst the hindfoot is fixed; which may be the only movement which reproduces discomfort in subtle injuries (Ref. Trevino and Kordos, 1995).

X-ray analysis should include weight-bearing antero-posterior, lateral, and oblique radiographs of the foot as non-weightbearing views of the foot can be normal (Mantas and Burks, 1994; Burroughs et al., 1998) . In addition, even if the first set of x-rays are normal, as the swelling decreases with time, this may allow the bones to move from their normal position, especially if the stabilizing ligaments have been torn. For this reason, it is often necessary to take x-rays during the healing process and evaluate for the possibility of delayed development of instability (Myession, 1989).

On x-rays, tarso-metatarsal dislocation is indicated by
(i)&nbsp &nbsp &nbsp &nbsp loss of the in-line arrangement of the lateral margin of the base of the first metatarsal with the lateral edge of the medial cuneiform.
(ii)&nbsp &nbsp &nbsp &nbsp Loss of the in-line arrangement of the medial boundary of the base of the second metatarsal with the medial boundary of the middle cuneiform. (Buzzard and Briggs, 1998) .

The lateral foot x-ray may indicate a “step-off”, suggesting that the dorsal surface of the proximal second metatarsal is higher than the dorsal surface of the middle cuneiform (Markowitz et al., 1989).

Differential Diagnosis and Associated Injuries longitudinal stress injuries

Cuboid fracture
Navicular Compression fracture
Ruptured tibialis posterior tendon
Comportment syndrome


Treatment
Early diagnosis of a Lisfranc joint injury is imperative for proper management and the prevention of a poor functional outcome (Mantas and Burks, 1994). Even when the diagnosis is established, the optimum treatment approach and prognosis are subject to controversy (Harwood and Rakin, 2003).

If clinical evaluation indicates a mild sprain (pain at the joint, with minimal swelling and no instability) or moderate sprain (increased pain and swelling at the joint,) According to Brown and Gumbs, (1991), treatment by immobilization in a short-leg walking cast (Heckman, 1991) or removable short-leg orthotic or non-weightbearing cast (Trevino and Kodros, 1995) is advocated for four to six weeks, or until symptoms have resolved.

Most investigators, though (Hesp et al., 1984; Heckman, 1991; Mantas and Burks, 1994; Buzzard and Briggs, 1998 have concluded that with fracture dislocations of greater than 2mm, there is little place for non-operative management, as it is difficult to maintain anatomic reduction by closed reduction and immobilization alone.

Immobilization in non weight bearing is usually recommended for at least eight weeks (and possibly up to twelve weeks) with the timing of screw removal being debatable (Myerson et al., 1986). Suggestions range from six weeks to six months from the time of surgery (Mantas and Burks, 1994; Trevino and Kodros, 1995; Myerson 1989), and some authors (Arntz & Hansen, 1987) recommend the patient continues to wear a protective shoe, with a well moulded orthotic for three months after cast removal.

Conclusion
Injuries to the tarso-metatarsal joint are uncommon, but it is important to be aware of these injuries when assessing patients with acute foot trauma.

[tomc90]

also some exercises and general fitness advise for such conditions (again many thanks for permission from Ian Horsley UK), tom c90:

Foot Fractures Rehabilitation


Rehabilitation exercises
Rehabilitation depends on the severity of the injury. Most rehabilitation for foot fractures includes rest and avoiding activities that stress, strain, or pressure the injury site. During rehabilitation, athletes can maintain cardiovascular fitness through aerobic activities such as cycling or swimming.
Of course, if your fracture requires surgery to put the bone back in place, your rehabilitation will be prescribed by your doctor and may vary depending on the severity of the injury.
Strengthening the muscles around the foot fracture hastens recovery and prevents recurrence of the injury. Athletes with a history of foot fractures should make these exercises part of their pre-training warm-up. Although the exercises are described for the injured-side foot or leg, you should also do them on the uninjured side. This is especially encouraged for athletes with recurring incidents of foot fracture, as the exercises are preventive as well as rehabilitative.
•&nbsp &nbsp &nbsp &nbsp Hurdler's stretch
Sit on the floor with the injured-side leg fully extended and the opposite leg bent at the knee so that the sole of the uninjured-side leg is against the inner thigh of the injured-side leg. Keep the extended leg straight while reaching for and grasping the toes of the injured-side foot. If the toes cannot be reached, put a towel around the underside of the injured-side foot and grasp its ends with the extended hand. Hold this position for 5 to 10 seconds. Relax for 5 seconds. Perform this cycle 10 to 15 times, 3 times daily.
•&nbsp &nbsp &nbsp &nbsp Foot and lower leg extension
Kneel on the floor with toes pointed backward and sitting on heels. Gradually lower your full body weight. Reach backward with the injured side hand and grasp the injured-side toes, pulling them gently upward and hold this position for 5 seconds. Release the grip on the toes and raise some of the body weight from the heels. Rest in this position for 5 seconds. Perform this cycle 5 times, 3 times daily.
•&nbsp &nbsp &nbsp &nbsp Arch stretch
Sit erect on a table or bed with the injured-side leg crossed over the opposite leg. Grasp the toes of the injured-side foot with the hand of the same side and the heel of the injured-side foot with the opposite hand. Gently pull the toes toward the shin. Hold this position for 5 seconds, then relax hands and rest for 5 seconds. Perform this cycle 5 times, 3 times daily.
•&nbsp &nbsp &nbsp &nbsp Top of foot stretch
Sit erect on a table or bed with injured-side leg crossed over the opposite leg. Grasp the top of the injured-side foot with the hand of the same side and the toes of the injured-side foot with the opposite hand, with fingers over the top of the injured foot. Gently pull the toes of the injured-side foot toward the ball of the foot in a curling motion and hold this position for 5 seconds. Relax hands and rest for 5 seconds. Repeat this cycle 5 times, 3 times daily.

Strengthening exercises
Try the following exercises for strengthening the muscles of the lower leg and those that control movements of the foot:
•&nbsp &nbsp &nbsp &nbsp Toe raises
Stand with hands resting on a chair back. Slowly elevate to the toes of both feet and hold this position for 10 to 15 seconds. Return to start position and rest for 5 seconds. Perform 20 times, 3 times daily.
•&nbsp &nbsp &nbsp &nbsp Single toe raises
After one week, or later if occasional pain is present, perform single toe raises. Stand to the side of a chair with one hand resting on the chair back. Bend the knee on the uninjured side and raise the foot from the floor. Slowly elevate to the toes of the opposite foot. Hold this position for 10 to 15 seconds. Return to start position and rest for 5 seconds. Perform this cycle 20 times, 3 times daily.
•&nbsp &nbsp &nbsp &nbsp Ankle flexion
Sit on a table with lower legs dangling over the side. Stabilize your body by holding the table edge with both hands. Turn the foot of the injured side upward and inward and hold this position for 5 to 10 seconds. Return to the start position and rest for 5 seconds. Turn the injured side foot upward and outward and hold for 10 seconds. Return to the starting position and rest for 5 seconds. Repeat this sequence 10 times, 3 times daily. Begin with no resistance and gradually add weight to the ankle over time. Add weight in 1Kg increments until you reach 8Kg .
•&nbsp &nbsp &nbsp &nbsp Side toe raises
Lie on your side on a table or bed with the injured-side leg uppermost and the uninjured leg bent at the knee with the uninjured side foot under the injured side calf. The injured-side foot should be extended over the end of the table or bed by a few inches. Relax the injured-side foot, then raise the injured-side toe upward and outward and hold this position for 5 seconds. Relax the injured-side foot. Rest for 5 seconds. Repeat this sequence 10 times, 3 times daily. Begin with no resistance and add weight to the forefoot with training time by 1Kg until 4Kg pounds can be managed.

Alternative exercises
During the period when normal training should be avoided, alternative exercises may be used. These activities should not require any actions that create or intensify pain at the site of injury. They include:
•&nbsp &nbsp &nbsp &nbsp swimming
•&nbsp &nbsp &nbsp &nbsp water running
•&nbsp &nbsp &nbsp &nbsp stationary bicycle (add resistance gradually from one session to the next, as pain allows).

When can I return to my sport or activity?
If the fracture is treated immediately following initial symptoms, athletes can usually return to competition within 4 to 6 weeks.
A foot fracture that is ignored by an athlete until the pain ultimately prevents him or her from competing, may take 8 to 10 weeks to fully heal. In any case, return to full participation in his or her sport must be delayed until all symptoms disappear, not only at rest, but when performing the skills and activities inherent to the sport or activity.
The goal of rehabilitation is to return you to your sport or activity as soon as is safely possible. If you return too soon, you may worsen your injury, which could lead to permanent damage. Everyone recovers from injury at a different rate. Return to your activity is determined by how soon your fracture recovers, not by how many days or weeks it has been since your injury occurred.
You may safely return to your sport or activity when, starting from the top of the list and progressing to the end, each of the following is true:
•&nbsp &nbsp &nbsp &nbsp You have full range of motion in the injured foot compared to the uninjured foot.
•&nbsp &nbsp &nbsp &nbsp You have full strength of the injured foot compared to the uninjured foot.
•&nbsp &nbsp &nbsp &nbsp You can jog straight ahead without pain or limping.
•&nbsp &nbsp &nbsp &nbsp You can sprint straight ahead without pain or limping.
•&nbsp &nbsp &nbsp &nbsp You can do 45-degree cuts, first at half-speed, then at full-speed.
•&nbsp &nbsp &nbsp &nbsp You can do 20m figures-of-eight, first at half-speed, then at full-speed.
•&nbsp &nbsp &nbsp &nbsp You can do 90-degree cuts, first at half-speed, then at full-speed.
•&nbsp &nbsp &nbsp &nbsp You can do 10m figures-of-eight, first at half-speed, then at full-speed.
•&nbsp &nbsp &nbsp &nbsp You can jump on both feet without pain and you can jump on the injured foot without pain.

[Physiobase]

Thanks tomc90 and Ian

[arkesh_physio]

thanx tom & ian for the article,
lets keep in touch,
regards,
ark.