Tarsometatarsal fracture dislocation
Causes / typical injury mechanism:
Tarsometatarsal injuries can be caused by direct or indirect mechanisms. Direct injuries are typically from high-energy blunt trauma or crush injury to the dorsum of the foot. Indirect injuries are caused by a rotational and/or axial force through a plantarflexed foot. Classic history and presentation:
Acute midfoot pain, swelling, and inability to bear weight after a high-energy crush or athletic injury.Prevalence:
Incidence of 1 per 55 000 persons, accounting for 0.2% of all fractures.
- Age – More common in the third decade of life.
- Sex / gender – More common in males.
Certain anatomic variations at the 2nd tarsometatarsal joint may increase risk for a Lisfranc injury.Pathophysiology
: A Lisfranc injury is a ligamentous and/or bony injury to the Lisfranc (tarsometatarsal) joint complex, which is critical to the stability of the midfoot and allows for normal gait. These injuries frequently manifest with widening between the 1st and 2nd metatarsal bases due to their limited ligamentous connections.Grade / classification system:
Multiple classification systems have been described but have limited utility.
S93.323A – Subluxation of tarsometatarsal joint of unspecified foot, initial encounter
S93.326A – Dislocation of tarsometatarsal joint of unspecified foot, initial encounter
S93.629A – Sprain of tarsometatarsal ligament of unspecified foot, initial encounter
209357009 – Closed fracture dislocation of tarsometatarsal joint
209365007 – Open fracture dislocation of tarsometatarsal joint
Differential Diagnosis & Pitfalls
- Lisfranc injuries can be difficult to diagnose and are often missed on initial assessment. If not detected and managed appropriately, they can result in long-term disability.
- Open injury, neurovascular compromise, and compartment syndrome must be ruled out, particularly with high energy mechanisms.
- The most common unrecognized injury pattern is the subtle injury involving the medial column (1st and 2nd metatarsal bases +/- 1-2 intercuneiform joints) that are unstable but not grossly displaced. A high index of suspicion is needed to allow for timely diagnosis and appropriate treatment.