Reduction of Lisfranc Dislocations Using Second Ray Axial Traction

Lisfranc fracture dislocations are an often misdiagnosed injury pattern, which if left unreduced can lead to signifi cant disability (1-5). The articulation between the bases of the 5 metatarsals, cuneiforms, and cuboid has been termed the Lisfranc joint (6, 7). Lisfranc joint represents a junction between the forefoot and the midfoot. Three functional columns make up the tarsometatarsal area, the medial, middle, and lateral columns. The base of the fi rst metatarsal articulates with the medial cuneiform to make up a medial column (8). The middle column is composed of an articulation between the second metatarsal and intermediate cuneiform, as well as the third metatarsal and the lateral cuneiform (7). Finally the fourth and fi fth metatarsals articulate with the cuboid to form a lateral column (7). The base of the second metatarsal sits in a recessed area between the medial and lateral cuneiforms forming a mortise or “keystone” of the tarsometatarsal joints (9). Due to this confi guration, the base of the second metatarsal is wedged between the base of the fi rst and third metatarsals and is thus only capable of roughly 0.6 mm of sagittal plane or transverse plane motion. It is this joint and an associated thick interosseous ligament spanning from the medial side of the base of the second metatarsal to the medial cuneiform, which is specifi cally known as “Lisfranc joint/ligament.” The Lisfranc joint is a key point of articulation in the midfoot. Since there is no proximal transverse ligament spanning between the fi rst and second metatarsals, Lisfranc joint is the weakest or least structurally reinforced of the tarsometatarsal joints (8). According to Peicha et al the anatomy of this second metatarsocuneiform “keystone” or mortise created by the second metatarsal base becomes a risk factor for dislocation injuries, enhanced by the depth of the mortice. In research done by Peicha et al, it was found that the majority of patients with a dislocation injury had a very shallow mortise when compared to those with a deeper mortise. The Lisfranc complex was named after Jacques Lisfranc (1790-1847), a French surgeon who served in the Napoleonic Army (10, 11). Lisfranc saw the majority of these injuries in soldiers whose feet would become caught in their riding stirrup while falling from their horses. It is related that Dr. Lisfranc often treated these injuries by amputating the forefoot at the tarsometatarsal joint. This level of amputation became known as a Lisfranc amputation. Today the Lisfranc fracture accounts for about 0.2% of all reported fractures (12-15). However, this number may be underestimated due to frequent misdiagnosis. According to well established research, about 20% of these injuries are commonly misdiagnosed (16).