Patel Serena, Piper Danielle, Fenton Paul
Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2TH, United Kingdom.
J Clin Orthop Trauma. 2024 Dec 22;61:102874. doi: 10.1016/j.jcot.2024.102874. eCollection 2025 Feb.
Lisfranc injuries describe a spectrum of midfoot and tarsometatarsal joint (TMTJ) trauma ranging from purely ligamentous to multiple fracture-dislocations. Lisfranc injuries represent 0.2 % of all fractures and are seen predictably, with mechanisms involving a fall from height, crushing, or torsion. Diagnosis can be challenging, with approximately 20 % of cases being missed, and relies upon clinical acumen and proficient image interpretation. Whilst multiple classification systems have described Lisfranc injuries using a 3-column concept, these add zero prognostic value and are therefore rarely used clinically. Furthermore, existing literature on diagnosis and management is limited to retrospective small series.
We present a review of 161 midfoot injuries, with the aim of highlighting characteristics of radiological instability and indication for operative management. CT scans and weight-bearing and non-weight-bearing X-rays were reviewed for features of joint instability. These features included metatarsal base, cuneiform and cuboid fractures, tarsometatarsal joint subluxation or dislocation and C1-MT2 diastasis. The subsequent "stable" and "unstable" injury groups were then compared to identify statistically significant indicators for instability.
Avulsion and intra-articular fractures of the medial, middle, or lateral column were all suggestive of instability. Although these appeared in multiple combinations, 95 % involved the middle column. Concomitant inter-cuneiform and cuboid fractures were additional indicators of instability. In cases of uncertain midfoot instability, weight-bearing radiographs were of value with 14.2 % demonstrating a diastasis of C1-MT2 >2 mm.
We propose the need for a new classification of midfoot injuries which emphasises the diagnosis of instability and guides surgical management. We propose that, based on non-weight-bearing X-ray and CT scans, these injuries can be initially classified as "stable", "unstable", or "stability uncertain". Weight-bearing X-rays are a safe and reliable method of detecting instability in the "stability uncertain" group. Fractures of the medial column and cuneiform on initial imaging were suggestive of midfoot instability.
Lisfranc损伤描述了一系列中足和跗跖关节（TMTJ）创伤，范围从单纯的韧带损伤到多发骨折脱位。Lisfranc损伤占所有骨折的0.2%，其发生机制可预测，包括高处坠落、挤压或扭转。诊断具有挑战性，约20%的病例会被漏诊，且依赖于临床敏锐度和熟练的影像解读。虽然多种分类系统使用三柱概念来描述Lisfranc损伤，但这些对预后没有价值，因此在临床上很少使用。此外，关于诊断和治疗的现有文献仅限于回顾性小样本系列研究。
我们对161例中足损伤进行了综述，旨在突出放射学不稳定的特征及手术治疗指征。回顾了CT扫描以及负重和非负重X线片以观察关节不稳定的特征。这些特征包括跖骨基底、楔骨和骰骨骨折、跗跖关节半脱位或脱位以及C1-MT2间隙增宽。随后比较“稳定”和“不稳定”损伤组，以确定不稳定的统计学显著指标。
内侧、中间或外侧柱的撕脱骨折和关节内骨折均提示不稳定。虽然这些骨折以多种组合形式出现，但95%涉及中间柱。同时存在的楔骨间和骰骨骨折是不稳定的额外指标。在中足不稳定情况不确定的病例中，负重X线片有价值，14.2%显示C1-MT2间隙增宽>2mm。
我们提出需要一种新的中足损伤分类方法，该方法应强调不稳定的诊断并指导手术治疗。我们建议，基于非负重X线片和CT扫描，这些损伤最初可分为“稳定”、“不稳定”或“稳定性不确定”。负重X线片是检测“稳定性不确定”组中不稳定情况的一种安全可靠方法。初始影像上内侧柱和楔骨骨折提示中足不稳定。
