Midfoot Fractures and Dislocations Anna N. Miller, MD, and Bruce Sangeorzan, MD University of...

Midfoot Fractures and Dislocations

Anna N. Miller, MD, and Bruce Sangeorzan, MDUniversity of Washington

Harborview Medical CenterRevised October 2011

Based on the work of Drs. A. Walling and C. Jones

1

ContentsMidfoot Anatomy

Mechanisms of Injury

Foot Function and Shape

Treatment Principles

Midfoot Crush– External Fixation– Internal Fixation

Forefoot Crush

• Lisfranc Joint Injury– Diagnosis– Treatment– Outcomes

• Midfoot Crush

• Navicular Injury

• Cuboid Injury

• Cuneiform Injury

Midfoot AnatomyFour 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 11

22 3344

Midfoot AnatomyOsseous stability is provided by the “Roman arch” of the metatarsals and the recessed

keystone of the second metatarsal base 11

55

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

forefoot. – Lateral column includes

calcaneocuboid joint and fourth and fifth metatarsals.

Midfoot AnatomyMedial column joints (tarsometatarsals (TMT)

1-3) are qualitatively different from lateral column joints (TMT 4-5)

Medial column joints more similar to inter-tarsal joints

Medial column joints need to be aligned and stiff

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

metatarsals

Dorsal Capsule Plantar Ligaments

Midfoot Anatomy

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 AnatomyInterosseous ligaments: – Connect the metatarsal bases

– ONLY 2-5, not 1-2– Dorsal and plantar

– Plantar are stronger and larger

Secondary stabilizers:– Plantar fascia

– Peroneus longus– Intrinsincs

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



54 cadaver LimbsFoot 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

Jun;6(2):156-69

Force applied directly to the TMT (Lisfranc’s) articulation on the dorsum of the foot.

Mechanisms of Injury: Direct

Axial loading or twisting hyper-plantarflexion and ligament rupture.

More common than direct.

Mechanisms of Injury: Indirect

Mechanisms of InjuryIndirect:

– More common (typical athletic injury)

– Rarely associated with open injury or vascular

compromise

Direct:– Less common (crush)

– Compartment syndrome more common than with

indirect

Mechanisms of Injury: Associated Fractures

Forceful abduction of the forefoot may result in:

– 2nd metatarsal base fracture

– Compression fracture of the cuboid (“nut

cracker”)

Mechanisms of Injury: Associated Fractures

Forceful abduction of the forefoot may result in:

– Avulsion of navicular

– Isolated medial cuneiform fracture


Plantigrade metatarsal headsOn heel rise, the [body weight] x

2.5 is supported by the metatarsal planes

Dense plantar ligaments prevent upward migration of metatarsals


Lateral column – Includes calcaneocuboid and 4,5 metatarsals

– Shortening = abducto planus deformity


Medial column – Talonavicular joint, cuneiforms, medial 3 rays

– Shortening = cavus foot


MUST – Restore alignment

– Protect talonavicular motion– Protect 4,5 TMT motion

Motion of other joints not important

Arthrodesis OK for most small joints


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

column

– 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 post-op

25% of poly trauma patients do not return to work at 1 year

Lower extremity fractures cause more disability than upper

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.

Midfoot Crush: Outcomes

Forefoot Crush

Forefoot Crush

• Maintain alignment

• Even weight distribution

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

injury

Lisfranc Joint Injuries

Generally considered rare – 1 per 55,000 people per year

– 15/5500 fractures

As index of suspicion increases, so does incidence

~20% of these injuries overlooked – Especially in polytraumatized patients!!

Lisfranc Joint Injuries

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 reduction


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


Check neurovascular status – Possible compromise of dorsalis

pedis artery

– Deep peroneal nerve injury

– COMPARTMENT SYNDROME


AP, Lateral and ObliqueStress views

– 2 plane instability– Standing views provide “stress” and may

demonstrate subtle diastasis

Comparison views are very helpful

Lisfranc Joint Injuries: Evaluation

Oblique radiograph:– Medial base of the 4th

metatarsal and medial margin of the cuboid

should be aligned


MRI– More Radiology Income $$$$$$

CT– Confusion, Total


On the lateral view, the metatarsal should not bedorsal to the cuneiform.

Step off at 2nd, gap between 1 and 2

Suspicious Signs

Fleck Sign

Suspicious Signs: Mills Line

Medial column line no longer intersects first metatarsal

Absolutely nobody cares

Simply determine: – Is this a fracture that enters the joint?

– Or is this a disruption of the supportive ligaments?

– Is there adequate resistance to dorsal translation of the metatarsals?

Lisfranc Joint Injuries: Classification

Early recognition is the key to preventing long term disability

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 fixation

Flexible joints: FLEXIBLE fixation


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 evenly

Bones heal, ligaments scar!


Plantar tarsometatarsal ligaments intact: short leg walking cast

Unstable in 2 planes due to fracture at base: K-wire fixation

Unstable in 2 planes due to ligament rupture: rigid fixation or arthrodesis


Naviculo-cuneiform not a mobile joint

Watch rotation of N-C joints

Primary fusion of immobile joints


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: Nonoperative Treatment

Surgical emergencies:

1. Open fractures

2. Vascular compromise (dorsalis pedis)

3. Compartment syndrome

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


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 UNreduced

Reduced


If reductions are anatomic, then proceed with permanent fixation:

– Screw fixation for the medial column

– Countersink to prevent dorsal cortex fracture



• Screws are POSITIONAL, not lag• 3.5 or 4.0 mm screws

Fractures fixed with K wires

Mobile joints fixed with K-wires (lateral MT often reduce w/medial column)

Stiff joints fixedwith screws. 3.5 mm or 4.0 mm



• If intercuneiform instability exists, use intercuneiform screw


57

• Intercuneiform joints treated rigidly

Screws

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

Complications

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

Complications

Compartment syndrome

Infection

Complex regional pain syndrome

Neurovascular injury

Hardware failure

Prognosis

Long rehabilitation (> 1 year)

Incomplete reduction leads to increased incidence of deformity and chronic foot

pain– Loss of rigidity:

Prognosis

Incidence of traumatic arthritis (0-58%) related to intraarticular surface damage and

comminution

Prognosis

Late collapse:

Late Collapse

Primary Arthrodesis: Yes or No?Yes

– Prospective trial 41 patients, 2 groups– ‘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 arthrodesis

• 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.

• Yes– 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 (MFA)

– 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?

No– Retrospective comparison of 28 patients, 3

groups, ‘severe’ injury– 12 ORIF; 5 partial and 6 complete arthrodesis– Higher pain in arthrodesis group (Baltimore

scale)– Complications higher in complete arthrodesis

• Mulier T, Reynders P, Dereymaeker G, Broos P. Severe Lisfrancs injuries: primary arthrodesis or ORIF? Foot Ankle Int 2002.

Outcomes

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 arthrodesisLigamentous 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.

Outcomes

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.

Outcomes

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

Anatomy– Horseshoe-shaped bone between

talus and cuneiforms– Numerous short ligaments attach

dorsally, plantarly, and laterally– Deltoid attaches medially

Navicular FracturesBlood supply: because of the large articular surfaces, vessels can

only enter dorsally, plantarly, and thru tuberosityMedial 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

sprain)

Treatment:– Immobilization & progressive

weight bearing

– Excision of fragment only if painful

Navicular Fractures

Tuberosity fractures: avulsion by posterior tibial tendon and spring

ligament

Usually minimally displaced

May have associated calcaneocuboid impaction

ORIF depending on degree of displacement (>5mm)

Navicular FracturesBody Fractures:

– High energy trauma with axial foot loading– Frequently associated with talonavicular

subluxation– CT scans helpful for preop planning

– Anatomic reduction essential

Navicular Body FracturesTreatment:

– 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


May require stabilization or fusion to cuneiforms

Avoid fusion of essential talonavicular joint if at all

possible

Missed navicular fx required ORIF and primary fusion due to arthritis


Prognosis: – With adequate reduction most have good result,

but few are “normal”

Type 3 worst prognosis:– Only ½ adequately reduced (60% of joint surface)– 6 of 21 developed ostonecrosis with one collapse

• Sangeorzan BJ, Benirschke SK, Mosca V, Mayo KA, Hansen ST Jr. Displaced intra-articular fractures of the tarsal navicular. JBJS-A 1989.

Navicular Stress FracturesUncommon; 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: Treatment

Incomplete fracture– Non-weightbearing cast until healed (variable

time)– Complete fracture or nonunion: ORIF with screws perpendicular to fracture plane +/- bone

graft– Complications: nonunion or persistent pain

Cuboid Fractures

Isolated fractures are rare

Most often associated with other fractures

Two types of fractures usually seen:

– Avulsion

– Nutcracker (axial loading with plantar flexion and forefoot

abduction)

Cuboid Fractures:Treatment

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 plate

– Can use small external fixator for distraction

– May have to bridge

joint to stabilize

subluxation

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

Summary

Midfoot: restore length and alignment relationships of the medial and lateral

column

Forefoot: plantigrade metatarsal heads

SummaryRigid fixation for unstable joints

Screws for dislocations of ‘stiff’ syndesmotic joints – TMT 1-3

K-wires for dislocations of mobile joints– TMT 4-5

SummaryBone 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

Summary

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 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.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):527-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):527-30.30.•Coss HS, Manos RE, Buoncristiani A, Mills WJ. Abduction stress and AP weightbearing radiography of purely ligamentous injury in the tarsometatarsal joint. 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. 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 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.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; Hunter JC, Sangeorzan BJ. A nutcracker fracture: cuboid fracture with an associated avulsion fracture of the tarsal navicular. AJR Am J Roentgenol. 1996Apr; 166(4):888.166(4):888.•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 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):514-injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg Am. 2006 Mar; 88(3):514-20.20.•MacKenzie EJ, Morris JA Jr, Jurkovich GJ, Yasui Y, Cushing BM, Burgess AR, DeLateur BJ, McAndrew MP, Swiontkowski MF. Return to work following 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.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.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 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):119-122.1996; 10(2):119-122.•Sangeorzan BJ. Fractures of the tarsal bones. Orthop Clin NorthAm. 2001 Jan; 32(1):21-33.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. 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, Benirschke SK, Mosca V, Mayo KA, Hansen ST Jr. Displaced intra-articular fractures of the tarsal navicular. J Bone Joint Surg Am. 1989 Dec; 71(10):1504-10.71(10):1504-10.•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, 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, 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.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 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.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):513-Schildhauer TA, Nork SE, Sangeorzan BJ. Temporary bridge plating of the medial column in severe midfoot injuries. J Orthop Trauma. 2003 Aug; 17(7):513-20. 20. •Teng AL, Pinzur MS, Lomasney L, Mahoney L, Havey R . Functional outcome following anatomic restoration of tarsal-metatarsal fracture dislocation. Foot 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.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 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. 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.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. Watson TS, Shurnas PS, Denker J. Treatment of Lisfranc joint injury: current concepts. J Am Acad Orthop Surg. 2010 Dec;18(12):718-28.

Bibliography

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