Article Synopsis: The diagnosis and treatment of injury to the tarsometatarsal joint complex - M. S. Myerson

Tarsometatarsal joint injury or eponym “Lisfranc dislocation” is prevalent in medicolegal practice and often has profound effects on mobility.  The linked article offers a useful review of the functional anatomy, aetiology, diagnosis, treatment objectives and prognosis.  As the article states, injuries to the midfoot are best described as those affecting the tarsometatarsal joint complex (TMC). High-energy injuries to the TMC occur commonly today after motor-vehicle, motorcycle, and industrial accidents.  Unfortunately, the magnitude of this type of injury is often not appreciated because partial spontaneous reduction of the joint complex may mask the true extent of the injury.  The radiological diagnoses of major fracture-dislocations are usually obvious but more minor subluxation is often missed. The finding of most significance is widening between the bases of the first and second metatarsals or between the middle and medial cuneiforms.  

In terms of treatment, there are very few indications for the non-operative management of displaced fractures or fracture-dislocations of the TMC.  Ideally, surgery should be performed within the first few weeks after injury.  The aim of treatment should be a stable anatomical reduction, which can be accomplished only by rigid internal fixation.  Patients are not allowed to bear weight for two weeks and the limb is immobilised in a below-knee posterior plaster splint. For eight weeks thereafter, toe-touch weightbearing in a removable articulated walking boot is allowed. Early movement of the foot is ideal and is enhanced by rigid skeletal fixation.

Perhaps the most common problem after injuries to the TMC is the development of post-traumatic arthritis.  Post-traumatic arthritis may be treated initially by nonoperative means including non-steroidal anti-inflammatory drugs, moulded orthotic insoles, a stiff-soled shoe with a rocker-bottom, and more rigid immobilisation by a polypropylene ankle-foot orthosis.  If these methods fail to relieve symptoms to an acceptable level, arthrodesis of the painful tarsometatarsal joints is the treatment of choice.  After operation, the patient is placed in a bulky compression dressing, which is changed to a cast at two weeks. Weight-bearing is begun at approximately eight weeks, in a below-knee walking cast or a commercially available walking boot, which may be used for an additional four to eight weeks, depending on the healing of the arthrodesis. After arthrodesis of the TMC, most patients are quite satisfied with their level of function and activity.