midfoot fractures and dislocations anna n. miller, md, and bruce sangeorzan, md university of...
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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
Mechanisms of Injury
Mechanisms of Injury
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
Foot Function and Shape
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
Foot Function and Shape
Lateral column – Includes calcaneocuboid and 4,5 metatarsals
– Shortening = abducto planus deformity
Foot Function and Shape
Medial column – Talonavicular joint, cuneiforms, medial 3 rays
– Shortening = cavus foot
Treatment Principles
MUST – Restore alignment
– Protect talonavicular motion– Protect 4,5 TMT motion
Motion of other joints not important
Arthrodesis OK for most small joints
Treatment Principles
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
Lisfranc Joint Injuries: Diagnosis
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
Lisfranc Joint Injuries: Diagnosis
Check neurovascular status – Possible compromise of dorsalis
pedis artery
– Deep peroneal nerve injury
– COMPARTMENT SYNDROME
Lisfranc Joint Injuries: Diagnosis
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
Lisfranc Joint Injuries: Evaluation
MRI– More Radiology Income $$$$$$
CT– Confusion, Total
Lisfranc Joint Injuries: Evaluation
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
Lisfranc Joint Injuries: Treatment
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!
Lisfranc Joint Injuries: Treatment
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
Lisfranc Joint Injuries: Treatment
Naviculo-cuneiform not a mobile joint
Watch rotation of N-C joints
Primary fusion of immobile joints
Lisfranc Joint Injuries: Treatment
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
Lisfranc Joint Injuries: Operative Treatment
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
Lisfranc Joint Injuries: Operative Treatment
If reductions are anatomic, then proceed with permanent fixation:
– Screw fixation for the medial column
– Countersink to prevent dorsal cortex fracture
Lisfranc Joint Injuries: Operative Treatment
Lisfranc Joint Injuries: Operative Treatment
• 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
Lisfranc Joint Injuries: Operative Treatment
Lisfranc Joint Injuries: Operative Treatment
• If intercuneiform instability exists, use intercuneiform screw
Lisfranc Joint Injuries: Operative Treatment
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
Navicular Body Fractures
Courtesy of David P. Barei, MD
Navicular Body Fractures
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
Navicular Body Fractures
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. 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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.
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