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We're here to talk about Lisfranc

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injuries, and we've got a case.

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We're going to talk about

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grading systems, though.

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The Quenu and Kuss grading system

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and the Vertullo grading system.

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But let's just quickly review what's happened

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to this patient that supposedly has a

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"fracture" and is in their 50s.

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Let's scroll a little bit from dorsal to plantar.

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We're in the axial projection,

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but we're seeing the foot as a long axis.

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And we're seeing all of the tarsal bones

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and the base of the metatarsal bones.

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And there are fractures out the yin yang.

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There are fractures involving

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virtually every cuneiform bone,

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virtually every metatarsal base.

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And we see the recessed appearance

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of the second metatarsal.

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That's normal compared to the other metatarsals,

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forming kind of a Roman arch or

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a columnar configuration and

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assisting in the stability of the midfoot.

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All things that we have discussed

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before as a quick review.

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We said that the Lisfranc ligament has plantar,

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proper middle, and then dorsal components.

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Let's have a quick look.

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We're dorsal.

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The Lisfranc is noted for its C1

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medial cuneiform to M2, base of second connection.

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It keeps this area together.

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So here we are dorsally.

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Here's C1.

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There's the ligament.

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It should go to C, it should go

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to M2, the base of the second.

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Here is the base of the second.

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It in no way makes it

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to the base of the second.

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That's torn.

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Let's go to the proper area,

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which is directly interosseous.

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We are interosseous.

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Here's the base of the fractured second.

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The fracture is a bad sign.

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In fact, it's one of the most

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reliable signs of a Lisfranc injury.

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The fact that you have a transverse

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fracture across the base of the second.

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More on that in a minute.

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Where's the ligament?

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Gone.

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Replaced by a bunch of junk, bunk, and blood.

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Well, let's keep going.

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Let's go to the plantar aspect of the foot.

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When we get to the plantar

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aspect, we said, remember, C1M2.

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We've got a C1M2 ligament,

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plantar one, right there.

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And it's a stump.

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There it is on T1.

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It's a stump.

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And then we also have,

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by the way, a C1M3 plantar ligament.

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There it is.

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It doesn't make it over to M3.

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It stops right there.

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I'll make it a little brighter for you.

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There's the stump of it.

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Why does it look so gray?

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It's got a lot of blood in it.

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So, all three components, dorsal,

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middle, and plantar, are injured.

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Now let's look at the short axis

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projection, because this is going to

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help us grade this type of injury.

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Now, oen classification you've heard about

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in other vignettes is the Quenu and Kuss

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classification, which talks about how

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the bones move relative to one another.

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So, homolateral injuries is when

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all five of the metatarsals shift to

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one side relative to the cuneiforms.

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Easy.

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Divergent means that the first goes medial and all

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the other columns go lateral, so they separate.

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That's easy.

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And isolated means that one or two

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metatarsals shift relative to the cuneiforms.

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That's also very simple to comprehend.

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Let's talk about the Vertullo classification.

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So this is a three-stage system and it

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incorporates some radiography in it.

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So that's one of the reasons why I

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like to kind of mix them together.

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And I'll often use both systems when

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I'm describing this to the clinician.

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So in a stage one injury, it's a low

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grade sprain of the Lisfranc ligament and

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there's also a dorsal capsular tear.

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But the joint itself is not unstable,

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and usually these are the ones that have

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a negative radiographic examination.

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There's no displacement, there's no

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widening, and even with weight bearing,

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there's often no separation or widening.

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Remember, that used to be the cardinal

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feature of diagnosing a Lisfranc injury.

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Syntagraphically, they're always hot,

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right around the second TMT.

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Then we've got stage two.

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Injuries that demonstrate about 2 to

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5 millimeters of diastasis on radiography.

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And we're gonna see we have that

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in the long axis, sort of axial

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projection, and no loss of arch height.

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Well, we do have loss of arch height.

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Let's talk about the arch.

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When we look at the base of the metatarsals,

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we wanna see something that looks like this.

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We want it to be continuous.

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We don't want anything dropping down.

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Well, let's see if we've got that.

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Let's scroll.

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Do we have anything dropping down?

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You bet we do.

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Look at that bone right there.

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Look at the base of the third.

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Oh, she's a sagger, isn't she?

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She's going right down towards the

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plantar aspect of the arch of the foot.

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So that leads us to stage 3 injuries,

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which demonstrate greater than five

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millimeters of diastasis between the

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base of the second and the cuneiform.

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And there is a basically

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fallen arch of the foot.

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In other words, the base of the metatarsals

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start to fall into a plantar position.

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And that, unfortunately,

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is exactly what's happening here.

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So now let's return to the long axis projection.

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And let's look at our space to see how wide it is.

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Well, unfortunately, you know, one of

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our bone fragments has actually kind

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of migrated over to the medial side.

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So the fracture has actually diminished

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the degree of diastasis on that cut.

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But let's go to a cut where

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the fracture isn't displaced.

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Like this one right here.

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And let's make a measurement.

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See what we get

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between the base of the second and the cuneiform.

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It's about 5 millimeters.

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So we're in a Vertullo stage 3 scenario.

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Do we have any displacement?

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Well, in fact, we do.

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Let's go back to our scrolling function here.

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And see if there's any offset between

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our metatarsals and our cuneiforms.

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And indeed, there is.

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166 00:06:27,270 --> 00:06:28,729 It's extremely subtle.

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Let's scroll it and keep looking.

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For instance, look at the alignment

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of the fourth relative to the cuboid.

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It should be along the medial edge of the cuboid.

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It's slightly shifted laterally.

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And a few of the other bones,

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they don't quite line up just perfectly.

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Obviously, there are complicated

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fractures here that maybe prevent

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your assessment of direct alignment.

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But if you are simply using the Quenu

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and, uh, Quenu and Kuss classification

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system, you might call this isolated.

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And that might denote that it's

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not as severe as it really is.

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So in this case, I really like the

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Vertullo classification system that tells

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you the severity of the injury.

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Also, the fractures are a tip

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off of the severity of injury.

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And finally, all three components,

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the dorsal, the plantar, and the proper

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component of the Lisfranc are torn.

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What are some other signs that you can use?

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Well, on plain film, the flex sign, a small

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chip fracture at the base of M2 or C1.

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That's an X-ray radiographic

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finding or a CT finding.

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It tells you something's wrong, but it

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doesn't really give you a full understanding

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of the severity and the scope of the injury.

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Alignment changes on radiography.

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Well, that's a tip-off.

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Unfortunately, they're not reliable because

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they're not always or often present.

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For And then, you know, looking at the columns

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and how the columns relate the metatarsal

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columns relate to the cuneiform columns.

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And we have talked about columnar anatomy.

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We said that the foot is broken down

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into a medial column, the first, a middle

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column, the second and the third with

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their cuneiforms, and a lateral column,

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the fourth and the fifth with their cuneiforms.

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So these are some very basic, basic

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findings to try and understand,

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what's happening.

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On CT, just as on MRI, you should be looking

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at the arch configuration of the

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metatarsals, just like on MRI, and we see

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that, once again, the arch is abnormal,

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with this bone sagging into a plantar position.

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There are some angle

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measurements you can make, too.

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The plantar surface of C1 is dorsal to the plantar

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aspect of M5, the fifth metatarsal, and also the

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tarsal metatarsal angle is less than 15 degrees.

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I don't use those very commonly.

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I'll just comment on them for completion,

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it's not really that practical.

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The most reliable indicator of a Lisfranc

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injury though is malalignment of the

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second TMT with lateral displacement

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of the base of M2 with respect to C2.

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Let's take a look at that on

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the, on the T1 weighted image.

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Here we've got it.

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And if we take out our fracture

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fragment, oh yeah, it's malaligned.

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Look at that second metatarsal

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coming down, down, down, down, down.

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Our column, our second column is not aligned.

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The edge of that bone is not

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aligned with the edge of this bone.

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Highly reliable sign for

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a serious lisfranc injury.

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This, a vertullo, stage 3 type of lisfranc,

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fracture, dislocation, subluxation

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with innumerable other injuries.