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Closed Distal Dislocation of the Intermediate Cuneiform in a Complex Lisfranc Fracture-Dislocation

A Case Report

Asuma, Matti P. MD; CPT1; Mansfield, Taylor D. MD; CPT1; Turner, Eric K. MD; MAJ1; Robbins, Justin MD; LTC1

doi: 10.2106/JBJS.CC.18.00332
Case Reports
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Disclosures

Case: A 21-year-old, active duty male sustained an irreducible, complex Lisfranc fracture-dislocation with distal extrusion of his intermediate cuneiform. He was treated in a staged manner with external fixator placement, followed by an extended midfoot fusion with autograft bone. At 19 months, he could perform all activities of daily living independently with minimal pain using an Intrepid Dynamic Exoskeletal Orthosis.

Conclusions: Complex Lisfranc injuries are severe and often result in chronic pain and disability after operative management. To our knowledge, this is the only case report describing a Lisfranc fracture-dislocation with a distally extruded intermediate cuneiform treated with a fusion.

1Orthopaedic Surgery Service, Madigan Army Medical Center, Tacoma, Washington

E-mail address for CPT M.P. Asuma: matti.p.asuma.mil@mail.mil or masuma@uwalumni.com

Investigation performed at Madigan Army Medical Center, Joint Base Lewis McChord, Washington

Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/A798).

The views expressed are those of the author(s) and do not reflect the official policy of the Department of the Army, the Department of Defense or the U.S. Government. The investigators have adhered to the policies for protection of human subjects as prescribed in 45 CFR 46.

Tarsometatarsal fracture-dislocations and cuneiform fracture-dislocations are rare, representing roughly 0.2%1 and 1.7%2,3 of all fractures, respectively. These injuries can involve the lateral4,5, intermediate6-14, and/or medial cuneiforms15-20. To our knowledge, all descriptions of these injuries involving the intermediate cuneiform describe either dorsal7,8,10,11,13,21,22 or plantar9,12,14 displacement. We describe a 21-year-old active duty male who sustained a unique divergent Lisfranc fracture-dislocation injury in which the intermediate cuneiform has extruded distally between the first and second metatarsals with associated fractures of the medial cuneiform and fifth metatarsal base.

The patient was informed that data concerning the case would be submitted for publication, and he provided consent.

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Case Report

A 21-year-old-male, active duty Forward Observer in the Ranger Battalion fell off a 20-ft cliff, sustaining a closed fracture-dislocation of his left midfoot. He was seen at an outside facility and transferred to our center approximately 30 hours after injury. Physical exam of his foot revealed a large serous blister with surrounding dusky-grey skin about the dorsum of his left foot as well as plantar ecchymosis and brisk capillary refill of his toes (Fig. 1). Plain radiographs demonstrated a comminuted medial cuneiform fracture with a distally extruded intermediate cuneiform with splaying between the first and second metatarsals and fracture-dislocation of the first tarsometatarsal joint (Fig. 2). An attempt at closed reduction was unsuccessful. A computed tomography (CT) scan with three-dimensional reconstructions was obtained for preoperative planning prior to urgent open reduction (Fig. 3).

Fig. 1

Fig. 1

Fig. 2

Fig. 2

Fig. 3

Fig. 3

An incision was made between the first and second metatarsals, approximately 1 cm medial to his dusky dorsal skin. The distal articular surface of the medial cuneiform was found to be rotated 90° facing the dorsum of the foot and the entire intermediate cuneiform was distally extruded into the 1 to 2 metatarsal interspace (Fig. 4). After reduction of the medial cuneiform, the intermediate cuneiform was reduced back into its fossa and the reduction was maintained with 0.062 inch Kirschner wires (K-wire) medially (Fig. 5), as the integrity of his dorsal and lateral skin was poor. He was placed in a splint postoperatively.

Fig. 4

Fig. 4

Fig. 5

Fig. 5

At his first postoperative appointment, he was found to have a large area of near full-thickness skin slough about his dorsal foot wound. The decision was made to place him into an ankle spanning external fixator and remove his provisional K-wires to allow for soft tissue healing with supervised wound care of his dorsal soft tissue envelope. A specialized wound care team managed his wound with non-adherent dressings and weekly hyperbaric therapy. Given the severity of his soft tissue and osseous injuries, subsequent treatment options included limb salvage versus amputation. Fortunately, he went on to heal his dorsal skin 11 weeks from the time of injury and his external fixator was removed to allow for epithelialization of his pin sites. A repeat CT scan was obtained which showed avascular necrosis of his intermediate cuneiform (Fig. 6). Three weeks after his soft tissue envelope and pin sites were adequately healed, we elected to proceed with a limb salvage procedure.

Fig. 6

Fig. 6

He then underwent an extended midfoot fusion spanning the naviculocuneiform and tarsometatarsal joints. We excised his necrotic intermediate cuneiform and harvested a size-matched piece of autologous tricortical iliac crest graft to recreate his intermediate cuneiform (Fig. 7). We fused his naviculocuneiform joint with a medial plate extending to the first and second metatarsal bases and subsequently fused across his second and third tarsometatarsal joints. He was kept nonweightbearing in a cast for 12 weeks and then transitioned to a controlled ankle movement boot. At 3 months post-operatively, his hardware remained intact with evidence of fusion and his wounds - healed uneventfully (Fig. 8). He was then referred for fabrication of an Intrepid Dynamic Exoskeletal Orthosis (IDEO) and started on a return-to-walk program. At 7 months, radiographs demonstrated bony fusion of his midfoot (Fig. 9). At 9 months, he was able to successfully complete an Army Physical Fitness Test (APFT) 2-mile walk with 1/10 pain on the visual analog scale and he was able to complete all activities of daily living (ADLs) independently.

Fig. 7

Fig. 7

Fig. 8

Fig. 8

Fig. 9

Fig. 9

At his most recent follow-up, 19 months post-fusion, he experiences minimal discomfort with ambulation while wearing his IDEO. His Foot and Ankle Ability Measure ADL subscale score was calculated based on his responses while not wearing his IDEO. He scored a 75/100 indicating preserved ability to perform most ADLs without difficulty, with the exception of certain recreational activities. When he wears his IDEO, his overall pain and function is improved. He is able to complete his ADLs independently without the IDEO and utilizes his IDEO for higher level activities.

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Discussion

Fracture-dislocation injuries to the tarsometatarsal joints with cuneiform involvement typically result from high-energy or crush mechanisms. These injuries are rare, with only case reports described in the literature22-25. Additionally, fracture-dislocations of the cuneiforms are rare injuries described in the literature with the intermediate cuneiform being the most commonly injured of the 326. This is due to weaker cuneonavicular, intercuneiform, and metatarsocuneiform ligamentous connections, favoring dorsal dislocations10,11,27,28.

Several case reports describe a variety of methods in managing both dorsal and plantar fracture-dislocations of the intermediate cuneiform with open reduction and capsular closure11, which include K-wire fixation6,7,9,12, Steinmann pins13,21, screws8,10,14, or naviculocuneiform fusion14, with acceptable clinical outcomes. In our patient, closed reduction was impossible given the distally extruded intermediate cuneiform. The delayed presentation and substantial soft tissue injury warranted urgent open reduction and K-wire fixation to provisionally reduce the complex fracture-dislocation. Because of severe injury to the overlying soft tissue envelope, we had discussions regarding limb salvage versus amputation with the patient. After external fixator placement and soft tissue recovery, we were able to perform an extended midfoot fusion with autologous bone grafting.

High energy, complex lower extremity injuries have been increasingly more common during Operation Enduring Freedom and Operation Iraqi Freedom29, and their rehabilitation after amputation or limb salvage has been a topic of extensive research as of late30-32. His military occupational specialty is one of the most physically demanding; however, with the application of an IDEO33-35 and institution of a return-to-walk program, he was able to complete the APFT 2-mile walk with minimal pain and he can perform ADL's independently after successfully salvaging his limb.

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Conclusion

Complex Lisfranc fracture-dislocations and cuneiform fracture-dislocations are exceedingly rare injuries that can be managed a variety of ways. All the reports in the literature, to our knowledge, describe dorsal and plantar cuneiform fracture-dislocations. In this case, we provide the first known case report to our knowledge of a midfoot fracture-dislocation with distal dislocation of the intermediate cuneiform, treated with an extended midfoot fusion and rehabilitated with an IDEO back to an independent lifestyle.

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References

1. Aitken AP, Poulson D. Dislocations of the tarsometatarsal joint. J Bone Joint Surg Am. 1963;45-A:246-60.
2. Vuori JP, Aro HT. Lisfranc joint injuries: trauma mechanisms and associated injuries. J Trauma. 1993;35(1):40-5.
3. Wiley JJ. The mechanism of tarso-metatarsal joint injuries. J Bone Joint Surg Br. 1971;53(3):474-82.
4. Papanikolaou A, Maris J, Arealis G, Papadimitriou G, Charalambidis C. Dislocation of the lateral cuneiform. Report of two cases: one with dorsal and one with plantar displacement. Foot Ankle Surg. 2010;16(4):e91-5.
5. Shah K, Odgaard A. Fracture of the lateral cuneiform only: a rare foot injury. J Am Podiatr Med Assoc. 2007;97(6):483-5.
6. Aggarwal PK, Singh S, Kumar S. Isolated dorsal dislocation of the intermediate cunieform: a case report and review of the literature. Arch Orthop Trauma Surg. 2003;123(5):252-3.
7. Bertoldi L, Molinari M, Soldini A, Mora R. Isolated fracture-dislocation of the second cuneiform bone: case report. Acta Orthop Scand. 1991;62(6):604-5.
8. Cain PR, Seligson D. Lisfranc's fracture-dislocation with intercuneiform dislocation: presentation of two cases an a plan for treatment. Foot Ankle. 1981;2(3):156-60.
9. Fujita M, Yamamoto H, Kariyama K, Yamakawa H. Isolated plantar dislocation of the middle cuneiform: a case report. J Orthop Sci. 2003;8(6):875-7.
10. Maitra R, DeGnore LT. Isolated dislocation of the middle cuneiform in a farmer: a case report and review of the literature. Foot Ankle Int. 1997;18(11):735-8.
11. McGlinchey JJ. Dislocation of the intermediate cuneiform bone. Injury. 1981;12(6):501-2.
12. Nashi M, Banerjee B. Isolated plantar dislocation of the middle cuneiform—a case report. Injury. 1997;28(9-10):704-6.
13. Sanders JO, McGanity PL. Intermediate cuneiform fracture-dislocation. J Orthop Trauma. 1990;4(1):102-4.
14. Saxby TS, Sharp RJ, Rosenfeld PF. Plantar fracture-dislocation of the intermediate cuneiform: case report. Foot Ankle Int. 2006;27(9):742-5.
15. Aitken SA, Shortt N. Dorsomedial fracture dislocation of the first ray and medial cuneiform: a case report. J Foot Ankle Surg. 2012;51(6):795-7.
16. Guler F, Baz AB, Turan A, Kose O, Akalin S. Isolated medial cuneiform fractures: report of two cases and review of the literature. Foot Ankle Spec. 2011;4(5):306-9.
    17. Hidalgo-Ovejero AM, Garcia-Mata S, Ilzarbe-Ibero A, Gozzi-Vallejo S, Martínez-Grande M. Complete medial dislocation of the first cuneiform: a case report. J Foot Ankle Surg. 2005;44(6):478-82.
      18. Levine BP, Stoppacher R, Kristiansen TK. Plantar lateral dislocation of the medial cuneiform: a case report. Foot Ankle Int. 1998;19(2):118-9.
        19. Patterson RH, Petersen D, Cunningham R. Isolated fracture of the medial cuneiform. J Orthop Trauma. 1993;7(1):94-5.
          20. Taylor SF, Heidenreich D. Isolated medial cuneiform fracture: a special forces soldier with a rare injury. South Med J. 2008;101(8):848-9.
          21. Smith JS Jr, Kanat IO, Pupp G, Pupp J. Fracture and dislocation of the middle cuneiform: a case report. J Am Podiatry Assoc. 1984;74(8):406-10.
          22. Wargon CA, Goldman FD. Lisfranc fracture dislocation: a variation. J Am Podiatr Med Assoc. 1986;76(8):466-8.
          23. Bulut G, Yasmin D, Heybeli N, Erken HY, Yildiz M. A complex variant of Lisfranc joint complex injury. J Am Podiatr Med Assoc. 2009;99(4):359-63.
            24. Harris AP, Gil JA, Goodman AD, Nacca CR, Borenstein TR. Acute plantar midtarsal dislocation with intercuneiform dislocation: case study, diagnosis and management. J Orthop. 2017;14(1):26-9.
              25. Hung JL, Chan SC. Intercuneiform and Lisfranc fracture-dislocation due to seizure: a case report. J Foot Ankle Surg. 2016;55(2):314-6.
              26. Mehlhorn AT, Schmal H, Legrand MA, Südkamp NP, Strohm PC. Classification and outcome of fracture-dislocation of the cuneiform bones. J Foot Ankle Surg. 2016;55(6):1249-55.
              27. Foucher J, Weber J, Tikhonof W, Suhler A, Fintz B. The law of series. In 2 days, 2 rare injuries of the tarsus: a dislocation of the 2d cuneiform bone; a dislocation of Chopart's joint [in French]. Bull Mens Soc Med Mil Fr. 1965;59(9):528-30.
              28. Jeffreys TE. Lisfranc's fracture-dislocation: a clinical and experimental study of tarso-metatarsal dislocations and fracture-dislocations. J Bone Joint Surg Br. 1963;45:546-51.
              29. Owens BD, Kragh JF Jr, Macaitis J, Svoboda SJ, Wenke JC. Characterization of extremity wounds in operation Iraqi freedom and operation enduring freedom. J Orthop Trauma. 2007;21(4):254-7.
              30. Fergason J, Keeling JJ, Bluman EM. Recent advances in lower extremity amputations and prosthetics for the combat injured patient. Foot Ankle Clin. 2010;15(1):151-74.
              31. Shawen SB, Keeling JJ, Branstetter J, Kirk KL, Ficke JR. The mangled foot and leg: salvage versus amputation. Foot Ankle Clin. 2010;15(1):63-75.
                32. Ursone RL. Unique complications of foot and ankle injuries secondary to warfare. Foot Ankle Clin. 2010;15(1):201-8.
                33. Patzkowski JC, Blanck RV, Owens JG, Wilken JM, Blair JA, Hsu JR. Can an ankle-foot orthosis change hearts and minds? J Surg Orthop Adv. 2011;20(1):8-18.
                34. Patzkowski JC, Blanck RV, Owens JG, Wilken JM, Kirk KL, Wenke JC, Hsu JR; Skeletal Trauma Research Consortium. Comparative effect of orthosis design on functional performance. J Bone Joint Surg Am. 2012;94(6):507-15.
                  35. Rawlings N. How this leg was saved: a small medical team is helping some of our best warriors return to the fight. Time. 2012;179(22):44-6.

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