What is the treatment for a small nondisplaced fracture of the medial cuneiform Lisfranc (Lisfranc joint) complex injury?

Treatment for Small Nondisplaced Fracture of Medial Cuneiform Lisfranc Complex Injury

For a small nondisplaced fracture of the medial cuneiform in a Lisfranc complex injury, non-weightbearing immobilization in a below-knee cast or splint for 6 weeks, followed by progressive weightbearing with arch support for an additional 6 weeks is the recommended treatment. 1

Initial Assessment and Imaging

When evaluating a suspected Lisfranc injury:

• Standard radiographs (anteroposterior, oblique, lateral views) are the first-line imaging study 1
• CT scan is essential for detecting non-displaced fractures that may be missed on radiographs (approximately 25% of midfoot fractures identified on CT are overlooked on radiographs) 1
• MRI is indicated for evaluation of the ligamentous complex when radiographs are normal but clinical suspicion remains high 1

Treatment Algorithm for Nondisplaced Medial Cuneiform Fracture in Lisfranc Complex

Conservative Management (for stable, nondisplaced fractures)

1. Initial Immobilization (0-6 weeks):

   • Non-weightbearing in a below-knee cast or splint 1
   • A non-removable knee-high total contact cast is the first-line option 1
   • Pre-fabricated knee-high walker is an acceptable second-line option 1

2. Intermediate Phase (6-12 weeks):

   • Transition to partial progressive weightbearing with arch support 1
   • Regular radiographic follow-up to ensure maintenance of alignment 1

3. Final Phase (12-16 weeks):

   • Full weightbearing and return to activity 1
   • Long-term use of appropriate footwear and orthoses to prevent recurrence 1

Surgical Indications

Surgery is indicated if any of the following are present:

• Displacement of the fracture
• Instability of the Lisfranc joint complex on stress examination
• Evidence of 2nd and 3rd metatarsal instability 1
• Preoperative kyphosis or excessive motion at the joints 1

Potential Complications and Pitfalls

• Delayed diagnosis (occurs in up to 20% of Lisfranc fractures) 2
• Inadequate immobilization 1
• Premature weightbearing 1
• Post-traumatic osteoarthritis (can occur in up to 45% of cases despite appropriate treatment) 1
• Chronic pain and disability 1

Follow-up Protocol

• Regular clinical and radiographic follow-up is essential to ensure proper alignment and healing 1
• Long-term monitoring for development of post-traumatic arthritis is necessary 1
• Functional rehabilitation once healing permits is critical to optimize outcomes 1

Key Points for Optimal Outcomes

• Early detection and appropriate management is essential to prevent progression to arthritis and long-term disability 1
• Anatomical reduction is the major determinant of good long-term outcomes 1, 2
• Stable fixation and adequate immobilization are crucial for proper healing 1
• Patient education regarding the importance of compliance with non-weightbearing restrictions is vital 1

The treatment of Lisfranc injuries requires careful attention to detail and strict adherence to immobilization protocols to achieve optimal outcomes and minimize the risk of long-term complications.