■ Case Report

Ipsilateral Floating Second Metatarsal and

Ankle Fracture Dislocation: Complications
and Outcome of a Rare Type of Injury
NG LASANIANOS, MD, NK KANAKARIS, MD, PHD, N HARRIS, FRCS, PV GIANNOUDIS, BSC, MB, FRCS

abstract
Full article available online at OrthoSuperSite.com/view.aspx?rID=00000

Lisfranc fracture dislocations are complex lesions which, when combined with addi-
tional trauma of the ankle and foot region, create a difficult to treat injury pattern. This
article presents a case of a patient with Lisfranc fracture dislocation combined with
metatarsophalangeal dislocation of the second toe and ankle fracture-dislocation.

Despite the compartment syndrome incidence, which was effectively managed, the
Figure: Anteroposterior and lateral view of the foot
patient regained an ankle- and foot-pain-free full range of motion (ROM). Although
at admission and anteroposterior view of the foot
an isolated case of a rare injury, several recommendations can be drawn out. Early and ankle post-operatively.
Computed Tomography (CT) scan should be used for injuries of the Lisfranc joints to
fully assess the distorted anatomy of the midforefoot which is essential for preoperative
planning, medicolegal issues, and the prognosis of the injury. The use of a spanning ex-
ternal fixator, especially in the setting of complex injuries as the one described, should
be preferred to cast immobilization and should be performed as a priority surgical
procedure early on in the patient’s admission. The development of compartment syn-
drome should be monitored and intracompartmental pressures measured especially
in the unconscious patients. The clinician should be actuated by a high degree of sus-
picion for early complications in complex fracture patterns, even if the initial clinical
assessment is reassuring.

Drs Lasanianos, Kanakaris, Harris, and Giannoudis are from the Academic Unit of Trauma and
Orthopedics, University of Leeds, Leeds General Infirmary, Leeds, United Kingdom.
Drs Lasanianos, Kanakaris, Harris, and Giannoudis have no relevant financial relationships to
disclose.
Correspondence should be addressed to: PV Giannoudis, Department of Trauma and Orthopedics,
School of Medicine, University of Leeds, Room 194, A’ Floor, Clarendon Wing, Leeds General Infirmary,
Great George Street, Leeds, LS1 3EX, United Kingdom (pgiannoudi@aol.com).
doi: 10.3928/01477447-20100329-28

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 ■ Case Report
T
he Lisfranc joint injury consists
of dislocation or fracture-disloca-
tion through the tarsometatarsal
(TMT) joints. It is an uncommon injury
with an incidence of 0.02 % to 0.9% of
all fractures.1 The combination of a Lis-
franc injury with dislocation of the sec-
ond metatarsophalangeal (MTTP) joint
(floating second metatarsal) is even more
rare.2 Herein, we describe a floating sec-
ond metatarsal associated with an ankle
fracture dislocation. This unusual type of
injury has not been previously reported to
the best of our knowledge. We focus on
the mechanism of injury and the timing
of diagnostic and therapeutic procedures,
which are required in order to minimize
the risk of complications and optimize the
functional outcome.
CASE REPORT
A 27-year-old man was transferred to our
emergency department after having sustained a
fall from a height of 15 feet. He reported pain
localized around his left ankle and foot. Initial
assessment revealed a closed, neurovascular
intact left ankle/foot deformity with soft tis-
1A
2A 2B
Figure 1A, 1B: Anteroposterior (AP) and lateral views of the foot showing all 3 basic injuries (2nd MTTP joint dislocation, Lisfranc fracture dislocation, ankle
fracture dislocation). Figure 2A, 2B, 2C: AP and lateral views of the ankle and AP view of the foot showing the application of the External Fixator. (The 2nd MTTP
joint dislocation has been reduced.) Figure 3A, 3B, 3C: CT axial views showing the fracture pattern around the Lisfranc joint and the fracture at the base of the
4th metatarsal.
2 ORTHOPEDICS | ORTHOSuperSite.com
ORTHO0510Lasanianos.indd 2
sue swelling. Ankle and foot movements were
eliminated. Radiographic control demonstrated
a closed Weber C-type lateral and posterior
malleolar fracture-dislocation, a type B2 (ac-
cording to Myerson’s classification3) Lisfranc
injury-dislocation of the second TMT joint and
a second MTTP dorsal dislocation (Figure 1).
The ankle and the second MTTP joint dislo-
cations were reduced following adequate pain
relief and the limb was immobilized in a be-
low-knee back slab. The patient was admitted
to the ward with instructions of elevation until
the soft tissue swelling had subsided and defin-
itive stabilization of the fractures could be per-
formed following the acquisition of a CT scan.
Nonetheless, 8 hours after admission the patient
began experiencing severe pain to his left fore-
foot. Prompt assessment revealed clinical signs
consistent with compartment syndrome of the
foot. Intra-operative measurement indicated
compartment pressures of 74 and 58 mm Hg in
the first and the fourth web space, respectively.
Fasciotomies were carried out accordingly and
the fractures were stabilized temporarily with
a Hoffmann II external fixation device (Figure
2). Fasciotomies closure with no complications
was performed 5 days later with the external
1B
2C 3A
fixator remaining in situ.
A CT scan was obtained on the seventh day
following the injury. The scan confirmed the
plain radiography findings and added to a more
detailed diagnosis. It additionally revealed cap-
sular avulsions at the first and third MTTP joints
and plantar/lateral displacement at the second
TMT joint with an intra-articular fracture in-
volving the cuneiform and the base of the sec-
ond metatarsal and an intra-articular fracture at
the base of the 4th metatarsal (Figure 3).
Definitive stabilization of the fractures was
carried out 12 days after the original injury. In-
tra-operatively, one syndesmosis screw and a
lag screw with a reconstruction plate were used
for the fixation of the ankle injury. Stabiliza-
tion of the Lisfranc fracture-dislocation was
achieved with 2 4-mm cannulated lag screws
transversing the base of the second metatarsal
towards the base of the middle and the medial
wall of the medial cuneiform, respectively
(Figure 4).
The extremity was immobilized in a be-
low-knee Jigsaw cast. The patient was advised
to mobilize nonweightbearing for 8 weeks
and toe touch weightbearing for the subse-
quent 4 weeks. Twelve weeks from the time
of injury, the ankle syndesmosis screw and the
two screws in the Lisfranc joint were removed
and the patient was referred to physiotherapy.
The patient reported transient swelling of his
ankle during the first year. At the last follow-
up appointment, 18 months postoperatively,
he was pain-free with a full ankle and foot
ROM and he had returned to his preinjury
3B 3C
4/12/2010 11:53:11 AM

level of activity.
DISCUSSION
The TMT (Lisfranc) joints are inher-
ently stable. They are stabilized by the
Lisfranc ligament and the transverse
metatarsal ligament.4 The mechanism
of injury may be associated with either
direct or indirect forces. When the force
is applied directly to the Lisfranc articu-
lation, it is usually from the dorsum and
thus, plantar displacement occurs. Indi-
rect injuries result from axial loading or
twisting. In such cases metatarsal bases
dislocate dorsally more often (97%) than
volarly (3%).5 Dorsal direction of disloca-
tions contributes to the rigid plantar stabi-
lization of the Lisfranc joint capsule being
reinforced by the plantar fascia.4
As reported in the past, simultaneous
dislocations of the TMT and MTTP joints
in a single ray are extremely infrequent.2
Only a few cases of floating metatarsals
have been described.2,6-9 Almost all of
them referred to, or included an injury
of the first metatarsal.6-9 Although, in our
patient, we faced a second MTTP joint
dislocation with the hallux in place. Add-
ing to the previously described fracture
pattern of the co-existing ankle fracture-
dislocation, one can realize the com-
plexity of the injury which required a
step-wise approach. The acute phase of
management included close reduction of
the second MTTP joint, reduction of the
ankle fracture-dislocation and temporary
immobilization into a cast. In closed in-
juries, early definite surgery is preferable
although the extent of soft tissue swelling
usually dictates the timing of intervention.
The diagnosis of compartment syndrome
of the first and fourth web spaces within
8 hours from injury necessitated emer-
gency surgical fasciotomies to be carried
out. An external fixator was chosen then
as a means of temporary stabilization to
allow soft tissue resuscitation by provid-
ing adequate stability of the fractures and
allowing care and daily inspection of the
surrounding soft tissues. Perhaps, espe-
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ORTHO0510Lasanianos.indd 3
IPSILATERAL METATARSAL AND ANKLE FRACTURE DISLOCATION | LASANIANOS ET AL
cially in the setting of complex injuries
that occur in restricted anatomical areas
(ankle, TMT, MTTP joints), temporary
stabilization with the implementation of
an external fixator should be considered as
the choice of temporary stabilization com-
pared to plaster of Paris.
Special comment should be made on
the radiographic approach of such cases
as it is reported that up to 35% of frac-
ture-dislocations of the TMT joint are
missed on initial radiographs and are con-
sequently mismanaged;10 Thus, additional
imaging in the form of CT scanning is
necessary. Haapamaki11 demonstrated the
benefit of using computed tomography
scans in high-energy injuries of the Lis-
franc joint. In his series CT scan revealed
additional occult fractures in the Lisfranc
joint in 6 (46%) out of 13 true positive
primary radiographs.11 It is our belief that
CT scan should be routinely obtained be-
fore the definite treatment of Lisfranc in-
juries. The CT scan performed in our case,
as part of the open reduction and internal
fixation (ORIF) preoperative planning, re-
vealed additional injuries which were not
diagnosed in radiographs. Among those
occult injuries, the fourth metatarsal frac-
ture justified the high compartment pres-
sures in the fourth web space that had to
be fasciotomized. Moreover, the informa-
tion gathered from the CT scan served as
a prognostic factor for the possibility of
mid- or long-term posttraumatic arthritis.
Both the syndesmosis and Lisfranc
screws were removed at 12 weeks fol-
lowing the injury. Whether the syndes-
mosis screw should be retained or re-
moved has been a topic of controversy.
Syndesmosis screws have had significant
problems including loosening, breakage
and late diastases, thus their removal has
been advocated in the past.12,13 Moore et
al14 suggest syndesmosis screw removal
only if symptomatic. Nonetheless, we
preferred to follow the routine procedure
of removing the syndesmosis screw. The
complexity of the injury pattern was dis-
couraging for the implementation of nov-
4A 4B
Figure 4A, 4B: AP and lateral views of the ankle
and foot showing the postoperative ORIF result.
el strategies that were felt less safe in our
eyes. Similarly, it was decided to remove
the screws from the Lisfranc joint. As
it has been suggested by other authors,
the screws need removal since they may
break in situ once weight bearing starts.15
Moreover, the insertion of the screws
causes further articular surface damage
to the one already caused by the injury
and their presence may increase the risk
of arthritis and osteolysis.16
CONCLUSION
The final result of pain-free full ROM
verified the effectiveness of the described
management plan. Although this is an iso-
lated case of a rare injury, we believe that
several recommendations can be made.
Early CT scan examination should be
used for injuries of the TMT (Lisfranc)
joints to fully assess the distorted anato-
my of the midforefoot which is essential
for preoperative planning, medicolegal is-
sues, and prognosis of the injury. The use
of a spanning external fixator, especially
in the setting of complex injuries as the
one described, should be preferred to cast
immobilization and should be performed
as a priority surgical procedure early on
in the patient’s admission. The develop-
ment of compartment syndrome should be
monitored and intra-compartmental pres-
sures measured especially in the uncon-
scious patients. The clinician should be
actuated by a high degree of suspicion for
3
4/12/2010 11:53:12 AM
 ■ Case Report
early complications in complex fracture
patterns, even if the initial clinical assess-
ment is reassuring.
REFERENCES
1. Richter M, Wippermann B, Krettek C, et al.
Fractures and fracture dislocations of the
midfoot: occurrence, causes and long-term
results. Foot Ankle Int. 2001; 22(5):392-398.
2. Mobarake MK, Saied A, Baron E. Concomi-
tant dislocation of the tarsometatarsal and
metatarsophalangeal joints of the second toe
(floating second metatarsal): a case report.
Cases J. 2009; 2:39.
3. Myerson MS, Fisher RT, Burgess AR, Ken-
zora JE. Fracture dislocations of the tarso-
metatarsal joints: end results correlated with
pathology and treatment. Foot Ankle. 1986;
6(5):225-242.
4. Hatem SF. Imaging of Lisfranc injury and
midfoot sprain. Radiol Clin North Am. 2008;
46(6):1045-1060.
5. Kinner B, Neumeier M, Roll C, Ganslmeier
A. Plantar Lisfranc dislocation fracture. Un-
fallchirurg. 2008; 111(3):206-210.
6. Shetty MS, Pinto D, Bhardwaj P. Isolated
floating first metatarsal: report of an unusual
injury. J Foot Ankle Surg. 2007; 46(3):185-
187.
7. Milankov M, Miljkovic N, Popovic N. Con-
comitant plantar tarsometatarsal (Lisfranc)
and metatarsophalangeal joint dislocations.
Arch Orthop Trauma Surg. 2003; 123(2-
3):95-97.
8. Kasmaoui el H, Bousselmame N, Bencheba
D, Boussouga M, Lazrek K, Taobane H. The
floating metatarsal. A rare traumatic injury.
Acta Orthop Belg. 2003; 69(3):295-297.
4 ORTHOPEDICS | ORTHOSuperSite.com
ORTHO0510Lasanianos.indd 4
9. Leibner ED, Mattan Y, Shaoul J, Nyska M.
Floating metatarsal: concomitant Lisfranc
fracture-dislocation and complex disloca-
tion of the first metatarsophalangeal joint. J
Trauma. 1997; 42(3):549-552.
10. Vuori JP, Aro HT. Lisfranc joint injuries:
trauma mechanisms and associated injuries.
J Trauma. 1993; 35(1):40-45.
11. Haapamaki V, Kiuru M, Koskinen S. Lisfranc
fracture-dislocation in patients with multiple
trauma: diagnosis with multidetector com-
puted tomography. Foot Ankle Int. 2004;
25(9):614-619.
12. Karapinar H, Kalenderer O, Karapinar L, Al-
tay T, Manisali M, Gunal I. Effects of three-
or four-cortex syndesmotic fixation in ankle
fractures. J Am Podiatr Med Assoc. 2007;
97(6):457-459.
13. Korkala O, Kiljunen V, Salminen S, Kuok-
kanen H, Niskanen R. Biodegradable screw
fixation of the syndesmosis together with
metallic osteosynthesis. Preliminary experi-
ence of 7 ankles. Ann Chir Gynaecol. 1999;
88(4):295-297.
14. Moore JA, Jr, Shank JR, Morgan SJ, Smith
WR. Syndesmosis fixation: a comparison of
three and four cortices of screw fixation with-
out hardware removal. Foot Ankle Int. 2006;
27(8):567-572.
15. Panchbhavi VK, Vallurupalli S, Yang J, An-
dersen CR. Screw fixation compared with su-
ture-button fixation of isolated Lisfranc liga-
ment injuries. J Bone Joint Surg Am. 2009;
91(5):1143-1148.
16. Alberta FG, Aronow MS, Barrero M, Diaz-
Doran V, Sullivan RJ, Adams DJ. Liga-
mentous Lisfranc joint injuries: a biome-
chanical comparison of dorsal plate and
transarticular screw fixation. Foot Ankle Int.
2005; 26(6):462-473.
4/12/2010 11:53:12 AM