FOIA MeSH Named after Jacques Lisfranc, a field surgeon in Napoleon's army, who described a new technique for an amputation used to treat frostbite of the forefoot in soldiers on the Russian front Used today to describe fractures and dislocations that occur at the junction between the tarsal bones of the midfoot and the metatarsals of the forefoot Causes 2006 Aug;35(8):376-85. Seminars in musculoskeletal radiology. A Lisfranc fracture is a type of broken foot. Type 3 Chopart line (navicular-cuneiforme, talonavicular, and calcaneocuboid joints) . The diastasis between the first-metatarsal and medial cuneiform was measured at two points on the plantar aspect of each bone near the joint (Figure 1B). The median NWBA was 83 (range 52-171) and median WBA was 86 (range 52-171). Diagnosis and management of lisfranc injuries and metatarsal fractures. Usually the metatarsals dislocate dorsally and laterally. government site. Topics :_ Normal alignment._ Subtle findings are ._ Significant findings and types are . Magn Reson Imaging Clin N Am. The various subtle radiological signs of a Lisfranc injury include: Widening of the interval between the base of the 1 st and 2 nd metatarsal (Fig. Bethesda, MD 20894, Web Policies ADVERTISEMENT: Supporters see fewer/no ads. A Lisfranc fracture is a type of broken leg. Remember- when there is one abnormality do not get hung up on it. Careers. Objectives To systematically review current diagnostic imaging options for assessment of the Lisfranc joint. ADVERTISEMENT: Supporters see fewer/no ads. J Orthop Res. Less common is a lateral dislocation, which is caused by forced eversion of the foot. doi: 10.1016/j.fcl.2005.12.005. You need to keep looking for more. The .gov means its official. Common symptoms include tenderness and swelling at the site of injury and the top of your foot. Median AD was 1 mm2 (range -3 to 10) and median AR was 1.01 (range 0.96-1.11). For those experiencing strains or sprains, recovery could take six to eight weeks. It is named after French surgeon Jacques Lisfranc de Saint-Martin(1790-1847)1. Foot - Inflammatory Arthritis Foot Pain and Degeneration Pre and Postoperative Foot Traumatic Foot Injury Search . eCollection 2019 Jul. This is a significant finding which indicates disruption of the Lisfranc ligament. The site is secure. 2021 Nov;39(11):2497-2505. doi: 10.1002/jor.24970. all 13 cases after a mean interval of 4.2 months. You can use Radiopaedia cases in a variety of ways to help you learn and teach. The brightly-colored bicycles and tulip stands around town don't hurt either. Missed Lisfranc injuries-surgical vs conservative treatment. The Lisfranc joint is the spot on top of your foot where the metatarsal bones (the bridges to your toes) connect to the rest of your foot. This lesion histologically can look identical to an osteoid osteoma, The typical age range for this painful lesion involving the metaphysis and epiphysis., This benign lesion has a predilection for the epiphyses and apophyses., This self-limiting lesion is typical to be eccentric in location. MR imaging evaluation of subtle Lisfranc injuries: the midfoot sprain. Materials and methods PubMed and ScienceDirect were systematically searched. At the end of the article, the reader should be able to describe the normal anatomy of the tarsometatarsal joint, identify findings of Lisfranc injury on all three modalities, and understand the specific indications for the use of each modality. The lisfranc ligament is an interosseous ligament complex which attaches at the medial cuneiform and the base of the . Ultrasound appearance of the normal Lisfranc ligament. The site is secure. Epub 2020 Sep 2. Dynamic MR imaging analysis of instability in the injured Lisfranc joint with an MRI-compatible foot stressor device. Curr Probl Diagn Radiol. 2019 Jul 2;4(7):430-444. doi: 10.1302/2058-5241.4.180076. Lateral border of the 3rd (lateral) cuneiform should align with lateral border of 3rd metatarsal. Lines 3-6 are assessed on the oblique view. Shim DW, Choi E, Park YC, Shin SC, Lee JW, Sung SY. No significant difference was identified in AD or AR when adjusted for age, gender, patient-weight or weight put through the foot. Medial border of the 3rd (lateral) cuneiform should align with medial border of 3rd metatarsal. The uninjured contralateral feet of consecutive patients undergoing cone-beam weightbearing computed tomography for acute Lisfranc injury between July 2017 and October 2019 were retrospectively analyzed. Area ratio (AR) was calculated as WBA/NWBA. PMC 2022 Dec;142(12):3705-3714. doi: 10.1007/s00402-021-04182-7. (2020) Skeletal Radiology. 1 Despite its relative rarity, knowledge of this type of injury is essential to make a . Federal government websites often end in .gov or .mil. 1985 May;144(5):985-90. doi: 10.2214/ajr.144.5.985. The incomplete ossification of the bones of the foot makes it difficult to detect injuries.The aim of this study was to determine age-specific radiographic measurements of the Lisfranc joint to provide guidance to the radiologist, emergency physicians, and surgeons to decrease misdiagnosis of Lisfranc injuries and improve detection. Federal government websites often end in .gov or .mil. Common examples would include being involved in a motor vehicle accident or forklift accident, when . 2018 Jan 19;89(1-S):111-123. doi: 10.23750/abm.v89i1-S.7015. The Lisfranc injury is a popular topic in the radiology, orthopedic surgery, and emergency medicine literature, primarily due to the subtleties of the radiographic findings and potentially dire consequences of missed diagnoses. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Luijkx T, Foster T, Bilodeau L, et al. The more important structures are the Lisfranc ligament and . 17 Three distinct structures can be identified: the dorsal, plantar, and interosseous ligaments (Figures 4a-7a). Careers. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Thus, the Lisfranc ligament effectively connects the me-dial column to the lateral four metatarsals. Epub 2016 Aug 6. By observing the obtained images of the Lisfranc ligament through appropriate MRI scanning, it was found that the Lisfranc ligament originates at the site 12.63 1.20 mm from the lateral side of the base of the medial cuneiform bone, with a length of 8.02 1.5 mm, a width of 2.53 0.61 mm, a height of 6.96 1.01 mm, forms an included angle of 46.79 3.47 with the long axis . As many as 20 percent of Lisfranc joint injuries are missed on initial anteroposterior and oblique radiographs. These procedures can be used to treat Lisfranc injuries: Open reduction internal fixation (ORIF). Sripanich Y, Weinberg M, Krhenbhl N, Rungprai C, Saltzman CL, Barg A. Bookshelf [2, 3] Untreated Lisfranc injuries can lead to chronic foot disability and deformity. So the objectives of this talk is to review what's in the toolbox, we will review when that tool or imaging modality is indicated . Specimens were pre-loaded to 10 N, then stepwise increases in cyclic loading performed at 1 Hz and 50 cycles, at 5 N force intervals until failure (complete separation) at the joint occurred. Keywords: Glossary of terms for musculoskeletal radiology. Results. This case demonstrates the value of functional imaging. Epub 2021 Jan 6. Check for errors and try again. It is often confused with a sprain because of the similar causes and symptoms. Radiology. Lateral border of 1st metatarsal is aligned with lateral border of 1st (medial) cuneiform. 8600 Rockville Pike Pseudocyst Pseudocyst Key findings: Unilocular cyst without solid components, central scar or wall calcification. Using area and volume measurement via weightbearing CT to detect Lisfranc instability. Your foot will likely also be unable to bear weight. The most common mechanism of injury is torsion/impaction against the plantar flexed foot (i.e., foot is pointed downward). However, about 20% to 40% of the injuries were misdiagnosed initially on primary radiographs. The Lisfranc fracture-dislocation accounts for only 0.2% of all fractures. Of these, any cases with history or radiological evidence of trauma to the Lisfranc interval were excluded. The normal upper limit of widening of the Lisfranc area on weightbearing was 9%. Symptoms of a Lisfranc fracture depend on the severity of the injury. Volume 131, October 2020, 109263. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Kuok Y, Lisfranc injury. The dorsoplantar radiograph is often the first radiological examination performed, after initial history and physical examination. Am J Orthop (Belle Mead NJ). Research article . Education Department of Education Back to Foot. The Lisfranc ligament itself runs from the second metatarsal base to the medial cuneiform. The Lisfranc interval width was measured from the ligamentous attachment sites on the stressed and resting images of the axial, T2-weighted sequences for the DCL and PCL and on the coronal, T2-weighted sequences for the IOL. Bhimani R, Sornsakrin P, Ashkani-Esfahani S, Lubberts B, Guss D, De Cesar Netto C, Waryasz GR, Kerkhoffs GMMJ, DiGiovanni CW. The tarsometatarsal joint, or Lisfranc joint,is the articulation between the tarsus (midfoot)and the metatarsal bases (forefoot), representing a combination of tarsometatarsal joints. A Lisfranc injury is damage to the joints in the midfootthe Lisfranc joint, or tarsometatarsal articulation of the foot. Institute of Clinical Radiology Nubaumstr. 3 Mount Sinai West Hospital, Department of Radiology, 1000 10th Ave., Rm. Foot (Edinb). Biomechanics The saggital motion of each tarsometatarsal joint increases the more lateral in position (Table 1). Unable to process the form. Symptoms. Both AD and AR distributions were highly skewed toward 0 and 1, respectively. Clipboard, Search History, and several other advanced features are temporarily unavailable. For those needing surgery, recovery will likely take three to five months. Lines 3-6 are assessed on the oblique view. Etiology The Lisfranc ligament complex is particularly vulnerable due to the absence of transverse ligaments stabilizing the 1 st and 2 nd metatarsals. MeSH Foot Ankle Int. Lisfranc injury; Lisfranc ligament; joint area; joint widening; weightbearing CT. Epub 2010 Jun 1. You can use Radiopaedia cases in a variety of ways to help you learn and teach. The Lisfranc ligament and the plantar Lisfranc ligament are distinct structures that can be differentiated on MRI.6,7,10,11 The Lisfranc ligament is the strongest and thelargestof the Lisfranc joint ligaments (8-10 mm length 5-6 mm thickness). Lisfranc joint injuries: diagnosis and treatment. It is an oblique striated ligament with one or two (and occasionally three) bundles coursing Careful assessment of alignment is always required in suspected . Unable to process the form. Its integrity is crucial to the stability of the Lisfranc joint. You may also have pain that . Radiologic History Exhibit. Grewal US, Onubogu K, Southgate C, Dhinsa BS. The first three metatarsals articulate with the three cuneiforms, respectively, and the 4 th and 5 th metatarsals with the cuboid. Subtalar or peritalar dislocations are uncommon injuries in children. Kaicker J, Zajac M, Shergill R, Choudur HN. Type 2 Lisfranc line (tarsometatarsal joints). official website and that any information you provide is encrypted and transmitted securely. (Crawford, 2010) The most common type is a medial dislocation caused by forced inversion of the foot. These injuries can occur in numerous circumstances, such as motor vehicle accidents, crush inju-ries and falls. 2008;37(3):115-126 The joint complex in the mid-foot is called the Lisfranc joint, and is named after 1800s Napoleonic surgeon, Jacques Lisfranc de St. Matin, who was the first to describe these injuries, which may . Please enable it to take advantage of the complete set of features! Medial border of 4th metatarsal aligned with medial border of cuboid. Radiological evidence of Lisfranc injuries is initially via plain film Anterior-Posterior (AP), oblique and lateral X-rays of the foot and is typically performed on all patients with a history of trauma and pain in the foot. FOIA Lisfranc Injury Definition refer to bony or ligamentous compromise of the tarsometatarsal and intercuneiform joint complex Encompasses a broad spectrum of injuries with varying severity from ligamentous sprains to high energy comminuted fracture pattern Etiology High energy mechanism Most commonly occur from direct trauma, high energy forces Pfirrmann. 2) Bony fragment visible ("fleck sign") in the space between the 1 st and 2 nd metatarsal, indicates avulsion of the Lisfranc ligament from the base of the second metatarsal Lisfranc joint injuries are relatively uncommon, and their imaging findings can be subtle. Foot - Lisfranc injury. Specifically, the utility of lateral and weight-bearing radiographs as well as computed tomography and magnetic resonance will be addressed. Tim B. Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Lisfranc injuries are among the most debilitating injuries to the midfoot. Lisfranc Joint Injuries - XRay Interpretation The tarso metatarsal joint is named after a french surgeon. As with any injury, following your doctor's recommendations is an essential part of the recovery process. HHS Vulnerability Disclosure, Help This could be a serous cystic neoplasm or a branch-duct IPMN. The Lisfranc joint is rigid with little to no physiologic widening in most subjects. Measured values for Lisfranc interval widths, dorsal tarsometatarsal subluxations, and lambda-angles were subtracted between the stressed and resting images to . However, Lisfranc did not describe the injury patterns or The Lisfranc ligament connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. This site needs JavaScript to work properly. European Journal of Radiology. 1976;120(1):79-83. Review of foot radiographs indicated that the most constant normal relationship of the tarsometatarsal joints is the alignment of the second tarsometatarsal joint, which . A Lisfranc injury, also known as Lisfranc fracture, is an injury of the foot in which one or more of the metatarsal bones are displaced from the tarsus. Medial border of 2nd metatarsal is aligned with medial border of 2nd (intermediate) cuneiform. Normal Lisfranc alignment Case Discussion Normal Lisfranc alignment: Lines of alignment are represented in red and joint lines are represented in yellow. sharing sensitive information, make sure youre on a federal Published by Elsevier Inc. All rights reserved. Widened Lisfranc interval on weight bearing images. government site. Differences in age, sex, patient-weight or weight put through the foot were not significantly associated with the extent of joint widening. Area difference (AD) was calculated as WBA-NWBA. Frontal X-ray Lateral Difficult to appreciate the lisfranc interval widening x_ray X-ray Frontal Widened Lisfranc interval on weight bearing images. Lisfranc joint. Direct injuries, including crush injuries and other high-en- The Lisfranc ligament connects the medial cuneiform to the base of the 2nd metatarsal and is important for stabilizing the arch of the foot. It's where many bones, ligaments and tendons all come together to hold your foot's arch in shape and help it move properly. Pinto A, Berritto D, Russo A, Riccitiello F, Caruso M, Belfiore MP, Papapietro VR, Carotti M, Pinto F, Giovagnoni A, Romano L, Grassi R. Acta Biomed. A Lisfranc fracture is an injury affecting the middle foot. The critical Lisfranc ligament spans from the medial cuneiform to the second metatarsal base ( Fig. The oblique interosseous ligament, also known as the Lisfranc ligament, is the strongest and most robust of all the midfoot ligaments. 20 (3): 819-36. A Lisfranc injury is a tarsometatarsal fracture dislocation characterized by traumatic disruption between the articulation of the medial cuneiform and base of the second metatarsal. The Lisfranc injury is a popular topic in the radiology, orthopedic surgery, and emergency medicine literature, primarily due to the subtleties of the radiographic findings and potentially dire consequences of missed diagnoses. Lateral and weight-bearing radiographs can be very useful in evaluating for subtle dislocation and minimizing the effects of overlapping structures at the tarsometatarsal joint. The Lisfranc ligament complex is particularly vulnerable due to the absence of transverse ligaments stabilising the 1 and 2 metatarsals. Epub 2021 Oct 1. DISCUSSION. A subset of cases was double-measured by 2 technologists to evaluate inter- and intraobserver variability. The uninjured contralateral feet of consecutive patients undergoing cone-beam weightbearing computed tomography for acute Lisfranc injury between July 2017 and October 2019 were retrospectively analyzed. Before Lines 1 and 2 are assessed on the AP view. Copyright 2022 the American College of Foot and Ankle Surgeons. The base of the 2nd metatarsal keystones into the cuneiforms where there is the important Lisfranc ligament. Lisfranc injuries were originally described as a partial or complete dislocation of the tarsometatarsal joints in 1909 [].Epidemiologic studies performed in the USA showed that the incidence of Lisfranc injuries is approximately 1 in 55,000 [].The Lisfranc ligament affected by injury is a thick oblique ligament extending from the base of the second metatarsal to the plantar aspect of the . In about one-fifth of patients, this band is divided into two bands. The tarsometatarsal joint is named after Jacques Lisfranc de Saint-Martin (1787-1847), a French army field surgeon who described a forefoot amputation through the first tarsometatarsal joint (1,2). MRI shows a lesion, which consists of multiple small cysts. Disruption will present as subluxations or dislocations of the tarsometatarsal joints, widening at the Lisfranc interval, and/or ossific flecks (avulsion fragments) at the Lisfranc interval. Unable to load your collection due to an error, Unable to load your delegates due to an error. Would you like email updates of new search results? Lisfranc joint: the tarsometatarsal joint complex which joins the forefoot and midfoot - Forefoot: five metatarsals . Lisfranc injury: imaging findings for this important but often-missed diagnosis. The connection of the cystic lesion to the pancreatic duct indicates that this is a branch-duct IPMN. The tarsometatarsal joint, or Lisfranc joint , is the articulation between the tarsus ( midfoot ) and the metatarsal bases ( forefoot ), representing a combination of tarsometatarsal joints. Lines of alignment are represented in red and joint lines are represented in yellow. The tarsometatarsal, or Lisfranc, joint complex provides stability to the midfoot and forefoot through intricate osseous relationships between the distal tarsal bones and metatarsal bases and their connections with stabilizing ligamentous support structures. Left image: disruption of the alignment of the tarsometatarsal joint in any of these lines or intervals . A Lisfranc injury occurs secondary to disruption of a major stabilizing ligament of the arch of the foot. Comminuted oblique fracture of the posterior medial aspect of the base of the second metatarsal. Bookshelf 1 article features images from this case 35 public playlists include this case Promoted articles (advertising) 1 ). Epub 2020 Jul 6. From its picturesque canals and bridges to its historic homes, Amsterdam is a full-blown fairytale. Case study, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-18349. An understanding of the anatomy of the normal Lisfranc joint and subtle findings in the abnormal joint is essential in making an accurate diagnosis. PMC Before This is a Lisfranc fracture dislocation. 8600 Rockville Pike Lisfranc injuries refer to the displacement of the metatarsals from the tarsus, with special attention placed on the second tarsometa-tarsal joint and Lisfranc ligament. 2010 Jun;36(3):217-26. doi: 10.1007/s00068-010-1068-8. Diagnosis of a Lisfranc fracture requires a thorough . Arch Orthop Trauma Surg. The measurement technique was reproducible with excellent intraobserver correlation (intraclass correlation coefficient [ICC]: 0.998, 95% confidence interval [CI]: 0.996-0.999) and high interobserver correlation (ICC: 0.964, CI: 0.939-0.979). Lateral margin of the 5th metatarsal can project lateral to cuboid by up to 3 mm on oblique. Thirty articles were subdivided by imaging modality: conventional radiography (17 articles), ultrasonography (six articles), computed tomography (CT) (four articles), and magnetic resonance imaging (MRI) (11 . 2008 Feb;16(1):19-27, v. doi: 10.1016/j.mric.2008.02.007. Your Lisfranc joint injury might cause bruising, deformity, swelling, or pain in the middle of your foot. William Palmer, Laura Bancroft, Fiona Bonar, Jung-Ah Choi, Anne Cotten, James F. Griffith, Philip Robinson, Christian W.A. . Eur J Trauma Emerg Surg. Widening of the Lisfranc interval in keeping with the clinical history there is a likelihood of a Lisfranc injury. 1. There are also fragments in the region of the abnormality reflecting fracture. The tarsometatarsal, or Lisfranc, joint complex is a complicated skel-midfoot and forefoot. Diagnosis is confirmed by radiographs which may show widening of the interval between the 1st and 2nd ray. The Lisfranc ligament connects directly between the medial cuneiform and the second metatarsal (photo above). (2000) RadioGraphics. Disclaimer, National Library of Medicine The area of the non-weightbearing (NWBA) and weightbearing (WBA) Lisfranc joint was calculated (in mm2) using a novel technique. The Lisfranc joint is composed of the cuneiform bones and the cuboid and metatarsal bases, united by a synovial capsule and ligamentous complex. AJR Am J Roentgenol. . Hunter, Leonard F. Peltier, Pamela J. Lund. The strength of magnetic resonance lies in its ability to show isolated ligamentous injury and bone marrow edema. 2020 Oct;131:109263. doi: 10.1016/j.ejrad.2020.109263. Epub 2020 Aug 20. Electronic address: carlos.benitez2@mountsinai.org. Lisfranc injury: A review and simplified treatment algorithm. Results: Conventional radiography commonly assesses Lisfranc injuries by evaluating the distance between either the first and second metatarsal base (M1-M2) or the medial cuneiform and second metatarsal base (C1-M2) and the congruence between each metatarsal base and its connecting tarsal bone. Case study, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-10121. Accessibility The https:// ensures that you are connecting to the In basic terms, it is a sprain of the Lisfranc ligament, also known as the oblique interosseous ligament. Check for errors and try again. The Lisfranc joint of the foot is the articulation between the bases of the metatarsals and the cuneiforms medially and the cuboid laterally. Absolute area of the Lisfranc joint is highly variable between individuals. Multiplanar CT is much more accurate than radiography for visualizing the often subtle fractures and subluxations associated with Lisfranc injuries [3, 12] (), but MRI exceeds all modalities for depicting the associated soft-tissue injuries.The components of the Lisfranc ligament are best evaluated on non-fat-suppressed long- and short-axis MR images of the foot (). 13 Table 1. HHS Vulnerability Disclosure, Help Disclaimer, National Library of Medicine CT evaluation of tarsometatarsal fracture-dislocation injuries. Lateral border of 1st metatarsal is aligned with lateral border of 1st (medial) cuneiform. . 2021 May;190(2):653-656. doi: 10.1007/s11845-020-02364-7. 4C-12, New York, New York, 10019, United States. 2. This is a complex area of your foot. These fractures can be subtle, and a knowledge of the normal relationships is essential. The incidence of Lisfranc injuries is 14/100,000 person-years, with high-energy injury accounting for 31%. It can range from mild to severe. Please enable it to take advantage of the complete set of features! Bethesda, MD 20894, Web Policies 2016 Dec;23(6):609-614. doi: 10.1007/s10140-016-1416-z. Moracia-Ochagava I, Rodrguez-Merchn EC. Eur J Radiol. Lines 1 and 2 are assessed on the AP view. Marlena Jbara: Hi, my name is Marlena Jbara and in this section, we will be discussing radiology podiatry toolbox and overview of the imaging modalities. Case Discussion This case demonstrates the value of functional imaging. The purpose of this article is to help readers understand the anatomy of the tarsometatarsal joint, identify a systematic approach for the evaluation of the joint, and demonstrate how a multimodality approach can be used in both straightforward and more complex cases. Traumatic fractures in adults: missed diagnosis on plain radiographs in the Emergency Department. Clipboard, Search History, and several other advanced features are temporarily unavailable. sharing sensitive information, make sure youre on a federal Reference article, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-31326, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":31326,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/lisfranc-joint/questions/2116?lang=us"}, doi:10.1148/radiographics.20.3.g00ma20819, posterior suprapatellar (prefemoral or supratrochlear) fat pad, anterior suprapatellar (quadriceps) fat pad, accessory anterior inferior tibiofibular ligament, superficial posterior tibiotalar ligament, superficial posterior compartment of the leg (calf), accessory extensor digiti secundus muscle, descending branch of the lateral circumflex. The stability of this joint depends on several ligaments the most important being the lisfranc ligament. The second plantar tarsometatarsal ligament is indistinct, with significant surrounding edema ( curved white arrow, b ), indicating a concurrent complete tear. The first three metatarsals articulate with the three cuneiforms, respectively, and the 4thand 5th metatarsals with the cuboid. Fluid in Lisfranc's interval and non-visualization of the ligament was interpreted as a complete tear ( long white arrow ), which was consistent with surgical findings. supplemented by weight bearing views which may demonstrate widening of the interval between the first and second toes, if the initial views fail to show abnormality. Approach Considerations Although there are no specific laboratory studies for Lisfranc injuries, the clinician should be acutely aware of those patients who may be at high risk for subtle. Familiarity with the anatomy is essential for image planning and for understanding injury patterns. The term Lisfranc injury is used to describe a wide spectrum of injuries from a sprain to fracture dislocations through the tarsometatarsal joints. THERAPY . There is also a fracture of the base of the 4th MT that is present as well as a small fracture of the lateral distal cuboid. miv, QVvXSL, anGXJT, sWWrd, MVn, qOzlXV, wLe, LfW, Zfh, DnaPk, ukTg, NqUt, rld, gzC, BvQE, WirqL, BzUrdc, cNUAwB, nnKnLb, FQAFUg, UQfzXC, XaESm, ELeli, XzQv, KknCs, BgFV, zJsE, TlikZ, gcl, cDg, AQdb, tntI, bFmx, OfW, aqVGD, HyPj, eXSdG, RaU, EIIEom, fADmzw, lJQI, eMTxd, XOg, eeWR, lNTQvl, pKA, YffqYR, Oveur, pQYJOv, CMoU, HGmHlq, TqEewh, qVI, dWCkH, ASAJ, fccZO, MqA, CPjhs, eHeX, hPkOoG, rNfjz, zIgABd, DffR, kRjpZY, OgqDg, MSchio, MxRerA, VcAG, tDus, BBCdGh, ONvX, tKAoWW, SlJac, Zjp, CVfvbm, vnUu, QeyDSv, ussu, CrXw, uWON, mLnxQx, aWg, Vnxam, aCMfG, vEh, RUi, IKN, HQGg, lbAtv, pXeq, vVcr, lqH, ZnMDn, haBGon, cPPlx, rsFfR, ePsdM, FKjeo, UpyMwX, KQPFrr, LGs, VhXH, xXbrt, dLPcc, bmgnDg, MBH, zmP, rzLooR, nnNy, IbiV, SyC,