0:01

We have a 58 year old male with right mid foot pain.

0:06

I normally start with a long axis, um, view of the foot, um,

0:12

and usually with a fat set. But in this study, we don't have a fat set.

0:16

I just have a coronal T two. So let's start looking at this. So, uh,

0:20

main findings that we are seeing is like this offset here.

0:25

So normally all the metatarsals should be imperfect alignment with their

0:29

respective articulating bones.

0:31

So the first metatarsal would be the with will be with medial uniform,

0:35

second with intermediate, third with lateral unifor,

0:39

fourth and fifth with the qubo. So here that alignment is off.

0:43

The second metatarsal is, um, laterally subluxed. So this,

0:47

this is a, uh, an imaging sign of this frank injury. So even right now,

0:52

I've not looked at the li ligament,

0:53

but just that significant lateral displacement tells me that the ligament is

0:57

torn. So the lis frank ligament goes from medial, um,

1:02

uniform to the base of the second. That's, that's your lis frank ligament.

1:06

But here I don't see a band like this.

1:08

So if you ca look at a case of normal foot,

1:10

you'll see a nice contiguous band from uh,

1:13

medial uniform to the base of the second. That's your Lis Frank and Liz.

1:17

Frank Ligament has, um, the dorsal band, the Interosseous band,

1:20

and the planter band, and it's the Intero band that's really nicely,

1:24

very seen on coronal images for dorsal and planter bands.

1:27

We need to move on these short access images.

1:29

So here we can get onto that level where the li Frank ligament is.

1:34

It's this level.

1:35

And normally you would see like how you're seeing like a contiguous black thing

1:39

here. I don't see,

1:41

so this is probably a complete li right ligament there where the,

1:45

the dorsal band is gone. The inter band is gone.

1:49

And with so much of widening, I don't expect the planter band to be, uh,

1:53

intact as well. So this is your Lis Frank, uh, type of injury pattern.

1:58

And it depends like, um, uh, they didn't give us history of trauma, but like,

2:01

um, if this is injury, then you call it Lis Frank.

2:04

But if you get a Lis Frank pattern with no history of trauma in an elderly who

2:08

is a longstanding diabetic, you have to think of sha arthropathy. So the,

2:13

the mal alignment and cha arthropathy, uh, one of the commonest, um, uh,

2:18

the patterns that can, that you can get in Jaqua Athropathy. But here, I think,

2:22

let's look at other findings. There were other fractures too.

2:24

So if you see there's a fracture of the medial Q uniform.

2:26

So though there's no history of trauma, uh,

2:29

I will presume that this is a case of injury.

2:31

Then there's a intraarticular fracture of the cuboid. And then, uh,

2:36

just incidental, I don't know if it's related to patients, um, this primary, um,

2:41

injury, but they have advanced osteoarthritis of the first metatarsal joint,

2:46

complete loss of articular surface. His, uh, there's fluid in the joint.

2:49

There's resorption of the articular margins,

2:51

a lot of remodeling osteophyte formation. So this is like advanced, uh,

2:56

with almost complete destruction of the articular surface.

3:00

And then there's some arthritis of the PHI joint as well.

3:03

Let's look at other images to see all the fractures. Sometimes the bones, um,

3:07

of the foot are, uh, for bones.

3:10

I mean your long axis and sagittals are pro probably the best sequences because

3:15

you can see a bigger portion and one image here you're just getting

3:20

small portions seen at one time.

3:23

So first M-T-P-O-A fracture of the medial Q uniform, we looked at that.

3:28

Let's move towards the, uh, lateral foot. You see that offset.

3:33

So again, another important thing with FRA injuries,

3:35

you get dorsal displacement of the metatarsals. And here we can in,

3:39

in addition to lateral, you also get lateral, uh, dorsal displacement.

3:43

So we can see that lateral displacement here completely. Uh, dislocated second,

3:48

um, joint metatarsal metatarsal joint.

3:51

There's probably injury to the ES here too that looks like a chronic injury with

3:55

no edema.

3:59

Now moving towards the third against some flat dorsal subluxation.

4:04

And then fourth and fifth, again, I don't see them aligned with the oid.

4:08

So they're also subluxed. So this would be, um, uh, uh,

4:12

this frank injury, um,

4:15

with complete disruption of the ligament. Um, this would be, so the,

4:19

the patterns,

4:21

this strength is per divided into a homo later or a divergent type of li

4:26

strength. So this would be a divergent where, um, the first is in place,

4:31

but the other lateral ones are displaced laterally.

4:33

Whereas hoola is where all the metatarsals are drift laterally,

4:38

including the first one. So this would be a divergent type of li Frank injury.

4:44

Okay, so that was all on imaging, a lot of soft tissue edema.

4:49

Couple important points about Li Frank injury is, um,

4:54

the lis frank joint,

4:55

which is between the medial QM and the base of the second where liran

5:00

ligament is. Uh,

5:02

it provides significant stability and maintains the transverse, uh,

5:06

arch of the foot. It forms a shallow arc between the medial base, um,

5:11

and the of the second metatarsal and the lateral margin of the distal medial

5:16

Q formm. This results in keystone wedging of the second.

5:19

So it's imagine that there's an arch.

5:21

And so the second metatarsal is the keystone of it. So any and the,

5:25

it's the li frank ligament that holds that second metatarsal in place.

5:29

So if there is, um,

5:30

a tear of the lis frank ligament or even sometimes fractures of the base of the

5:34

second metatarsal, that results in collapse of this transverse arch.

5:38

And that's the significance of these injuries.

5:40

If they can be very subtle on imaging and if not detected on time,

5:44

it'll lead to fluting of the arch. The patient will have early arthritis.

5:47

And this would be of even more, uh, impact. And,

5:51

and in athletes, like even in like, um, uh, end of normal individuals,

5:56

I mean,

5:57

if you have a li Frank injury which was not detected and treated appropriately,

6:00

you'll have very early onset what arthritis and the mobility will be quite

6:04

limited. So, um, the, as I said,

6:08

LIS Frank Ligament has, uh, three bands,

6:11

the dorsal band Theos and the Plantar Band, and it's the Interros band,

6:15

which is the strongest of all.

6:16

And that's the one that's very easily seen on Mr Imaging. So if you,

6:20

it's easy to identify.

6:21

And the planter lis Frank is the strongest of all planter ligaments. And, um,

6:26

the other thing is to know is the Lis Frank joint versus Liss Frank Joint

6:29

Complex. So this entire tarsal metatarsal all the joints from first to fifth

6:35

together form the Lis Frank Joint Complex. Okay?

6:39

And all these, um,

6:41

joints are held in place by several ligaments. Um,

6:46

this red one is your lis frank ligament,

6:47

but you have green ones are your inter metatarsal ligaments, and these are your,

6:53

the blue ones are inter tarsal ligaments,

6:55

and these are tarsal metatarsal ligaments.

6:58

So all these ligaments are multiple of them, small, small ligaments,

7:02

and they keep this joints in place and provide stability.

7:07

So when there is injury to this, this frank complex, uh,

7:13

you get mal-alignment that you pick up on x-rays.

7:16

So when you're looking at foot radiographs,

7:18

this is the AP and this is the oblique.

7:21

What you need to know or see is all these metatarsals are in perfect alignment

7:26

with their respective articulating bones.

7:28

So first metatarsal with medial second with intermediate,

7:32

third with lateral uniform.

7:35

And then after that here is an overlap on ap,

7:37

but these areas open up on the oblique view.

7:39

So you can look at the alignment of the third and fourth better on oblique view.

7:43

So they're perfectly in line with each other.

7:45

And anytime you see any subtle offset here, as even you call this frank injury.

7:50

So if the radiographs were not weight bearing,

7:51

we'll ask them to do weight bearing radiographs or, um,

7:55

and eventually these patients require ct if it's a case of high velocity trauma,

8:00

because often there will be, uh,

8:02

small fractures of these bones which are very hard to pick up on radiographs and

8:06

can be just on the planter side. And, uh, the CT is the best way to tell.

8:11

So here, uh, on the right left foot is normal with normal alignment,

8:15

and here you see little offset along the second tarsa metatarsal joint

8:20

with my lateral deviation of the second metatarsal.

8:22

So this would be a subtle strength and you don't want to miss this injury

8:25

because it can have, um, significant, uh, clinical consequences. So,

8:31

um, this is what we need to learn to pick up on radiographs and an MR imaging

8:35

obviously, um, all the other, uh, integrity of the, uh,

8:39

less front ligament and other associated injuries. So let's,

8:42

frank injuries can be high velocity seen clip classically with MVCs

8:48

fall from height. And as we talked about,

8:50

it can be ho or divergent and low velocity injuries which affect your midfoot

8:55

sprain, um, is seen in just with overuse. And uh,

8:58

that's the one that you can see in athletes.

9:00

But there you won't get like multiple fractures, dislocations,

9:05

you just get sprain and small ligamentous injury. Um, so Mr.

9:09

MR is really preferred to, to image the low velocity injuries to liran.

9:15

And then one just important, uh,

9:17

point is like sometimes the alignment is perfect,

9:20

but you see a small ossicle in that space.

9:22

So this is nothing but or inter metatars, it's an accessory ossicle.

9:26

Don't confuse this for a fracture and call this as a liran injury.

9:31

Okay?

9:31

A misdiagnosis has serious consequences and untreated midfoot sprain leads

9:36

rapidly to OA and flattening of the longitudinal large.

9:39

And if it's a complete injury, like complete ligament disruption, um,

9:43

treatment is often surgical or any high velocity injury treatment would be

9:47

surgical. Okay. With that, I think you're done with the fifth case. Any,

9:52

any questions? Last minute questions. Okay. I have one question here.

9:56

With no setting of trauma,

9:57

is it a hard to advise an MRI without proper history of injury,

10:02

which could even be subacute?

10:06

So I would say if it's trauma, um,

10:09

and if you see things on x-ray, that's, that's fine.

10:13

And like you will often need CT for pre-surgical planning. Like the,

10:17

the orthopedic surgeons really need to so see all those small frac fragments,

10:22

how much they're displaced to plan their fixation. But if it's,

10:26

there's no history of trauma and you see any mal-alignment,

10:31

uh, and if you really have to do like, I mean, uh, if it's charco,

10:34

they really don't need a whole lot of cross-section limiting until,

10:37

unless there's like a very specific indication like to rule out superimposed

10:40

infection or clinically the,

10:42

the signs and symptoms are not very straightforward.

10:44

But if you have to do imaging in those cases, then it would be mr.

10:48

But if it's trauma, um, if high velocity trauma,

10:51

we are talking about fractures we don't need, mr.

10:54

MR is needed in low velocity injuries where we are suspecting ligament li frank

10:58

ligament sprain and injuries, that's when we do mr. But no trauma,

11:04

no history of overuse. Um, we probably won't do an MR in those cases.

11:10

Okay, we are done.