Plyometrics and jumping exercises: Jumping and landing, single leg hop, drop jump. Recently, a fourth category to Myersons modified Hardcastle classification (type D injury) has been introduced, which corresponds to the partial injury of the Lisfranc joint [28]. Reinhardt KR, Oh LS, Schottel P, Roberts MM, Levine D. Mulier T, Reynders P, Sioen W, Van Den Bergh J, De Reymaeker G, Reynaert P, Broos P. Sheibani-Rad S, Coetzee JC, Giveans MR, DiGiovanni C. I give my consent to Physiopedia to be in touch with me via email using the information I have provided in this form for the purpose of news, updates and marketing. Haapamaki VV, Kiuru MJ, Koskinen SK. This study compared six articles to 193 patients. All authors agree that the severity of the injury, a quick diagnosis and anatomical reduction are the main determinants of the biomechanical and functional long-term outcomes. The classification evolution of Lisfranc complex injuries is summarized in the flow-chart in Figure 2. Stress testing is painful and is typically done intraoperatively. Radiologic outcomes after Lisfranc fracture dislocation. AJR Am J Roentgenol. Ponkilainen VT, Partio N, Salonen EE, Laine HJ, Maenpaa HM, Mattila VM, Haapasalo HH. AJR Am J Roentgenol. Tenderness along the metatarsal joints supports the diagnosis of midfoot sprain with potential for segmental instability. The degree of malalignment is somewhat subtle but can be typical for these injuries. 3. These can be divided into joint saving or joint sacrificing. These may be combined with soft-tissue injury and present as open fractures. A prospective, randomized study. . Pain can localize to the medial or lateral aspect of the foot at the tarsometatarsal region on direct palpation, or it can be produced by abduction and pronation of the forefoot while the hindfoot is held fixed.[3]. No other bony abnormality. Avulsion of the Lisfranc ligament represented by the fleck sign, a small bone fragment in the first intermetatarsal space; 4. I'm almost 3 weeks post surgery - 4 fractures which required 2 plates , a screw and 2 wires to be put in . To identify the affected TMT joint is useful the piano key test, consisting in moving the head of the affected metatarsal holding the midfoot and hindfoot firmly [13]. Interventions include: oedema reduction, strengthening to address post immobilisation atrophy, flexibility exercises, Gait, and manufacturing of foot orthoses to help support the tarsometatarsal articulations. The intraoperative stress test can uncover instability that may not be apparent in a static x-ray. Received 2021 Dec 31; Accepted 2022 Apr 22. ADVERTISEMENT: Supporters see fewer/no ads. In most cases Physiopedia articles are a secondary source and so should not be used as references. 20 (3): 819-36. [2], The Lisfranc ligament is a large band of plantar collagenous tissue that spans the articulation of the medial cuneiform and the second metatarsal base. High-energy injuries are more common than low-energy injuries which in most cases involve sports activities, usually occurring during football, gymnastic and running [4]. Internal fixation is the most common treatment. [19], A systematic review compared primary partial arthrodesis to ORIF and this study shows that the AOFAS-score of ORIF patients was 72.5/100. CT scan is useful to detect nondisplaced fractures and minimal bone sub-dislocation. Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). An anatomical and radiological case control study. However, also after open reduction and internal fixation (ORIF), about 40 to 94% of patients will suffer post-traumatic OA, demanding conversion to a joint fusion to solve the pain, to such an extent that some authors recommend primary arthrodesis (PA) in some cases to avoid the need for re-surgery [36]. Although of questionable accuracy, bilateral weightbearing radiographs are considered the current gold standard to assess these injuries. Ankle and foot strengthening exercises: These exercises are the same exercises as the range of motion exercises, but with a resistance band. In case of open Lisfranc injuries or severe soft tissue compromise and major metatarsal diastasis, temporary stabilization with multiple Kirschner wires (K-wire) or external fixator (EF) should be considered especially in case of comminution and soft-tissue loss. MRI may be indicated for the identification of pure ligamentous injuries. Incidence, classification and treatment. Englanoff G et al. (2004) ISBN:0781750067. Lisfranc complex injuries are a spectrum of midfoot and tarsometatarsal (TMT) joint trauma, more frequent in men and in the third decade of life. Associated fractures most often occur at the base of the second metatarsal, seen as the fleck sign. 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 ). No other bony abnormality. In this report 3 patients were treated with this relatively fast and minimally invasive technique, achieving satisfactory short-term results. An indirect trauma is caused when a twisting of the foot happens after it gets caught on something. Boston, In stable lesions and in those without dislocation, conservative treatment with immobilization and no weight-bearing is indicated for a period of 6 weeks. Clinical concern for subtle or occult Lisfranc instability in any patient should trigger weightbearing imaging like WB radiographic assessment because this injury can be missed on NWB images Early recognition of Lisfranc instability is critical for optimizing clinical outcomes, given that surgical delays lead to poorer prognoses. A Lisfranc injury, also known as Lisfranc fracture, . The https:// ensures that you are connecting to the Magn Reson Imaging Clin N Am. Weight-bearing x-rays should be obtained if tolerated, to assess the extent of displacement, angulation and shortening on each view. Lisfranc complex injuries are a spectrum of injuries of the TMT joints, ranging from purely ligamentous sprains, usually occurring in athletes, to fracture dislocations, commonly a consequence of high-energy trauma. ADVERTISEMENT: Supporters see fewer/no ads. Greco T, Cianni L, De Mauro D, Dughiero G, Bocchi MB, Cazzato G, Ragonesi G, Liuzza F, Maccauro G, Perisano C. Foot metastasis: current knowledge. First of all, theyll need a walker. When Lisfranc joint complex injury is suspected, palpation of the foot should begin distally and continue proximally to each tarsometatarsal articulation. In that setting, they generally require a cast or splint and no weight bearing for several weeks to months. 6. [20] observed that MRI had a sensitivity of 90% for evaluating the stability of the Lisfranc joint compared to intraoperative results [21]. Crim J. MR imaging evaluation of subtle Lisfranc injuries: the midfoot sprain. Balance exercises: On 1 leg, with your eyes closed, standing on a foam pillow, standing on a wobble board. As previously mentioned, fractures at the base of the second metatarsal should raise suspicion for Lisfranc injury. severe vascular disease, peripheral neuropathy) or pre-existing inflammatory arthritis 12. On standard X-ray the signs consistent with a diagnosis of Lisfranc injuries are: 1. From the case rID: 10948), Metatarsal Diastasis (https://sportsinjuryupdatedotcom.files.wordpress.com), Your email address will not be published. {"url":"/signup-modal-props.json?lang=us"}, Gaillard F, Lustosa L, Murphy A, et al. [8] Athletes may have pain with running on the toes and with push-off phase of running. [26], in 1982, divided the injuries in three types: type A (with complete displacement of all the metatarsal bones), B (with displacement of one or more of the metatarsal bones), and C (divergent pattern). Then they start with more difficult exercises (cycling, rowing, stepping). Lisfranc injury. Eleftheriou KI, Rosenfeld PF, Calder JD. Indirect injuries result from an axial load to a plantarflexed foot, forced abduction of the forefoot, or both. Vascular lesions are rare, in relation to which compartment syndromes or lesions of the deep peroneal nerve can occur [15]. Radiologic history exhibit. Moracia-Ochagavia I, Rodriguez-Merchan EC. An injury can be caused by an indirect or direct trauma. The term Lisfranc injuries refers to a range of midfoot and tarsometatarsal (TMT) joint lesion that can vary from a simple single joint injury to a complex lesion that disrupts multiple different joints with multiple fractures [1], depending on the severity of the trauma. That is usually the journal article where the information was first stated. Unable to process the form. 2nd edition. If stable, injuries can be treated conservatively in a non-weight bearing cast for 6 weeks . MRI of injuries to the first interosseous cuneometatarsal (Lisfranc) ligament. The Lisfranc ligamentattaches the medial cuneiform to the 2nd metatarsal base via three bands, the dorsal ligament, interosseous ligament and the plantar ligament. A recent systematic review has shown how with the use of CT, compared to X-ray, it is possible to detect 60% more metatarsal fractures and twice the tarsal fractures and joint misalignments [18]. MR imaging of the tarsometatarsal joint: analysis of injuries in 11 patients. Old healed fracture of the left 5th metatarsal. Weight-bearing x-rays are an alternative to MRI to assess the integrity of the Lisfranc joint. Core EM is dedicated to bringing Emergency Providers all things core content Emergency Medicine. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. [16], therefore about 20% of lesions remain undiagnosed. In a prospective randomized study analyzing 101 patients with purely ligamentous injuries, 92% of the patients treated with PA achieved previous level of activity in the postoperative period. Three-dimensional (3-D) CT imaging provides a complete assessment of the lesion and associated with multiplanar reconstructions provides anatomical details, including neurovascular ones, that increase optimal surgical pre-operative planning [19]. Shapiro MS, Wascher DC, Finerman GA. Rupture of Lisfrancs ligament in athletes. and transmitted securely. Benirschke SK, Meinberg E, Anderson SA, Jones CB, Cole PA. Fractures and dislocations of the midfoot: lisfranc and Chopart injuries. An indirect mechanism is more common than a direct one. Screws, plates and screws or even pins . Sripanich Y, Weinberg M, Krhenbhl N et al. Philpott A, Lawford C, Lau SC, Chambers S, Bozin M, Oppy A. 9. X-rays are taken while the foot is under stress (eg, the patient is standing on the foot). Tafur M, Rosenberg ZS, Bencardino JT. This helps to identify the injured ligaments. 5. Loss of in-line arrangement of the medial margin of the second metatarsal base with the medial edge of the middle cuneiform in the weight-bearing anteroposterior view. Injuries to the joint are often missed due to anatomical complexity and rarity. 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. [18], Another study tells us that primary arthrodesis does not have any benefits regarding severe fracture-dislocations. The projection is utilized to assess the joint under stress and better demonstrate structural and functional deformities. Emergency Department Evaluation and Management of Foot and Ankle Pain. Comparison with contralateral foot can be important and help in the diagnosis; obviously except for cases with bilateral lesions, found in precipitated patients. Direct or indirect forces may cause Lisfranc injuries. Watch out, never cross the pain threshold during the exercises. In a study on 217 patients with 12 months follow up the authors concluded that, excluding surgery for implant removal, patients treated with ORIF or PA didnt have a different reoperation rate [47]. Gustilo RB, Anderson JT. If at six weeks the pain persists, an orthopedic boot with weight-bearing is used for four more weeks and is undertaken a course of physical therapy including taping, modalities (ice, ultrasound, and iontophoresis), and sports-specific exercises [33]. 2010;34(8):1083-91. The gap sign indicative of separation between first and second fingers is a suggestive sign of lesion of the Lisfranc [14]. Woodward S, Jacobson JA, Femino JE et-al. Check for errors and try again. This could be due to the small study population, and should be clarified through future research, given that abnormalities in these measurements can be associated with Lisfranc instabilityespecially as injuries become more severe. Diastasis >2 mm between the base M1 and M2 or a greater than 1 mm difference than that of the contralateral uninjured foot (AP view); 5. TAS have been questioned because of joint damage (from 2% to 6% depending on the cases) [44]. And how can we improve? Unable to process the form. Beware of a patient who was told in the Emergency Room that they had a "sprained foot". Through this incision it is achieved access to all the individual TMT joints. Currently, there arent in literature randomized controlled trials that compare nonoperative and surgical treatment for Lisfranc injuries. On x-ray, dislocation of the tarsometatarsal joint is indicated by: The Lisfranc injury can also be physical examined. The third part is the hindfoot consisting of the talus (lower ankle) and the calcaneus (heel). Lisfranc injuries: an update. [39] in a group of 10 patients (11 feet) with midfoot open injuries treated with uniplanar EF, maintained for a mean duration of 9 weeks (range 6-15 weeks), experienced a high rate of complications including residual pain and foot and ankle function, ability to stand on tiptoe, presence of a limp, deformity of plantar arch, range of motion of the ankle, subtalar and metatarsophalangeal joints. Lisfranc Injuries - Everything You Need To Know - Dr. Nabil Ebraheim. Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Arthrodesis versus ORIF for Lisfranc fractures. Lisfranc injuries, also called Lisfranc fracture-dislocations, are the most common type of dislocation involving the foot and correspond to the dislocation of the articulation of the tarsus with the metatarsal bases. CT evaluation of tarsometatarsal fracture-dislocation injuries. [34] reported successful conservative treatment for stable injuries even in 9 athletes, showing a return to competition in an average time of 4 months. Motor vehicle and industrial accidents constitute the majority of Lisfranc injuries. However, based on our clinical experience and above all on the available literature, conservative treatment is indicated only for stable and non-displaced injuries with pure ligament sprains (stage I according to Nunley and Vertullo) [29]. Hi everyone - just wanting to ask when you were allowed to weight bear ? The diagnostic accuracy of radiographs in Lisfranc injury and the potential value of a craniocaudal projection. The Lisfranc joint complex is a tarso-metatarsal articulation named for Jacques Lisfranc (1790-1847), one of Napoleons battlefield surgeons. An injury at the Lisfranc joint is mostly the result of the combined external rotation and compression force. Check for errors and try again. Does open reduction and internal fixation versus primary arthrodesis improve patient outcomes for Lisfranc trauma? Cianni L, Bocchi MB, Vitiello R, Greco T, De Marco D, Masci G, Maccauro G, Pitocco D, Perisano C. Arthrodesis in the Charcot foot: a systematic review. Old healed fracture of the left 5th metatarsal. American Academy of Orthopaedic Surgeon. Hardcastle PH, Reschauer R, Kutscha-Lissberg E, Schoffmann W. Injuries to the tarsometatarsal joint. primary partial arthrodesis is a beneficial therapy for a Lisfranc injury. Otherwise normal bony alignment. Weight-bearing x-rays are an alternative to MRI to assess the integrity of the Lisfranc joint. van den Boom NAC, Stollenwerck G, Lodewijks L, Bransen J, Evers S, Poeze M. Lisfranc injuries: fix or fuse? Lateral displacement of 2nd metatarsal on middle cuneiform, 3. official website and that any information you provide is encrypted Orthopedics About. Ponkilainen VT, Mattila VM, Laine HJ, Paakkala A, Maenpaa HM, Haapasalo HH. Reference article, Radiopaedia.org (Accessed on 02 Jun 2023) https://doi.org/10.53347/rID-1590, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":1590,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/lisfranc-injury/questions/1576?lang=us"}, Figure 4: Nunley-Vertullo classification of Lisfranc injuries (illustrations), Figure 6: Myerson classification - illustrations, Figure 7: Nunley-Vertullo classification - illustrations, Case 5: traumatic homolateral LisFranc fracture dislocation, View Frank Gaillard's current disclosures, View Leonardo Lustosa's current disclosures, see full revision history and disclosures, Gustilo Anderson classification (compound fracture), Anderson and Montesano classification of occipital condyle fractures, Traynelis classification of atlanto-occipital dissociation, longitudinal versus transverse petrous temporal bone fracture, naso-orbitoethmoid (NOE) complex fracture, cervical spine fracture classification systems, AO classification of upper cervical injuries, subaxial cervical spine injury classification (SLIC), thoracolumbar spinal fracture classification systems, AO classification of thoracolumbar injuries, thoracolumbar injury classification and severity score (TLICS), Rockwood classification (acromioclavicular joint injury), Neer classification (proximal humeral fracture), AO classification (proximal humeral fracture), AO/OTA classification of distal humeral fractures, Milch classification (lateral humeral condyle fracture), Weiss classification (lateral humeral condyle fracture), Bado classification of Monteggia fracture-dislocations (radius-ulna), Mason classification (radial head fracture), Frykman classification (distal radial fracture), Hintermann classification (gamekeeper's thumb), Eaton classification (volar plate avulsion injury), Keifhaber-Stern classification (volar plate avulsion injury), Judet and Letournel classification (acetabular fracture), Harris classification (acetebular fracture), Young and Burgess classification of pelvic ring fractures, Pipkin classification (femoral head fracture), American Academy of Orthopedic Surgeons classification (periprosthetic hip fracture), Cooke and Newman classification (periprosthetic hip fracture), Johansson classification (periprosthetic hip fracture), Vancouver classification (periprosthetic hip fracture), Winquist classification (femoral shaft fracture), Schatzker classification (tibial plateau fracture), AO classification of distal femur fractures, Lauge-Hansen classification (ankle injury), Danis-Weber classification (ankle fracture), Berndt and Harty classification (osteochondral lesions of the talus), Sanders CT classification (calcaneal fracture), Hawkins classification (talar neck fracture), anterior superior iliac spine (ASIS) avulsion, anterior cruciate ligament avulsion fracture, posterior cruciate ligament avulsion fracture, avulsion fracture of the proximal 5th metatarsal, direct crush injury or an indirect load onto a plantarflexed foot, forefoot abduction-type injuries where the hindfoot is fixed and there is rotation around the joint such as changing direction with a foot planted firmly i.e. Emergency Medicine Clinics of North America May 2015: 33 (2); 371-372. The most common causes of re-surgeries are post-traumatic OA in patients treated with ORIF and non-union in those treated with PA. It is named after Jacques Lisfranc De Saint Martin (1790-1847), the chief of surgery at the Hpital de la Pitie in Paris 2. Kirzner N, Zotov P, Goldbloom D, Curry H, Bedi H. Dorsal bridge plating or transarticular screws for Lisfranc fracture dislocations: a retrospective study comparing functional and radiological outcomes. Injuries can be caused by either direct or indirect trauma. Philpott et al. Accessibility The Lisfranc jointarticulates the tarsus with the metatarsal bases, whereby the first three metatarsals articulate respectively with the three cuneiforms, and the 4thand 5th metatarsals with the cuboid. Lisfranc injuries,also called Lisfranc fracture-dislocations, are the most common type of dislocation involving the footand correspond to the dislocation of the articulation of the tarsus with the metatarsal bases. Now automobile accidents, falls and sport injuries can also lead to an injury on the Lisfranc joint. Old healed fracture of the left 5th metatarsal. Bone stability is determined by the trapezoidal shape of the base of the M1-M2-M3, with their respective cuneiform bones forming a stable arch known as a transverse arch or Roman arch with the second TMT joint as the keystone [7,8]. Computed tomography should be reserved for questionable cases such as the severely injured foot where adequate positioning cannot be obtained or cases where the multiplicity of fractures and dislocations makes complete evaluation difficult. Injury mechanisms are varied and include: Tarsometatarsal dislocation may also occur in the diabetic neuropathic joint (Charcot). When refering to evidence in academic writing, you should always try to reference the primary (original) source. Conclusion: Primary partial arthrodesis produces well clinical and patient based outcomes. What is a Lisfranc injury? The initial radiographs of a suspected Lisfranc joint injury should include weight-bearing anteroposterior and lateral views, as well as a 30-degree oblique view. Quenu E, Kuss G. Etude sur les luxations du metatarse (luxations mtatarso-tarsiennes) du diastasis entre le 1er et le 2e mtatarsien. The Lisfranc joint complex is made up by the three cuneiform bones (C1 to C3) and the cuboid bone (Cu) proximally and the five metatarsal (M1 to M5) bases distally linked together by a ligamentous capsule structure [6]. Lippincott Williams & Wilkins. The Lisfranc joints are tarsometaral articulations. Following ORIF, the foot is usually immobilized for 8-12 weeks.[9]. As a library, NLM provides access to scientific literature. Typical features of an avulsion fracture at the main insertion of the Lisfranc ligament. Radiographics. These results demonstrated that crush injuries with severe trauma and soft tissue injury of the midfoot often result in persistent morbidity despite even early management with external fixation. Long-term outcome of high-energy open Lisfranc injuries: a retrospective study. The researchers identified 26 patients in the Mass General Brigham patient data registry who presented with a Lisfranc injury between July 1991 and October 2018. The Lisfranc ligament connects directly between the medial cuneiform and the second metatarsal (photo above). 55 Fruit Street Federal government websites often end in .gov or .mil. Computed tomography should also be used when adequate reduction cannot be achieved to determine the presence of bony fragments or entrapped soft tissues that may be hindering reduction. Injuries to the tarsometatarsal joint. Indications for non-operative treatment include undisplaced injuries that are stable with weight-bearing or poor surgical candidates such as non-ambulatory patients, patients with significant comorbidities that have high risk for complications (e.g. In cases treated with ORIF only 65% achieved pre-injury activity levels in the post-operative period [48]. CT is particularly useful to detect nondisplaced fractures or minimal bone sub-dislocations. In particular, in the senior author's experience, C1-M2 and C1-C2 significant diastasis are often found to require surgical stabilization once directly visualized in the operating room. Subtle lisfranc subluxation: results of operative and nonoperative treatment. Typically occurs when an axial load is applied to a plantar-flexed foot. Treatment may be non-operative or operative, with the aim being to have a painless, plantigrade and stable foot 12. Coetzee JC. Lisfranc injury: How frequently does it get missed? It can be disrupted in a severe dislocation. Indications This projection is utilized to assess the structural integrity of the ankle joint. Skeletal Radiol. [1] In accordance with the recent literature the current trend is non-surgical treatment for undisplaced injuries, whilst all injuries that show load instability or diastasis of the TMT joints required surgical treatment with anatomical reduction and internal fixation. More severe injuries may be treated with open reduction and internal fixation (ORIF). inability to bear weight), Obtaining CT in ED will depend on department resources and orthopedic referral availability, Strict non-weight bearing (NWB) on crutches, Orthopedic or podiatry follow-up within one week for possible surgical reduction and fixation, When initially misdiagnosed/untreated, Lisfranc injuries carry a poor prognosis, often resulting in deformity, functional deficit, and chronic pain, When diagnosed appropriately, patients who undergo open reduction and internal fixation of fractures have superior outcomes to those with purely ligamentous injury (, Patients with no fracture on CT and no displacement on weight-bearing films generally are managed non-operatively, A Lisfranc injury must be part of the differential for any midfoot trauma because of the significant morbidity associated with missed diagnosis, Physical exam findings, including deformity, swelling and ecchymosis, may be subtle or absent, Normal foot x-rays do not rule out a Lisfranc injury, weight-bearing views or CT are essential. Old healed fracture of the left 5th metatarsal. Rankine JJ, Nicholas CM, Wells G, Barron DA. Useful for assessing the ligamentous injury. It occurs when traumatic injury causes swelling and bleeding to raise the pressure within the tissues of the body. Avalaible from: Moracia-Ochagava I, Rodrguez-Merchn EC. The degree of malalignment is somewhat subtle but can be typical for these injuries. [6], Like in most cases of injury, an injury to the Lisfranc joint can have some complications. Current concepts review: Lisfranc injuries. The injury can be potentially career ending.[12]. The name is attributed to a French surgeon of the Napoleonic era, which in 1825 was the first to describe injuries and amputations at this level of the foot [1]. Alberta FG, Aronow MS, Barrero M, Diaz-Doran V, Sullivan RJ, Adams DJ. This explains why the dislocation is often dorsal; ii. Nunley JA, Vertullo CJ. High-energy injuries also require careful soft tissue examination (to select appropriate treatment, timing for surgery and minimize postoperative skin and wound complications), and if the evidence leads to a high suspicion of compartment syndrome a surgical fasciotomy is required [4,37]. In the presence of non-diagnostic X-ray and CT scans, if clinical suspicion persists, magnetic resonance imaging (MRI) is appropriate. HHS Vulnerability Disclosure, Help Objectives: To systematically review current diagnostic imaging options for assessment of the Lisfranc joint. To describe the Lisfranc complex injuries have been proposed numerous classification. Subsequent conversion should be scheduled 10-15 days later, once soft tissues are back in good condition [38], and the wrinkles sign can be helpful [39]. Pathology Anatomy There is a high incidence amongst football players. Ann Emerg Med 1995: 26 (2); 229-233. Gallagher SM, Rodriguez NA, Andersen CR, Granberry WM, Panchbhavi VK. Prediction of midfoot instability in the subtle Lisfranc injury. Another option is to take the x-rays while applying a force to the forefoot in an attempt to recreate the mechanism of injury. Sometimes there is a x-ray needed of the uninjured foot to see if there is an injury or not. Ligamentous structure of the Lisfranc joint can be divided schematically in: i. dorsal ligament and plantar ligament: the first the smallest and the weakest crossing each TMT joint, while the second is twice as large as the first. The tarsal-metatarsal joint of the second metatarsal lies oblique to the x-ray beam on the anteroposterior radiograph, and we have shown that a craniocaudal angulation of 28.9 would optimally reveal the joint in a population of patients being investigated for midfoot injury. Crates JM, Barber FA, Sanders EJ. government site. However, conventional radiography is a 2D technique that can neither display nor measure the true dimensions of a detailed 3D object, such as the tarsal bones in the foot.
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