II. Pathophysiology

  1. Lisfranc Joint: Tarsometatarsal articulation of foot
    1. First and second Metatarsal bases
    2. First and Second Cuneiforms
  2. Lisfranc ligament
    1. Attaches second Metatarsal base to medial Cuneiform (plantar surface stronger, dorsum weaker)
    2. Key to midfoot stability (susceptible to Trauma)
  3. Keystone wedging of base of second Metatarsal
    1. Articulates with Second Cuneiform
    2. Straddled by first and Third Cuneiform
  4. Lisfranc joint transfers force from mid to forefoot
    1. Critical to plantar and dorsiflexion

III. Mechanism

  1. Rotational force to forefoot OR plantar hyperflexion with axial loading
  2. Displaces second Metatarsal dorsally

IV. Causes

  1. Lateral Ankle Sprain
  2. High energy injury
    1. Motor vehicle accident
    2. Fall from high height

V. Symptoms: Persist >5 days after injury

  1. Midfoot swelling
  2. Difficult weight bearing

VI. Signs

  1. Ecchymosis at plantar surface of midfoot
  2. Tenderness at tarsometatarsal joint
  3. Difficult weight bearing while on tiptoes

VII. Imaging: XRay foot

  1. Consider Foot CT or Foot MRI if XRay not diagnostic
    1. Foot CT or Foot MRI is commonly needed for diagnosis (but start with xray)
  2. Efficacy: Initial False Negative Rate approaches 50%
    1. Weight bearing images are critical for accurate diagnosis
  3. Views
    1. Lateral weight bearing foot XRay
    2. Anteroposterior weight bearing foot XRay
    3. Oblique view of foot (30 degrees)
  4. Anteroposterior foot xray
    1. Widening of space (diastasis) between first and second Metatarsal heads
    2. Widening of space (diastasis) >2 mm between second Metatarsal base and medial Cuneiform
    3. Malalignment or step-off at medial borders of second/middle Cuneiform and second Metatarsal
    4. Avulsed bone fragments (fleck sign)
    5. Proximal second metarsal is most common associated Fracture
  5. Oblique XRay View
    1. Lateral borders of third Metatarsal and lateral Cuneiform malalignment
    2. Medial borders of fourth Metatarsal and Cuboid malalignment
  6. Lateral foot xray: Step-off on dorsal foot surface
    1. Loss of arch height (Stage III injury)
    2. Proximal second Metatarsal displaced upward
    3. Middle Cuneiform top below Metatarsal top
  7. Avulsion Fractures suggestive of Lisfranc Injury
    1. CuneiformFracture
    2. Metatarsal base Fracture

VIII. Management: Conservative Management

  1. Orthopedic or podiatry Consultation is recommended for all suspected Lisfranc injuries
  2. Splint patients if any suspicion of Lisfranc Injury
  3. Short-leg walking cast (or CAM walker) for 4-6 weeks
    1. Non-weight bearing if XRay widening between first and second metarsals (standing xray)
    2. Bobby Jones splint with crutch walking only
  4. Rehabilitation after cast removal
  5. Reassess 2 weeks after starting rehabilitation
    1. Repeat weight bearing XRays to assess for instability

IX. Management: Surgery

  1. Indications (controversial)
    1. Displacement greater than 2 mm
  2. Timing
    1. Best performed within first 24 hours of injury
    2. Some prefer to wait 7-10 days for less swelling

X. Complications

  1. Post-Traumatic arthrosis

XI. Prognosis

  1. High risk of morbidity

XII. References

  1. Feden and Kiel (2017) Crit Dec Emerg Med 31(11): 3-10
  2. Burroughs (1998) Am Fam Physician 58(1): 118-24 [PubMed]

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Related Studies (from Trip Database) Open in New Window

Ontology: Closed fracture dislocation, tarsometatarsal joint (C0434943)

Concepts Injury or Poisoning (T037)
SnomedCT 209357009
English Cls frac disl, tarsometatars j, Closed Lisfranc fracture dislocation, fracture dislocation of foot joint closed tarsometatarsal (diagnosis), fracture dislocation of foot joint closed tarsometatarsal, closed fracture dislocation of tarsometatarsal joint, Closed fracture dislocation, tarsometatarsal joint, Closed fracture dislocation, tarsometatarsal joint (disorder)
Spanish fractura-luxación no expuesta de la articulación tarsometatarsiana (trastorno), fractura-luxación no expuesta de articulación tarsometatarsiana, fractura-luxación no expuesta de articulación tarsometatarsiana (trastorno), fractura-luxación no expuesta de la articulación tarsometatarsiana, fractura-luxación no expuesta de Lisfranc