II. Epidemiology
- Accounts for 0.1 to 0.4% of all Fracture dislocations
III. Pathophysiology
- Lisfranc Joint: Tarsometatarsal articulation of foot (between midfoot and forefoot)
- First three Metatarsal articulate with the Cuneiform Bone
- Fourth and Fifth Metatarsals articulate with the Cuboid Bone
- Lisfranc ligament
- Attaches second Metatarsal base to medial Cuneiform (plantar surface stronger, dorsum weaker)
- Key to midfoot stability (susceptible to Trauma)
- Keystone wedging of base of second Metatarsal
- Articulates with Second Cuneiform
- Straddled by first and Third Cuneiform
- Lisfranc joint transfers force from mid to forefoot
- Critical to plantar flexion and dorsiflexion
- Lisfranc is also central to foot arch
- Helps stabilize foot in standing and gait
IV. Precautions
- Lisfranc joint injury may be subtle and is missed or misdiagnosed in 20% of cases
V. Mechanism
- Foot in plantar flexion, undergoes rotation or compression, then axial loading
- Displaces second Metatarsal dorsally
- Types of injuries
- High Energy Direct Injury
- Motor Vehicle Accident
- Heavy equipment related crush injury
- Low Energy Indirect Injury
- Sports (e.g. football, dance)
- Missed step on staircase, and falls forward onto plantar-flexed foot
- High Energy Direct Injury
VI. Causes
- Lateral Ankle Sprain
- High energy injury
- Motor Vehicle Accident
- Fall from high height
VII. Symptoms: Persist >5 days after injury
- Midfoot swelling
- Difficult weight bearing
VIII. Signs
- Ecchymosis at plantar surface of midfoot
- Tenderness at tarsometatarsal joint
- Difficult weight bearing while on tiptoes
IX. Types
- Homolateral Lisfranc Dislocation
- Lateral Metatarsal displacement
- Divergent Lisfranc Dislocation
- Medial Metatarsal displacement of first Metatarsal Bone
- Lateral Metatarsal displacement of other Metatarsal Bones
- Isolated Lisfranc Dislocation
- Dorsal dislocation of 1 or 2 Metatarsal Bones
X. Imaging: XRay foot
- Consider Foot CT or Foot MRI if XRay not diagnostic
- Efficacy
- Initial False Negative Rate approaches 50%
- Weight bearing images are critical for accurate diagnosis
- Views
- Lateral weight bearing foot XRay
- Anteroposterior weight bearing foot XRay
- Oblique view of foot (30 degrees)
- Anteroposterior foot xray
- Widening of space (diastasis) between first and second Metatarsal heads
- Wide if >=2.7 mm
- Widening of space (diastasis) >2 mm between second Metatarsal base and medial Cuneiform
- Malalignment or step-off at medial borders of second/middle Cuneiform and second Metatarsal
- Draw a line along the second Metatarsal medial shaft and base AND the medial middle Cuneiform
- Draw a line along the fourth Metatarsal medial shaft and base AND the medial Cuboid
- Avulsed Metatarsal base of Cuneiform Bone fragments (fleck sign)
- Proximal second metarsal is most common associated Fracture
- Widening of space (diastasis) between first and second Metatarsal heads
- Oblique XRay View
- Lateral borders of third Metatarsal and lateral Cuneiform malalignment
- Medial borders of fourth Metatarsal and Cuboid malalignment
- Lateral foot xray: Step-off on dorsal foot surface
- Loss of arch height (Stage III injury)
- Proximal first or second Metatarsal displaced dorsally or upward
- Middle Cuneiform top below Metatarsal top
- Avulsion Fractures suggestive of Lisfranc Injury
XI. Management: Conservative Management
- Orthopedic or podiatry Consultation is recommended for all suspected Lisfranc injuries
- Unstable injuries should receive emergent Consultation for surgical intervention
- Stable Fractures or dislocations may be splinted and followed up in orthopedics in 1-2 weeks
- Reduce significant acute, closed dorsal dislocations in the emergency department
- Splint patients if any suspicion of Lisfranc Injury
- Short-leg walking cast (or CAM walker) for 4-6 weeks
- Non-weight bearing if XRay widening between first and second metarsals (standing xray)
- Bobby Jones splint with crutch walking only
- Rehabilitation after cast removal
- Expect 6-12 months before resuming full activity after a significant lisfranc joint injury
- Reassess 2 weeks after starting rehabilitation
- Repeat weight bearing XRays to assess for instability
XII. Management: Surgery
- Indications (controversial)
- Displacement greater than 2 mm
- Unstable Fracture dislocations with instability
- Timing
- Best performed within first 24 hours of injury
- Some prefer to wait 7-10 days for less swelling
XIII. Complications
- Compartment Syndrome (due to associated soft tissue swelling)
- Post-Traumatic arthrosis
XIV. Prognosis
- High risk of morbidity with Disability related to ambulation
XV. References
- Young (2022) Crit Dec Emerg Med 36(8): 16-7
- Gaskin and Denq (2020) Crit Dec Emerg Med 34(4): 16-7
- Feden and Kiel (2017) Crit Dec Emerg Med 31(11): 3-10
- Burroughs (1998) Am Fam Physician 58(1): 118-24 [PubMed]
- Grewel (2020) Foot 45:101719 [PubMed]