II. Epidemiology

  1. Accounts for 0.1 to 0.4% of all Fracture dislocations

III. Pathophysiology

  1. Lisfranc Joint: Tarsometatarsal articulation of foot (between midfoot and forefoot)
    1. First three Metatarsal articulate with the Cuneiform Bone
    2. Fourth and Fifth Metatarsals articulate with the Cuboid Bone
  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 flexion and dorsiflexion
    2. Lisfranc is also central to foot arch
    3. Helps stabilize foot in standing and gait

IV. Precautions

  1. Lisfranc joint injury may be subtle and is missed or misdiagnosed in 20% of cases

V. Mechanism

  1. Foot in plantar flexion, undergoes rotation or compression, then axial loading
  2. Displaces second Metatarsal dorsally
  3. Types of injuries
    1. High Energy Direct Injury
      1. Motor Vehicle Accident
      2. Heavy equipment related crush injury
    2. Low Energy Indirect Injury
      1. Sports (e.g. football, dance)
      2. Missed step on staircase or curb, and falls forward onto plantar-flexed foot

VI. Causes

  1. Lateral Ankle Sprain
  2. High energy injury
    1. Motor Vehicle Accident
    2. Fall from high height

VII. Symptoms: Persist >5 days after injury

  1. Midfoot swelling
  2. Difficult weight bearing

VIII. Signs

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

IX. Types

  1. Homolateral Lisfranc Dislocation
    1. Lateral Metatarsal displacement
  2. Divergent Lisfranc Dislocation
    1. Medial Metatarsal displacement of first Metatarsal Bone
    2. Lateral Metatarsal displacement of other Metatarsal Bones
  3. Isolated Lisfranc Dislocation
    1. Dorsal dislocation of 1 or 2 Metatarsal Bones

X. Imaging: XRay Foot

  1. Consider Foot CT or Foot MRI if XRay not diagnostic
    1. Foot MRI is preferred
    2. Foot CT identifies 60% more Metatarsal Fractures and twice as many Tarsal Fractures as XRay
    3. Foot CT or Foot MRI is commonly needed for diagnosis (but start with xray)
    4. Also consider Foot CT if the patient cannot bear weight for a Lateral XRay
  2. Efficacy
    1. Initial False Negative Rate approaches 50%
    2. Weight bearing images are critical for accurate diagnosis
  3. Views (consider comparison views with opposite foot)
    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
      1. Wide if >=2.7 mm
    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
      1. Draw a line along the second Metatarsal medial shaft and base AND the medial middle Cuneiform
      2. Draw a line along the fourth Metatarsal medial shaft and base AND the medial Cuboid
    4. Avulsed Metatarsal base of Cuneiform 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 malaligned
    2. Medial borders of fourth Metatarsal and Cuboid malaligned
  6. Lateral foot xray (weight bearing): Step-off on dorsal foot surface
    1. Loss of arch height (Stage III injury)
    2. Proximal first or second Metatarsal displaced dorsally or upward
    3. Middle Cuneiform top below Metatarsal top
    4. Cuboid not aligned with Metatarsals
  7. Avulsion Fractures suggestive of Lisfranc Injury
    1. Cuneiform Fracture
    2. Metatarsal base Fracture

XI. Management: Conservative Management

  1. Orthopedic or podiatry Consultation is recommended for all suspected Lisfranc injuries
    1. Unstable injuries should receive emergent Consultation for surgical intervention
    2. Stable Fractures or dislocations may be splinted and followed up in orthopedics in 1-2 weeks
    3. Other referral indications (see surgery indications below)
      1. Lisfranc joint displacement >2 mm
      2. Joint Instability
  2. Reduction Indications (Regional Anesthesia or Procedural Sedation)
    1. Reduce significant acute, closed dorsal dislocations in the emergency department
  3. Immobilization
    1. Splint patients and avoid weight bearing if any suspicion of Lisfranc Injury
    2. Start: Short-leg Non-weight bearing cast or boot for first 4-6 weeks
    3. Next: Short-leg weight bearing cast or boot for another 2 to 4 weeks
  4. Rehabilitation after cast or boot removal
    1. Expect 6-12 months before resuming full activity after a significant lisfranc joint injury
  5. Reassess 2 weeks after starting rehabilitation
    1. Repeat weight bearing XRays to assess for instability

XII. Management: Surgery

  1. Indications
    1. Displacement greater than 2 mm
    2. Unstable Fracture dislocations with instability
      1. Most Lisfranc injuries evident on imaging are unstable
  2. Timing
    1. Best performed within first 24 hours of injury
    2. Some prefer to wait 7-10 days for less swelling
  3. Efficacy
    1. Best functional outcomes are with surgery (unless Lisfranc Injury is stable)

XIII. Complications

  1. Compartment Syndrome (due to associated soft tissue swelling)
  2. Post-Traumatic arthrosis

XIV. Prognosis

  1. High risk of morbidity with Disability related to ambulation

XV. References

  1. Young (2022) Crit Dec Emerg Med 36(8): 16-7
  2. Gaskin and Denq (2020) Crit Dec Emerg Med 34(4): 16-7
  3. Feden and Kiel (2017) Crit Dec Emerg Med 31(11): 3-10
  4. Burroughs (1998) Am Fam Physician 58(1): 118-24 [PubMed]
  5. Grewel (2020) Foot 45:101719 [PubMed]
  6. Silver (2024) Am Fam Physician 109(2): 119-29 [PubMed]

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