eMedicine Specialties > Orthopedic Surgery > Foot & Ankle

Lisfranc Fracture Dislocation: Multimedia

Author: Saul G Trevino, MD, Professor of Clinical Orthopedic Surgery, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine
Coauthor(s): Allison M Wade, MD, Fellow, Penn State Bone and Joint Institute, Penn State University Milton S Hershey Medical Center, Hershey, PA; John S Early, MD, Foot/Ankle Specialist, Texas Orthopaedic Associates, LLP; Co-Director, North Texas Foot and Ankle Fellowship Baylor University Medical Center; Santaram Vallurupalli, MD, Research Resident, Department of Orthopedic Surgery, University of Missouri at Columbia
Contributor Information and Disclosures

Updated: Oct 6, 2009

Multimedia

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Media file 1: Radiograph illustrating diabetic patient with first ray instability of the right foot. The articular surfaces of the second and first metatarsal are level in the transverse plane, indicating proximal migration of the first ray. The left foot shows the advanced stage of an untreated Lisfranc injury with similar first ray instability.

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Radiograph illustrating diabetic patient with first ray instability of the right foot. The articular surfaces of the second and first metatarsal are level in the transverse plane, indicating proximal migration of the first ray. The left foot shows the advanced stage of an untreated Lisfranc injury with similar first ray instability.

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Media file 2: Clinical identification of typical plantar ecchymosis pattern observed in Lisfranc injuries.

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Clinical identification of typical plantar ecchymosis pattern observed in Lisfranc injuries.

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Media file 3: In this anteroposterior radiograph of a Lisfranc dislocation, note the disruption of the normal second tarsometatarsal alignment.

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In this anteroposterior radiograph of a Lisfranc dislocation, note the disruption of the normal second tarsometatarsal alignment.

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Media file 4: In this lateral radiograph of a typical Lisfranc injury, note the malalignment of the metatarsal bases with the midfoot.

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In this lateral radiograph of a typical Lisfranc injury, note the malalignment of the metatarsal bases with the midfoot.

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Media file 5: In this medial oblique radiograph of a normal foot, note the medial borders of the cuboid and fourth metatarsal base. They should be even, as depicted by the black lines.

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In this medial oblique radiograph of a normal foot, note the medial borders of the cuboid and fourth metatarsal base. They should be even, as depicted by the black lines.

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Media file 6: In this medial oblique radiograph of a Lisfranc injury, note the loss of alignment between the cuboid and fourth metatarsal base (black lines). This is diagnostic of a Lisfranc injury and is as important as recognition of the second tarsometatarsal instability.

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In this medial oblique radiograph of a Lisfranc injury, note the loss of alignment between the cuboid and fourth metatarsal base (black lines). This is diagnostic of a Lisfranc injury and is as important as recognition of the second tarsometatarsal instability.

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Media file 7: Stress view. This patient, with a suspected Lisfranc injury, presents with a normal appearing anteroposterior radiograph of the foot. Plantar ecchymosis and clinical presentation of pain warrant further investigation. In this radiograph, alignment of the medial border of the second metatarsal and the medial cuneiform is near normal. Patient is unable to bear weight due to a femur fracture sustained in the same accident.

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Stress view. This patient, with a suspected Lisfranc injury, presents with a normal appearing anteroposterior radiograph of the foot. Plantar ecchymosis and clinical presentation of pain warrant further investigation. In this radiograph, alignment of the medial border of the second metatarsal and the medial cuneiform is near normal. Patient is unable to bear weight due to a femur fracture sustained in the same accident.

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Media file 8: In this stressed view, with adequate anesthesia to the patient, the foot is stressed in a medial/lateral plane. The forefoot is forced laterally with the hindfoot brought medially. Note that the second tarsometatarsal joint opens up, and the normal alignment between the medial border of the second metatarsal base and the middle cuneiform is distorted. This injury requires surgical stabilization.

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In this stressed view, with adequate anesthesia to the patient, the foot is stressed in a medial/lateral plane. The forefoot is forced laterally with the hindfoot brought medially. Note that the second tarsometatarsal joint opens up, and the normal alignment between the medial border of the second metatarsal base and the middle cuneiform is distorted. This injury requires surgical stabilization.

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Media file 9: Standard anteroposterior radiograph demonstrates a Lisfranc fracture dislocation. Determining the extent of fracture involving the joint is difficult with plain radiographs.

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Standard anteroposterior radiograph demonstrates a Lisfranc fracture dislocation. Determining the extent of fracture involving the joint is difficult with plain radiographs.

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Media file 10: CT scan in the coronal plane can demonstrate the extent of injury at the joint. Compare with the plain radiograph of this injury in Image 8. Note the plantar avulsion, suggesting severe disruption of the plantar ligamentous structures.

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CT scan in the coronal plane can demonstrate the extent of injury at the joint. Compare with the plain radiograph of this injury in Image 8. Note the plantar avulsion, suggesting severe disruption of the plantar ligamentous structures.

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Media file 11: This diagram depicts the suggested fixation order of placement and alignment of screws for surgical fixation of unstable Lisfranc injuries.

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This diagram depicts the suggested fixation order of placement and alignment of screws for surgical fixation of unstable Lisfranc injuries.

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Media file 12: Preoperative anteroposterior radiograph demonstrates a Lisfranc dislocation.

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Preoperative anteroposterior radiograph demonstrates a Lisfranc dislocation.

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Media file 13: Preoperative lateral radiograph demonstrates a Lisfranc dislocation.

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Preoperative lateral radiograph demonstrates a Lisfranc dislocation.

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Media file 14: Postoperative anteroposterior radiograph demonstrates reduction and fixation of Lisfranc dislocation.

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Postoperative anteroposterior radiograph demonstrates reduction and fixation of Lisfranc dislocation.

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Media file 15: Postoperative lateral radiograph illustrates placement of fixation screws for stabilization of Lisfranc joint.

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Postoperative lateral radiograph illustrates placement of fixation screws for stabilization of Lisfranc joint.

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Media file 16: Preoperative anteroposterior radiograph demonstrates a Lisfranc injury with proximal tarsal instability. The medial cuneiform is displaced medially, bringing the joint line level with the second. The proximal anatomy must be restored and stabilized before addressing the tarsometatarsal joint.

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Preoperative anteroposterior radiograph demonstrates a Lisfranc injury with proximal tarsal instability. The medial cuneiform is displaced medially, bringing the joint line level with the second. The proximal anatomy must be restored and stabilized before addressing the tarsometatarsal joint.

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Media file 17: Postoperative anteroposterior radiograph demonstrates restoration of normal midfoot alignment. Screw fixation was used to stabilize the cuneiform prior to realigning the Lisfranc joint. Due to comminution of the second and third metatarsal shafts, Kirschner wires were used to hold their position. In this case, due to continued instability, a wire through the fourth tarsometatarsal joint was also used.

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Postoperative anteroposterior radiograph demonstrates restoration of normal midfoot alignment. Screw fixation was used to stabilize the cuneiform prior to realigning the Lisfranc joint. Due to comminution of the second and third metatarsal shafts, Kirschner wires were used to hold their position. In this case, due to continued instability, a wire through the fourth tarsometatarsal joint was also used.

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Media file 18: Preoperative anteroposterior radiograph demonstrates a Lisfranc injury with associated distal fracture. Note the displacement of the base of the first metatarsal.

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Preoperative anteroposterior radiograph demonstrates a Lisfranc injury with associated distal fracture. Note the displacement of the base of the first metatarsal.

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Media file 19: Postoperative anteroposterior radiograph demonstrates fixation of the metatarsal, as well as stabilization of the Lisfranc joint.

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Postoperative anteroposterior radiograph demonstrates fixation of the metatarsal, as well as stabilization of the Lisfranc joint.

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Media file 20: Preoperative anteroposterior radiograph demonstrates a missed old Lisfranc injury with subsequent valgus foot deformity and painful weight bearing throughout the midfoot.

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Preoperative anteroposterior radiograph demonstrates a missed old Lisfranc injury with subsequent valgus foot deformity and painful weight bearing throughout the midfoot.

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Media file 21: Preoperative lateral radiograph demonstrates loss of plantar integrity through Lisfranc joint area. The normal linear alignment of the bones from the metatarsal to the talus is lost, with a sag at the tarsometatarsal joint.

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Preoperative lateral radiograph demonstrates loss of plantar integrity through Lisfranc joint area. The normal linear alignment of the bones from the metatarsal to the talus is lost, with a sag at the tarsometatarsal joint.

(Enlarge Image)

Media file 22: In this postoperative anteroposterior radiograph demonstrating reduction of Lisfranc alignment and screw configuration for tarsometatarsal fusion, note that only the medial 3 joints are fused. The lateral 2 joints remain mobile and actually open up when compared with the previous pictures.

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In this postoperative anteroposterior radiograph demonstrating reduction of Lisfranc alignment and screw configuration for tarsometatarsal fusion, note that only the medial 3 joints are fused. The lateral 2 joints remain mobile and actually open up when compared with the previous pictures.

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Media file 23: Postoperative lateral radiograph demonstrates restoration of alignment with tarsometatarsal fusion.

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Postoperative lateral radiograph demonstrates restoration of alignment with tarsometatarsal fusion.

More on Lisfranc Fracture Dislocation

Overview: Lisfranc Fracture Dislocation

Workup: Lisfranc Fracture Dislocation

Treatment: Lisfranc Fracture Dislocation

Follow-up: Lisfranc Fracture Dislocation

Multimedia: Lisfranc Fracture Dislocation

References

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Cook KD, Jeffries LC, O'Connor JP, Svach D. Determining the strongest orientation for "Lisfranc's screw" in transverse plane tarsometatarsal injuries: a cadaveric study. J Foot Ankle Surg. Jul-Aug 2009;48(4):427-31. [Medline].
Kaar S, Femino J, Morag Y. Lisfranc joint displacement following sequential ligament sectioning. J Bone Joint Surg Am. Oct 2007;89(10):2225-32. [Medline].
Hardcastle PH, Reschauer R, Kutscha-Lissberg E, et al. Injuries to the tarsometatarsal joint. Incidence, classification and treatment. J Bone Joint Surg Br. 1982;64(3):349-56. [Medline]. [Full Text].
Desmond EA, Chou LB. Current concepts review: Lisfranc injuries. Foot Ankle Int. Aug 2006;27(8):653-60. [Medline].
Lattermann C, Goldstein JL, Wukich DK, et al. Practical management of Lisfranc injuries in athletes. Clin J Sport Med. Jul 2007;17(4):311-5. [Medline].
Curtis MJ, Myerson M, Szura B. Tarsometatarsal joint injuries in the athlete. Am J Sports Med. Jul-Aug 1993;21(4):497-502. [Medline].
Patillo D, Rudzki JR, Johnson JE, et al. Lisfranc injury in a national hockey league player: a case report. Int J Sports Med. Nov 2007;28(11):980-4. [Medline].
Chilvers M, Donahue M, Nassar L, et al. Foot and ankle injuries in elite female gymnasts. Foot Ankle Int. Feb 2007;28(2):214-8. [Medline].
Kadel N, Boenisch M, Teitz C, et al. Stability of Lisfranc joints in ballet pointe position. Foot Ankle Int. May 2005;26(5):394-400. [Medline].
Bulut G, Yasmin D, Heybeli N, Erken HY, Yildiz M. A complex variant of Lisfranc joint complex injury. J Am Podiatr Med Assoc. Jul-Aug 2009;99(4):359-63. [Medline].
Gaweda K, Tarczynska M, Modrzewski K, et al. An analysis of pathomorphic forms and diagnostic difficulties in tarso-metatarsal joint injuries. Int Orthop. Jun 15 [Epub ahead of print] 2007;[Medline].
Perron AD, Brady WJ, Keats TE. Orthopedic pitfalls in the ED: Lisfranc fracture-dislocation. Am J Emerg Med. Jan 2001;19(1):71-5. [Medline].
Sherief TI, Mucci B, Greiss M. Lisfranc injury: how frequently does it get missed? And how can we improve?. Injury. Jul 2007;38(7):856-60. [Medline].
Raikin SM, Elias I, Dheer S, Besser MP, Morrison WB, Zoga AC. Prediction of midfoot instability in the subtle Lisfranc injury. Comparison of magnetic resonance imaging with intraoperative findings. J Bone Joint Surg Am. Apr 2009;91(4):892-9. [Medline].
Nunley JA, Vertullo CJ. Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med. Nov-Dec 2002;30(6):871-8. [Medline].
Smith SE, Camasta CA, Cass AD. A technique for isolated arthrodesis of the second metatarsocuneiform joint. J Foot Ankle Surg. Sep-Oct 2009;48(5):606-11. [Medline].
Lee CA, Birkedal JP, Dickerson EA, et al. Stabilization of Lisfranc joint injuries: a biomechanical study. Foot Ankle Int. May 2004;25(5):365-70. [Medline].
Panchbhavi VK, Vallurupalli S, Yang J, Andersen CR. Screw fixation compared with suture-button fixation of isolated Lisfranc ligament injuries. J Bone Joint Surg Am. May 2009;91(5):1143-8. [Medline].
Philbin T, Rosenberg G, Sferra JJ. Complications of missed or untreated Lisfranc injuries. Foot Ankle Clin. Mar 2003;8(1):61-71. [Medline].
Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg Am. Mar 2006;88(3):514-20. [Medline].
Coetzee JC, Ly TV. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. Surgical technique. J Bone Joint Surg Am. Mar 2007;89 Suppl 2 Pt.1:122-7. [Medline].
Thordarson DB, Hurvitz G. PLA screw fixation of Lisfranc injuries. Foot Ankle Int. Nov 2002;23(11):1003-7. [Medline].
Lui TH. Arthroscopic tarsometatarsal (Lisfranc) arthrodesis. Knee Surg Sports Traumatol Arthrosc. May 2007;15(5):671-5. [Medline].
Alberta FG, Aronow MS, Barrero M, et al. Ligamentous Lisfranc joint injuries: a biomechanical comparison of dorsal plate and transarticular screw fixation. Foot Ankle Int. Jun 2005;26(6):462-73. [Medline].
Buzzard BM, Briggs PJ. Surgical management of acute tarsometatarsal fracture dislocation in the adult. Clin Orthop. Aug 1998;(353):125-33. [Medline].
Chandran P, Puttaswamaiah R, Dhillon MS, et al. Management of complex open fracture injuries of the midfoot with external fixation. J Foot Ankle Surg. Sep-Oct 2006;45(5):308-15. [Medline].
Coss HS, Manos RE, Buoncristiani A. Abduction stress and AP weightbearing radiography of purely ligamentous injury in the tarsometatarsal joint. Foot Ankle Int. Aug 1998;19(8):537-41. [Medline].
Davies MS, Saxby TS. Intercuneiform instability and the "gap" sign. Foot Ankle Int. Sep 1999;20(9):606-9. [Medline].
Faciszewski T, Burks RT, Manaster BJ. Subtle injuries of the Lisfranc joint. J Bone Joint Surg Am. Dec 1990;72(10):1519-22. [Medline].
Kuo RS, Tejwani NC, Digiovanni CW. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am. Nov 2000;82-A(11):1609-18. [Medline].
Meyer SA, Callaghan JJ, Albright JP. Midfoot sprains in collegiate football players. Am J Sports Med. May-Jun 1994;22(3):392-401. [Medline].
Myerson MS, Fisher RT, Burgess AR. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle. Apr 1986;6(5):225-42. [Medline].
Richter M, Thermann H, Wippermann B, et al. Foot fractures in restrained front seat car occupants: a long-term study over twenty-three years. J Orthop Trauma. May 2001;15(4):287-93. [Medline].
Wilson DW. Injuries of the tarso-metatarsal joints. Etiology, classification and results of treatment. J Bone Joint Surg Br. Nov 1972;54(4):677-86. [Medline]. [Full Text].

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Keywords

tarsometatarsal injuries, TMT injuries, Lisfranc dislocation, Lisfranc injury, midfoot injury, Lisfranc ligament, open reduction and internal fixation, ORIF

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Contributor Information and Disclosures

Author

Saul G Trevino, MD, Professor of Clinical Orthopedic Surgery, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine
Saul G Trevino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Clinical Orthopaedic Society, Mid-America Orthopaedic Association, Phi Beta Kappa, and Texas Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Allison M Wade, MD, Fellow, Penn State Bone and Joint Institute, Penn State University Milton S Hershey Medical Center, Hershey, PA
Allison M Wade, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Mid-America Orthopaedic Association, Southern Orthopaedic Association, and Tennessee Medical Association
Disclosure: Nothing to disclose.

John S Early, MD, Foot/Ankle Specialist, Texas Orthopaedic Associates, LLP; Co-Director, North Texas Foot and Ankle Fellowship Baylor University Medical Center
John S Early, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, and Texas Medical Association
Disclosure: Zimmer Inc Consulting fee Consulting; Smith Nephew Consulting fee Consulting; AO North America Honoraria Speaking and teaching; Osteotech Consulting fee Consulting; Stryker Consulting fee Consulting

Santaram Vallurupalli, MD, Research Resident, Department of Orthopedic Surgery, University of Missouri at Columbia
Disclosure: Nothing to disclose.

Medical Editor

James K DeOrio, MD, Director of Foot and Ankle Fellowship Program, Assistant Professor of Orthopedic Surgery, Orthopedic Surgery, St Lukes Hospital, Jacksonville, Florida
James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Florida Medical Association, and German Society of Neurology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Shepard R Hurwitz, MD, Executive Director, American Board of Orthopaedic Surgery
Shepard R Hurwitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American College of Rheumatology, American College of Sports Medicine, American College of Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement of Automotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic Trauma Association, and Southern Orthopaedic Association
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FACS, Frank J Kloenne Chair in Orthopedic Surgery, Professor and Chair, Department of Orthopedics, The Ohio State University Medical Center
Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Missouri State Medical Association, Musculoskeletal Infection Society, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, and Texas Orthopaedic Association
Disclosure: Nothing to disclose.

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eMedicine Specialties > Orthopedic Surgery > Foot & Ankle

Lisfranc Fracture Dislocation: Multimedia

Multimedia

Clinical identification of typical plantar ecchymosis pattern observed in Lisfranc injuries.

In this anteroposterior radiograph of a Lisfranc dislocation, note the disruption of the normal second tarsometatarsal alignment.

In this lateral radiograph of a typical Lisfranc injury, note the malalignment of the metatarsal bases with the midfoot.

In this medial oblique radiograph of a normal foot, note the medial borders of the cuboid and fourth metatarsal base. They should be even, as depicted by the black lines.

In this medial oblique radiograph of a Lisfranc injury, note the loss of alignment between the cuboid and fourth metatarsal base (black lines). This is diagnostic of a Lisfranc injury and is as important as recognition of the second tarsometatarsal instability.

Standard anteroposterior radiograph demonstrates a Lisfranc fracture dislocation. Determining the extent of fracture involving the joint is difficult with plain radiographs.

CT scan in the coronal plane can demonstrate the extent of injury at the joint. Compare with the plain radiograph of this injury in Image 8. Note the plantar avulsion, suggesting severe disruption of the plantar ligamentous structures.

This diagram depicts the suggested fixation order of placement and alignment of screws for surgical fixation of unstable Lisfranc injuries.

Preoperative anteroposterior radiograph demonstrates a Lisfranc dislocation.

Preoperative lateral radiograph demonstrates a Lisfranc dislocation.

Postoperative anteroposterior radiograph demonstrates reduction and fixation of Lisfranc dislocation.

Postoperative lateral radiograph illustrates placement of fixation screws for stabilization of Lisfranc joint.

Preoperative anteroposterior radiograph demonstrates a Lisfranc injury with proximal tarsal instability. The medial cuneiform is displaced medially, bringing the joint line level with the second. The proximal anatomy must be restored and stabilized before addressing the tarsometatarsal joint.

Preoperative anteroposterior radiograph demonstrates a Lisfranc injury with associated distal fracture. Note the displacement of the base of the first metatarsal.

Postoperative anteroposterior radiograph demonstrates fixation of the metatarsal, as well as stabilization of the Lisfranc joint.

Preoperative anteroposterior radiograph demonstrates a missed old Lisfranc injury with subsequent valgus foot deformity and painful weight bearing throughout the midfoot.

Preoperative lateral radiograph demonstrates loss of plantar integrity through Lisfranc joint area. The normal linear alignment of the bones from the metatarsal to the talus is lost, with a sag at the tarsometatarsal joint.

In this postoperative anteroposterior radiograph demonstrating reduction of Lisfranc alignment and screw configuration for tarsometatarsal fusion, note that only the medial 3 joints are fused. The lateral 2 joints remain mobile and actually open up when compared with the previous pictures.

Postoperative lateral radiograph demonstrates restoration of alignment with tarsometatarsal fusion.

More on Lisfranc Fracture Dislocation

References

Further Reading

Keywords

Contributor Information and Disclosures

Author

Coauthor(s)

Medical Editor

Pharmacy Editor

Managing Editor

CME Editor

Chief Editor