eMedicine Specialties > Orthopedic Surgery > Foot & Ankle

Lisfranc Fracture Dislocation

Saul G Trevino, MD, Professor of Clinical Orthopedic Surgery, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine
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

Updated: Oct 6, 2009

Introduction

The Lisfranc joint, which represents the articulation between the midfoot and forefoot, is composed of the 5 tarsometatarsal (TMT) joints. The Lisfranc ligament is attached to the lateral margin of the medial cuneiform and medial and plantar surface of second metatarsal (MT) base. This is the only ligamentous support between first and second ray at midfoot level. Lisfranc joint injuries are rare, complex, and often misdiagnosed or inadequately treated. Lisfranc injuries can vary from simple ligament sprains to complete disruption of the TMT joint. Lisfranc fracture dislocations and sprains carry a high risk of chronic secondary disability. Best outcomes for these injuries require prompt recognition and then anatomic reduction and stabilization.

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

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

History of the Procedure

Jacques Lisfranc de Saint-Martin (1790-1847), a field surgeon in Napoleon's army serving on the Russian front, described a new amputation technique across the 5 TMT joints — one that did not require any bony osteotomy — as a swift solution to forefoot gangrene secondary to frostbite. This anatomical landmark became known as the Lisfranc joint, a term that is used today in the description of a wide spectrum of traumatic injuries to the TMT area of the foot.  However, Lisfranc did not actually describe the injury pattern well known by this eponym. A Lisfranc injury encompasses everything from a sprain to a complete disruption of normal anatomy through the TMT joints. This type of injury was later described in equestrian riders who got their foot caught in a stirrup when they fell from a horse.

Problem

The Lisfranc ligament is a solitary ligament that connects the first ray (first metatarsal-medial cuneiform articulation) to the middle and lateral columns of the foot.  Injury to this ligament, even in isolation, will result in functional instability with loss of longitudinal and transverse arch.³   Lisfranc injuries are commonly undiagnosed and carry a high risk of chronic secondary disability. Early recognition and treatment of this injury are important to preserve normal foot biomechanics and function. Injuries to the Lisfranc articulations frequently lead not only to arthritis but also to severe pain. 

Frequency

Lisfranc injuries account for 0.2% of all fractures.⁴ Incidence of this uncommon injury is reported as approximately 1 per 55,000 persons per year. It can occur in all ages but is more common in the third decade and is more common in males.⁵  Subtle Lisfranc sprain and diastasis have become more commonly diagnosed in athletes.^6,7

Etiology

The 2 major causes of Lisfranc injuries are low-energy, sports-related injuries and high-energy motor vehicle and industrial accidents. In low-energy settings, TMT injuries are caused by a direct blow to the joint or by axial loading along the MT, either with medially or laterally directed rotational forces. In high-energy injuries, the method of loading is not significantly different, but the energy absorbed by the articulations results in significantly more collateral damage to bony and soft-tissue structures, creating such injuries as MT fractures, cuneiform instabilities, and cuboid fractures.

The damage to the tight, ligamentous structures of this joint complex creates an unstable foot for weight bearing. The sense of instability and pain can occur whether or not overt evidence of instability is present. Chronic sprains resulting from relatively minor trauma can be the most debilitating sprains due to pain with weight bearing.

Pathophysiology

In diabetic patients with neuropathy or those with idiopathic insensate feet, subacute diastasis can occur over time without notable pain. Due to the absence of pain, this gradual process occurs, so that a minor injury can lead to a Lisfranc injury. In the authors’ opinion, the hallmark of an impending Lisfranc injury is the loss of the recess of the second MT base with the cuneiform, also known as the keystone. Radiographs are considered abnormal when weight-bearing anteroposterior (AP) views of the foot show the first TMT joint to be at the same level as the second TMT joint, indicating proximal migration of the first ray (Image 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.

Presentation

Patients with Lisfranc injuries can present with obvious anatomic deformities or with variable amounts of pain with weight bearing. Lisfranc injury should be excluded in any patient with midfoot pain on either the dorsal or the plantar aspect of the foot during weight bearing.

Clinical signs of Lisfranc injury are the following:

• Swelling out of proportion with a normal radiograph
• Plantar midfoot ecchymosis (see Image 2)

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

• Pain along the TMT joints with palpation, motion, and/or weight bearing
• Midfoot instability

All suspected injuries require a careful workup. Even significant injuries can reduce spontaneously, thereby hiding the initial deformity. The exaggerated swelling is the key in the differential diagnosis of subtle injuries. Special attention should be paid to patients with decreased sensation in the feet, such as diabetics, because they may be more at risk for progressive neuropathic changes.

Athletes

Lisfranc injuries are seen more commonly in football players, gymnasts, ballet dancers, and track-and-field athletes. Lisfranc injury in a professional hockey player has also been reported.⁸ The Lisfranc injury can potentially be a career-ending injury, particularly in elite gymnasts, as noted by Chilvers and colleagues.⁹ The mechanism of injury for most athletes is axial loading on a hyperplantarflexed midfoot. For ballet dancers, the pointe shoe design has been shown to stabilize the Lisfranc joint while in the en pointe position.¹⁰

Lisfranc injuries in athletes have been classified according to the American Medical Association’s Standard Nomenclature of Athletic Injuries. First- and second-degree sprains have been classified as partial ligament tears with swelling, focal pain, no instability, and normal radiographs. Instability and diastasis between the first and second MT of greater than 2 mm as seen on AP radiographs is consistent with a third-degree sprain.^6,7

Indications

Patients with undisplaced injuries are treated conservatively. Patients with displaced Lisfranc injuries should undergo closed or open reduction. All Lisfranc injuries that cannot be reduced and be made to remain stable by closed means should undergo internal fixation. An absolute indication for open reduction is vascular compromise that does not improve with closed reduction.⁴

Relevant Anatomy

The Lisfranc joint is composed of 5 TMT joints in which the first through third MTs articulate with their corresponding medial, middle, and lateral cuneiforms. The fourth and fifth MTs articulate with the cuboid. The Lisfranc joint can be functionally divided longitudinally into the first ray, or medial column; the middle column, consisting of the second and third TMT joints; and the lateral column, consisting of the fourth and fifth TMT joints. A transverse line through these joints is not straight but highlights a recess, termed the keystone (similar to a Roman arch), formed by the second TMT joint. This joint lies approximately 1 cm proximal to the first TMT joint line and 0.5 cm proximal to the third TMT joint line.

The joints are bound by thick plantar ligaments that form an interlocking pattern between the tarsal and lesser MT bones 2-5. These are reinforced by attachments of the posterior tibialis tendon. The first TMT joint also has strong plantar ligaments across the joint; these are reinforced by the attachment of the peroneus longus and anterior tibialis tendons. Also present between the lesser MTs is a series of intermetatarsal ligaments, which force the group to function more as a unit. No intermetatarsal ligaments exist between the first and second MTs, which is why they often exhibit divergent behavior. The weaker dorsal ligaments explain the majority of dorsal dislocations.¹¹

The Lisfranc ligament originates from the plantar lateral aspect of the medial cuneiform and attaches to the plantar medial aspect of the second MT base. It is the thickest of the ligaments in this region, measuring up to 1 cm wide. This ligament provides the only soft-tissue link between the medial ray and the lesser MT and is responsible for this area's stability.

Motion at the TMT joints is variable. The second and third joints are the stiffest, with minimal motion in the dorsal/plantar plane and none in the medial or lateral plane. The third and first TMTs exhibit progressively more motion in both planes but still are relatively stiff and mainly function as areas of adjustment to allow the MT heads to share weight equally. The lateral 2 TMT joints demonstrate roughly 3 times more motion in the dorsal or plantar plane than does the first TMT joint. That motion is significant in the function of the foot and must be preserved to maintain normal function, especially if stiffness occurs in the medial and middle columns.

In the column theory, the middle column is more important for rigidity, and the medial and lateral columns are more important for shock absorption during gait. The lateral joints are more important for their mobile contributions to the balancing of forefoot weight bearing. This principle is important in treating these injuries.

Contraindications

Anatomic alignment is important for stable function, but the risk of infection and soft-tissue compromise may preclude surgery until the tissues stabilize. Patients with open injuries or vascular compromise should be approached carefully. A delayed fusion of the medial 3 TMT joints can be performed if pain persists with weight bearing.

Workup

Laboratory Studies

Although there are no specific lab studies for Lisfranc injuries, the clinician should be acutely aware of those patients who may be at high risk for subtle injuries, such as undiagnosed diabetics who have decreased sensation in their feet.

Imaging Studies

Lisfranc injuries, especially subtle injuries, can often be missed.¹² Up to 20% of Lisfranc injuries are missed on initial presentation to the emergency department (ED).¹³ Often, the initial radiograph is normal, particularly in athletes with only a first- or second-degree sprain. In a study by Sherief and colleagues, 8 of the 9 clinicians who participated in the study missed a subtle Lisfranc injury in a diabetic neuropathic foot, and only 61% of the Lisfranc injuries in the study were accurately diagnosed by all of the clinicians.¹⁴

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.

• Radiographs
  • Obtain initial radiographs of the injured foot in all patients, as follows:
    • Anteroposterior (AP) view of the foot in a standing position, if possible - In the normal image, the medial border of the base of the second MT and middle cuneiform should line up. Any gross diastasis greater than 2 mm between the base of the first and second MT suggests a Lisfranc injury. (See Image 3.)
    • Lateral view of the foot in a standing position, if possible - In this view, the superior border of the first MT base should align with the superior border of the medial cuneiform. (See Image 4.)
    • Medial 30º oblique view of the foot - In this view, the cuboid should align with the medial border of the fourth MT. (See Images 5-6.)
  • If a subtle injury is suspected, obtain a weight-bearing, AP view of both feet on the same cassette for direct comparison.
  • A “fleck sign” seen on the AP radiograph is pathognomonic for a Lisfranc injury. This sign is reportedly present in 90% of Lisfranc ligament injuries. It represents an avulsion fracture from either the second MT base or the medial cuneiform, due to forceful abduction of the forefoot that avulses the strong Lisfranc ligament between the base of the second MT and the medial cuneiform. The literature offers many classifications for Lisfranc injuries based on radiographic appearance. The value of these classifications is for reporting only. For treatment purposes, the major determinant is whether the joint complex is stable or unstable. This is determined by the above-described radiographic stress views.
• Computed tomography (CT) scan
  • A routine CT scan through the midfoot is suggested to visualize any bony injury to the plantar bony structures.
  • CT scan also allows a 3-dimensional assessment of surrounding joint stability.
  • Midfoot stability is vital to adequate Lisfranc injury recovery.

Other Tests

Magnetic resonance imaging (MRI)

• When compared with CT scans and weight-bearing radiographs, MRI has an advantage in identifying partial ligament injuries and subtle ligament injuries
• With this technology, one can identify isolated tears of the Lisfranc ligament, as well as associated injuries to the interosseous ligaments. Raikin et al have shown that MRI is accurate for detecting traumatic injury of the Lisfranc ligament and for predicting Lisfranc joint complex instability when the plantar Lisfranc ligament bundle is used as a predictor. Rupture or grade-2 sprain of the plantar ligament between the first cuneiform and the bases of the second and third metatarsals is highly suggestive of an unstable midfoot, which will require stabilization.¹⁵

Bone scan

• Bone scanning is best used for suspected acute and chronic injuries of the TMT joints.
• A bone scan can demonstrate Lisfranc injuries that occurred 3 months before presentation and continue with painful weight-bearing.
• Increased uptake on bone scan indicates degenerative changes that are not yet visible on plain films.

Diagnostic Procedures

With an ankle block or intravenous sedation, stress the foot under fluoroscopic examination with pressure on the medial forefoot, pushing laterally while the hindfoot is pushed medially. An AP view of the TMT joints reveals any significant instability (see Images 7-8).

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.

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.

Histologic Findings

Intra-operative findings that suggest a possible pathologic process should be sent to pathology for accurate diagnosis.

Staging

In athletic injuries, Nunley and Vertullo suggested a 3-stage diagnostic classification, as follows¹⁶ :

• Stage I - A tear of dorsal ligaments and sparing of the Lisfranc ligament
• Stage II - Direct injury to the Lisfranc ligament with elongation or rupture.
• Stage III - A progression of the above, with damage to the plantar TMT ligaments and joints, along with potential fracture and loss of arch.

Treatment

Medical Therapy

Medical treatment is reserved for injuries that are anatomically stable and nondisplaced. This type of injury is best labeled as a sprain, although associated fractures in the surrounding bone may be present (eg, MT fracture). An athlete with a stable Lisfranc injury usually cannot compete for the remainder of the season. Early return to high-level activity can lead to chronic pain and progressive arthropathy. Therefore, athletes should be given special consideration.

Initial treatment should consist of a well-molded, non – weight-bearing, short leg cast worn for a minimum of 6 weeks. Advancement of ambulation depends on resolution of symptoms. Because many of these injuries initially present with midfoot edema that may help to stabilize damaged tissues, all stable injuries should be re-examined approximately 2 weeks following injury. Obtain weight-bearing radiographs at 4-6 weeks to ensure continued anatomic alignment.

After 6 weeks, progressive weight bearing can be allowed in a well-molded cast, advancing as comfort allows. When full weight bearing in a cast is comfortable, the patient can be advanced to a supportive shoe and reconditioning. The patient can be advanced to an accommodative orthotic with a contoured carbon shank so as to minimize midfoot stress.

Combined closed reduction and casting has no role in the treatment of unstable injuries. Constantly maintaining reduction with casting alone has proven to be too difficult. In addition, interposing soft tissues can impede closed reduction. For example, the anterior tibial tendon can block reduction of a lateral Lisfranc dislocation; similarly, the peroneus brevis tendon can block a medial dislocation reduction.

Surgical Therapy

All injuries that are displaced and unstable require surgery. Complete assessment of the intercuneiform and cuboid integrity is important when determining stability. Clinical outcome is highly dependent on restoration of normal anatomic alignment. Present recommendations for treatment consist of open reduction of the unstable area, as well as rigid fixation, with an option in terms of the screws employed, such as 3.5-mm cortical screws or 4.0-4.5 cannulated screws (depending on the size of the bone). Multiple Kirschner wires (K-wires) also have been advocated, but maintaining reduction with them is more difficult (see Image 9).¹⁷ In fact, screw fixation has been shown to have significantly greater biomechanical stability than does K-wire fixation.¹⁸

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

Presentation variations

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.

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.

• Pure dislocation - Openly reduce all joints and follow with fixation of the medial joints with 3.5-mm cortical screws. Once anatomically aligned and fixed, the lateral 2 joints can be stabilized with 1.6-mm K-wires, if needed to maintain position. Wires are often not required, due to the ligamentous interconnections (see Images 10-13).
• Proximal instability - This includes tarsal instability and longitudinal impaction injuries that can disrupt the normal arcade of the TMT joints. Openly reduce and hold with fixation screws any instability between tarsal bones. If necessary, a mini-external fixator can be used to control proximal migration and comminution. Anatomically restore any shortening of the tarsals, and graft the defect with a structural graft from the iliac crest or proximal tibia. If more than 50% of the joint surface is destroyed, perform primary fusion among the involved bones to preserve long-term stability. Treatment then can proceed as it would for a pure dislocation (see Images 14-15).
• Distal fractures - MT fractures distal to the Lisfranc joint sometimes can interfere with stable fixation. In these instances, use intramedullary K-wires in conjunction with open reduction to anatomically realign the foot (see Images 16-17).
• Interarticular injury - This involves destruction of the articular surface through either bony fracture or through traumatic removal of cartilage from the subchondral bone. Anatomically restore large fragments. Remove interarticular debris, and assess the remaining joint. If greater than 50% of the joint surface of the medial 3 joints is destroyed, seriously consider acute fusion of these joints. Irrespective of the amount of damage to the articular surface of the lateral 2 joints, they should never undergo acute fusion.
• Patients with diabetes - If the dislocation is found acutely before onset of significant Charcot arthropathy, arthrodesis of the involved first, second, and third TMT joints can be beneficial. Take special care to document that blood flow is adequate for healing from the surgical procedure (transcutaneous pressure of oxygen [tcPO₂] or toe pressure >40 mm Hg). Fuse the medial 3 TMT joints, regardless of their articular integrity. Prolonged non – weight-bearing in a total contact cast is necessary to prevent reinjury due to neuropathy. Casting should be changed every 2 weeks. Weight-bearing status is assessed by evidence of solid fusion on follow-up radiographs. Fusions frequently take twice as long as nonneuropathic patients.

Preoperative Details

Often, surgery should be delayed until excessive swelling has resolved, because swelling places the soft tissues at risk. Supine position with a thigh or ankle tourniquet is recommended. Be aware of and ready to address all injuries present before beginning surgery.

Intraoperative Details

A 2-incision approach works best for complete visualization. The medial incision is in line with the first webspace. The branches of the superficial peroneal nerve are identified and protected. The muscle belly of the extensor hallucis brevis covers the neurovascular bundle. Identify and protect the deep peroneal nerve, dorsalis pedis artery, and extensor tendons. Once the area of the second TMT joint is reached, perform subperiosteal dissection across the Lisfranc joint to minimize damage to soft-tissue structures. If needed, a second incision is based over the lateral border of the third MT and is carried distally. The extensor digitorum brevis is divided bluntly, and the TMTs are entered subperiosteally. In this region, the third, fourth, and fifth TMT joints literally are one on top of the other and are easily visualized.

With the tarsus stabilized and the joints inspected, reduction usually is easy. The author finds it easiest to reduce the medial column first, by placing a provisional wire across the first TMT joint and, if necessary, a provisional wire between the first and second cuneiform. If acceptable, appropriate cannulated screws are then placed. The second part of the procedure is connecting the medial and middle columns. A cannulated screw is placed across the medial cuneiform to the base of the second MT so as to reduce the Lisfranc diastasis. Other authors suggest starting with the second MT to medial cuneiform fixation. A large, pointed bone-reduction clamp can be used to hold the reduction while screws are placed. The position of the fixation screws is depicted in Image 15.²

Because no real tissue layers are present at this level of the foot, wound closure can be accomplished with an absorbable suture to close joint capsules and a nonabsorbable suture in using a vertical or horizontal mattress technique to close the skin.

Postoperative Details

Immediately postoperatively, the authors recommend a well-padded posterior splint until swelling subsides in 1-2 weeks. At that time, the splint can be converted to a non – weight-bearing, short leg cast if swelling permits. Immobilization in a cast is up to 3 months. The period of time that screws should remain is controversial, as is the question of whether weight bearing should be permitted before screws are removed. Physicians agree that screws across viable joints should be left in no longer than 6 months from the time of surgery. Some advocate that no weight bearing be allowed until the screws are removed, at 3 months after surgery.

Follow-up

• Remove sutures during the 2-week postoperative visit.
• Patient should remain immobilized in a non – weight-bearing, short-leg cast until 6-8 weeks after surgery.  At that time, as symptoms permit, the cast can be switched to a removable boot or walking cast for another 6 weeks.
• During the 6-week postoperative visit, radiographically assess healing. If K-wires are used, they should be removed at the 6-week postsurgery follow-up visit.
• Follow up on a monthly basis until full weight bearing is achieved.
• During the 4-6 month postoperative visit, remove fixation screws across the TMT joints. Allow weight bearing as tolerated in a supportive shoe with accommodative insole and carbon shank.

Complications

The following factors can be considered complications of this injury:

• Foot compartment syndrome after a major trauma
• Nonanatomic reduction or alignment
• Posttraumatic midfoot arthritis (most common)¹
• Painful hardware, hardware failure, or breakage
• Flatfoot deformity with instability with weight bearing
• Complex regional pain syndrome (only 2 cases reported)
• Neuromas (usually the superficial peroneal nerve)
• Infections and wound complications

Along this joint line, continued chronic pain with weight bearing is best treated with fusion of the first, second, and third TMT joints in an anatomically correct position. With realignment and stabilization of the medial joints, laterally based pain usually subsides.

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.

Treat persistent lateral pain following realignment of the medial joints with interposition arthroplasty rather than fusion. This is best performed using a segment of extensor digitorum brevis tendon rolled up and interposed into the debrided joint. This allows continued motion and prevents the compressive bony contact that generates the pain (see Images 19-22).

Outcome and Prognosis

Stable anatomic alignment is the best predictor of outcome. The presence of fractures and/or articular destruction leads to poorer results, regardless of alignment. Incidence of posttraumatic arthritis reportedly ranges from 0-58%.²⁰  One study reported that up to 25% of patients develop posttraumatic arthritis even after fixation. This same study showed that there was no difference between acute and delayed (>6 weeks) surgical fixation. Purely ligamentous injuries seemed to have poorer outcomes.  Good results are achieved with open reduction and internal fixation (ORIF) at up to 6 weeks, but poor outcomes are seen after this time due to articular destruction, malalignment, and poor soft-tissue envelope.

Future and Controversies

Role of acute fusion

Stability at this joint level of the foot is the primary concern, and instability appears to be the primary pain generator. Primary fusion of the medial 3 TMT joints has been advocated due to the unpredictability of adequate ligamentous healing to support the foot.

In 2006, Ly and colleagues reported the results of their study comparing primary arthrodesis with ORIF in primarily ligamentous Lisfranc injuries.^21,22 Twenty patients were treated with ORIF, and 21 were treated with arthrodesis of the medial 2 or 3 TMT joints, with an average follow-up period of 42.5 months. Using outcome measures, the authors reported that the members of the arthrodesis group reached a postoperative activity level that was an estimated 92% of their pre-injury activity level, while in the ORIF group, members achieved an activity level that was only 65% of their pre-injury level. The authors concluded that a stable, primary arthrodesis seemed to have better short- and medium-term outcomes. Whether this improves long-term results is not yet known.

Length of time before screw removal

Suggestions of length of time that screws should remain in place range from 6 weeks to 3 months after weight bearing begins (up to 6 months from the time of surgery). Results demonstrate that if fixation screws remain in place indefinitely, they have a high tendency to break with time, thereby causing pain. If the joint is not fused purposely during surgery, then some motion is expected; this constant motion causes hardware failure.

The timing of screw removal remains a question. Advocates of early removal stress the fear of early screw failure as the main reason for removal. Others believe that the screws should remain in place even during early weight bearing to slowly help condition the damaged ligaments to resume supporting the foot. Long-term follow-up is needed before this issue can be resolved.

Use of different bio-absorbable materials

The advantage of using different bio-absorbable materials to provide short-term stability following surgical reduction is that no screws need to be removed. Issues are 2-fold:

• What effect do degradation products have on joint chemistry?
• Is the sheer strength of bio-absorbable screws sufficient to maintain the reduction in this situation?

Multimedia

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.

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

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

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

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.

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.

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.

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.

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

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.

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

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

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

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

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

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.

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.

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

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

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

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.

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.

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

References

1. Gaines RJ, Wright G, Stewart J. Injury to the tarsometatarsal joint complex during fixation of Lisfranc fracture dislocations: an anatomic study. J Trauma. Apr 2009;66(4):1125-8. [Medline].

2. 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].

3. 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].

4. 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].

5. Desmond EA, Chou LB. Current concepts review: Lisfranc injuries. Foot Ankle Int. Aug 2006;27(8):653-60. [Medline].

6. 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].

7. Curtis MJ, Myerson M, Szura B. Tarsometatarsal joint injuries in the athlete. Am J Sports Med. Jul-Aug 1993;21(4):497-502. [Medline].

8. 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].

9. 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].

10. 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].

11. 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].

12. 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].

13. 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].

14. 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].

15. 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].

16. 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].

17. 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].

18. 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].

19. 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].

20. Philbin T, Rosenberg G, Sferra JJ. Complications of missed or untreated Lisfranc injuries. Foot Ankle Clin. Mar 2003;8(1):61-71. [Medline].

21. 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].

22. 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].

23. Thordarson DB, Hurvitz G. PLA screw fixation of Lisfranc injuries. Foot Ankle Int. Nov 2002;23(11):1003-7. [Medline].

24. Lui TH. Arthroscopic tarsometatarsal (Lisfranc) arthrodesis. Knee Surg Sports Traumatol Arthrosc. May 2007;15(5):671-5. [Medline].

25. 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].

26. Buzzard BM, Briggs PJ. Surgical management of acute tarsometatarsal fracture dislocation in the adult. Clin Orthop. Aug 1998;(353):125-33. [Medline].

27. 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].

28. 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].

29. Davies MS, Saxby TS. Intercuneiform instability and the "gap" sign. Foot Ankle Int. Sep 1999;20(9):606-9. [Medline].

30. Faciszewski T, Burks RT, Manaster BJ. Subtle injuries of the Lisfranc joint. J Bone Joint Surg Am. Dec 1990;72(10):1519-22. [Medline].

31. 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].

32. Meyer SA, Callaghan JJ, Albright JP. Midfoot sprains in collegiate football players. Am J Sports Med. May-Jun 1994;22(3):392-401. [Medline].

33. 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].

34. 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].

35. 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].

Keywords

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

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.

Related eMedicine topics

Athletic Foot Injuries

Dislocation, Foot

Metatarsals, Fractures

Clinical studies

A Comparison of Stainless Steel and Bioabsorbable Screw Fixation of Lisfranc Foot Injuries

A Comparison of Steel and Bioabsorbable Screw Fixation of Lisfranc Foot Injuries

© 1994- by Medscape.
All Rights Reserved
(http://www.medscape.com/public/copyright)