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Lisfranc Fracture Dislocation Workup

  • Author: Saul G Trevino, MD; Chief Editor: Thomas M DeBerardino, MD  more...
 
Updated: Jan 04, 2016
 

Approach Considerations

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

Lisfranc injuries, especially subtle injuries, can often be missed.[14] As many as 20% of Lisfranc injuries are missed on initial presentation to the emergency department (ED).[15] Often, the initial radiograph is normal, particularly in athletes with only a first- or second-degree sprain. In a study by Sherief et al, eight of the nine 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 nine.[16]

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Imaging Studies

Plain radiography

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 metatarsal (MT) and the middle cuneiform should line up; any gross diastasis greater than 2 mm between the bases of the first and second MTs suggests a Lisfranc injury (see the first and second images below)
  • 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 the third image below)
  • Medial 30º oblique view of the foot - In this view, the cuboid should align with the medial border of the fourth MT (see the fourth and fifth images below)
In this anteroposterior radiograph of a Lisfranc d In this anteroposterior radiograph of a Lisfranc dislocation, note the disruption of the normal second tarsometatarsal alignment.
Standard anteroposterior radiograph demonstrates a Standard anteroposterior radiograph demonstrates a Lisfranc fracture dislocation. Determining the extent of fracture involving the joint is difficult with plain radiographs.
In this lateral radiograph of a typical Lisfranc i 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 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 in 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.

If a subtle injury is suspected, obtain a weightbearing 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, resulting from 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 approaches to classifying Lisfranc injuries on the basis of radiographic appearance. The value of these classifications is for reporting only. For the purposes of treatment, the major determinant is whether the joint complex is stable or unstable. This is determined by the above-described radiographic stress views.

Computed tomography

A routine computed tomography (CT) scan through the midfoot is suggested to visualize any bony injury to the plantar bony structures. CT also allows a three-dimensional (3D) assessment of surrounding joint stability. Midfoot stability is vital to adequate Lisfranc injury recovery. (See the image below.)

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

Magnetic resonance imaging (MRI)

When compared with CT and weightbearing radiography, magnetic resonance imaging (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 showed 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.[17] Rupture or grade 2 sprain of the plantar ligament between the first cuneiform and the bases of the second and third MTs is highly suggestive of an unstable midfoot, which will require stabilization.

Bone scanning

Bone scanning is best used for suspected acute and chronic injuries of the tarsometatarsal (TMT) joints. A bone scan can demonstrate Lisfranc injuries that occurred 3 months before presentation and are continuing with painful weightbearing. Increased uptake on bone scans indicates degenerative changes that are not yet visible on plain films.

Ultrasonography

Nonvisualization of the of the dorsal C1-M2 ligament and a C1-C2 distance greater than 2.5 mm on ultrasonography are indirect signs of a Lisfranc ligament tear. This technique also lends itself to being used in a dynamic fashion that might help make the diagnosis in patients with subtle injuries.[18]

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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 will reveal any significant instability (see the images below).

Stress view. This patient, with a suspected Lisfra 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 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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Histologic Findings

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

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Staging

In athletic injuries, Nunley and Vertullo suggested a three-stage diagnostic classification, as follows[19] :

  • Stage I - Tear of dorsal ligaments with sparing of the Lisfranc ligament
  • Stage II - Direct injury to the Lisfranc ligament with elongation or rupture
  • Stage III - Progression of the above, with damage to the plantar TMT ligaments and joints, along with potential fracture and loss of arch
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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, Texas Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

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, Texas Medical Association

Disclosure: Received honoraria from AO North America for speaking and teaching; Received consulting fee from Stryker for consulting; Received consulting fee from Biomet for consulting; Received grant/research funds from AO North America for fellowship funding; Received honoraria from MMI inc for speaking and teaching; Received consulting fee from Osteomed for consulting; Received ownership interest from MedHab Inc for management position.

Allison M Wade, MD Orthopedic Surgeon, Vero Orthopedics, Vero Neurology

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, Tennessee Medical Association, Florida Orthopaedic Society

Disclosure: Nothing to disclose.

Santaram Vallurupalli, MD Assistant Professor, University of Oklahoma Health Sciences Center

Disclosure: Nothing to disclose.

David L Flood, MD Assistant Professor of Clinical Orthopedic Surgery, University of Missouri-Columbia School of Medicine; Sports Medicine and Arthroscopic Surgery Subspecialist, Clinic Director of Missouri Orthopedic Institute at Capital Region Medical Center

David L Flood, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Western Orthopaedic Association, California Orthopedic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Thomas M DeBerardino, MD Associate Professor, Department of Orthopedic Surgery, Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder, Team Physician, Orthopedic Consultant to UConn Department of Athletics, University of Connecticut Health Center

Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Arthrex, Inc.; Ivy Sports Medicine; MTF; Aesculap; The Foundry, Cotera; ABMT<br/>Received research grant from: Histogenics; Cotera; Arthrex.

Additional Contributors

James K DeOrio, MD Associate Professor of Orthopedic Surgery, Duke University School of Medicine

James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society

Disclosure: Received royalty from Merete for other; Received royalty from SBi for other; Received royalty from BioPro for other; Received honoraria from Acumed, LLC for speaking and teaching; Received honoraria from Wright Medical Technology, Inc for speaking and teaching; Received honoraria from SBI for speaking and teaching; Received honoraria from Integra for speaking and teaching; Received honoraria from Datatrace Publishing for speaking and teaching; Received honoraria from Exactech, Inc for speaking a.

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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.
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.
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.
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 the related image. 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.
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.
 
 
 
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