Lisfranc Fracture Dislocation Workup

  • Author: Saul G Trevino, MD; Chief Editor: Jason H Calhoun, MD, FACS   more...
 
Updated: Feb 17, 2012
 

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.

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Imaging Studies

Lisfranc injuries, especially subtle injuries, can often be missed.[19] Up to 20% of Lisfranc injuries are missed on initial presentation to the emergency department (ED).[20] 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.[21]

  • 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 below). In this anteroposterior radiograph of a Lisfranc dIn this anteroposterior radiograph of a Lisfranc dislocation, note the disruption of the normal second tarsometatarsal alignment.
      • 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 below). In this lateral radiograph of a typical Lisfranc iIn this lateral radiograph of a typical Lisfranc injury, note the malalignment of the metatarsal bases with the midfoot.
      • Medial 30º oblique view of the foot - In this view, the cuboid should align with the medial border of the fourth MT (see images below). In this medial oblique radiograph of a normal footIn 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 inIn 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 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.
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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.[22]

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.

Ultrasound

  • Nonvisualization of the of the dorsal C1-M2 ligament and a C1-C2 distance of greater than 2.5 mm are indirect signs of a Lisfranc ligament tear. This technique also lends itself to be used in a dynamic fashion that might help make diagnosis in subtle injuries.[23]
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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 reveals any significant instability (see images below).

Stress view. This patient, with a suspected LisfraStress 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 toIn 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

Intra-operative 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 3-stage diagnostic classification, as follows[24] :

  • 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.
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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  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, Florida Orthopaedic 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: AO North America Honoraria Speaking and teaching; Osteotech Consulting fee Consulting; Stryker Consulting fee Consulting; Biomet Consulting fee Consulting; AO North America Grant/research funds fellowship funding; MMI inc Honoraria Speaking and teaching

Santaram Vallurupalli, MD  Resident Physician, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine

Disclosure: Nothing to disclose.

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

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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, Florida Medical Association, and German Society of Neurology

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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.

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

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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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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