History and Physical Examination
Patients with Lisfranc injuries can present with obvious anatomic deformities or with variable amounts of pain with weightbearing. Lisfranc injury should be excluded in any patient with midfoot pain on either the dorsal or the plantar aspect of the foot during weightbearing.
Clinical signs of Lisfranc injury are the following:
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Swelling out of proportion with a normal radiograph
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Plantar midfoot ecchymosis (see the image below)
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Pain along the tarsometatarsal (TMT) joints with palpation, motion, or weightbearing
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Midfoot instability
Clinical identification of typical plantar ecchymosis pattern observed in Lisfranc injuries.
For all suspected injuries, a careful workup is warranted. 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 (eg, those with diabetes) because they may be at greater risk for progressive neuropathic changes. Likewise, trauma patients who are nonweightbearing because of other injuries should be carefully screened and examined in the presence of midfoot pain or characteristic ecchymosis.
Athletes
Lisfranc injury is seen more commonly in football players, gymnasts, ballet dancers, and track-and-field athletes; it has also been reported in a professional hockey player. [15] The Lisfranc injury can potentially be a career-ending injury, particularly for elite gymnasts, as noted by Chilvers et al. [16] 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 in the en-pointe position. [17]
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 greater than 2 mm between the first and second metatarsals (MTs), as seen on anteroposterior (AP) radiographs, is consistent with a third-degree sprain. [8, 9]
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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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Clinical identification of typical plantar ecchymosis pattern observed in Lisfranc injuries.
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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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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 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 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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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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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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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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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.
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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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Preoperative anteroposterior radiograph demonstrates a Lisfranc dislocation.
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Preoperative lateral radiograph demonstrates a Lisfranc dislocation.
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Postoperative anteroposterior radiograph demonstrates reduction and fixation of Lisfranc dislocation.
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Postoperative lateral radiograph illustrates placement of fixation screws for stabilization of Lisfranc 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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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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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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Postoperative anteroposterior radiograph demonstrates fixation of the metatarsal, as well as stabilization of the Lisfranc joint.
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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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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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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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Postoperative lateral radiograph demonstrates restoration of alignment with tarsometatarsal fusion.
