Residency · Residency · Orthopedic Surgery
Lisfranc Injuries: Diagnosis and Fixation Strategies
Introduction
Lisfranc injuries encompass a spectrum of pathology at the tarsometatarsal (TMT) joint complex, ranging from subtle ligamentous sprains to frank fracture-dislocations. These injuries are frequently missed on initial evaluation, leading to chronic pain, midfoot instability, and post-traumatic arthritis. A high index of suspicion and systematic assessment are essential for timely diagnosis and appropriate management.
Anatomy
The Lisfranc joint complex comprises the articulations between the three cuneiforms and cuboid proximally, and the five metatarsal bases distally. The Lisfranc ligament is the critical stabilizer: a strong plantar ligament running from the medial cuneiform to the base of the second metatarsal. Critically, there is no intermetatarsal ligament between the first and second metatarsals, creating the weak link in the midfoot. The second metatarsal base is recessed into the intercuneiform mortise (Roman arch configuration), providing intrinsic bony stability. The dorsalis pedis artery passes between the first and second metatarsals and may be injured in displaced Lisfranc injuries.
The three-column concept divides the midfoot into the medial column (first metatarsal-medial cuneiform, requiring mobility for gait), the middle column (second and third metatarsals with their cuneiforms, which is rigid and load-bearing), and the lateral column (fourth and fifth metatarsals with cuboid, which is mobile and accommodative).
Mechanism of Injury
High-energy mechanisms include motor vehicle accidents, falls from height, and industrial crush injuries, producing obvious fracture-dislocations. Low-energy mechanisms occur in athletics (football, soccer) with axial load on a plantarflexed foot with rotation, often producing purely ligamentous injuries that are more easily missed. Direct mechanisms cause crush injury to the midfoot, while indirect mechanisms involve axial load through the metatarsals with the foot in equinus and slight rotation.
Classification
Myerson Classification (Modified Quenu and Kuss)
Type A involves total incongruity with all five metatarsals displaced in the same direction (lateral or dorsal). Type B involves partial incongruity: B1 is medial dislocation of the first metatarsal only, and B2 is lateral displacement of one or more of the lesser metatarsals. Type C is a divergent pattern where the first metatarsal displaces medially while the lesser metatarsals displace laterally.
Column-Based Classification
The column-based classification is increasingly used for surgical planning. It identifies involvement of the medial, middle, and lateral columns independently and distinguishes between ligamentous injuries and fracture-dislocations in each column.
Diagnosis
Clinical Evaluation
Patients present with midfoot pain, swelling, and inability to bear weight after injury. Plantar ecchymosis at the midfoot is highly suggestive of a Lisfranc injury. Pain is elicited with passive abduction-pronation of the forefoot while stabilizing the hindfoot. Point tenderness is present over the TMT joints, particularly the first-second intermetatarsal space. The dorsalis pedis pulse and foot perfusion must be assessed.
Imaging
Plain Radiographs
Weight-bearing AP, lateral, and 30-degree oblique views of the foot are essential. On the AP view, the medial border of the second metatarsal should align with the medial border of the middle cuneiform. On the oblique view, the medial border of the fourth metatarsal should align with the medial border of the cuboid. On the lateral view, there should be no dorsal step-off at the TMT joints. The fleck sign (a small avulsion fragment between the first and second metatarsal bases) indicates a Lisfranc ligament avulsion. Diastasis greater than 2 mm between the first and second metatarsal bases on the AP view is abnormal. Comparison views with the contralateral foot may be helpful.
Stress Radiographs
Abduction stress views under fluoroscopy can unmask subtle instability by comparing the first-second intermetatarsal distance between stressed and unstressed views.
Advanced Imaging
Weight-bearing CT is the emerging gold standard for subtle injuries, detecting occult fractures, subtle diastasis, and plantar ligament disruption. MRI evaluates the integrity of the Lisfranc ligament directly and is useful for purely ligamentous injuries occult on radiographs. Non-weight-bearing CT is useful for preoperative planning of fracture-dislocations.
Treatment
Nonoperative Management
Nonoperative management is indicated only for truly nondisplaced, stable injuries confirmed on weight-bearing imaging. Treatment involves a non-weight-bearing cast for 6 weeks followed by progressive weight-bearing in a stiff-soled boot. Close follow-up with repeat weight-bearing radiographs at 1-2 weeks ensures no displacement.
Operative Management
Indications
Surgery is indicated for any displacement or instability on weight-bearing radiographs, diastasis greater than 2 mm between the first and second metatarsal bases, and fracture-dislocation patterns.
Open Reduction and Internal Fixation (ORIF)
The dorsal approach uses one or two longitudinal incisions between the first-second and third-fourth metatarsals. The second metatarsal base is reduced to the middle cuneiform first (the keystone of the arch). The Lisfranc joint (medial cuneiform to second metatarsal base) is reduced and fixed with a transarticular screw or bridge plate. Reduction and fixation then proceeds to the medial column, followed by the lateral column. Rigid fixation of the middle column is critical (screws or bridge plates). The lateral column (fourth and fifth TMT) may be treated with temporary K-wire fixation (removed at 6 weeks) or flexible fixation to preserve its natural mobility.
Primary Arthrodesis
Primary arthrodesis is increasingly favored for purely ligamentous Lisfranc injuries, which have higher rates of post-traumatic arthritis and hardware failure after ORIF. It involves cartilage removal and fusion of the affected TMT joints (typically the medial and middle columns). The lateral column (fourth and fifth TMT) must not be fused, as these joints require mobility for normal gait accommodation. Several randomized trials demonstrate superior functional outcomes with primary arthrodesis compared to ORIF for purely ligamentous injuries. For fracture-dislocation patterns, ORIF remains the standard approach.
Fixation Options
Cortical screws (3.5 mm) provide traditional transarticular fixation but require removal at 4-6 months before weight-bearing. Bridge plates (dorsal plating across the TMT joints) provide stable fixation without joint penetration and can be left in situ. Suture button devices allow some physiologic motion but have limited long-term data.
Postoperative Protocol
Patients remain non-weight-bearing for 6-8 weeks. Sutures are removed at 2 weeks with serial radiographs at 6 and 12 weeks. Progressive weight-bearing in a boot proceeds from 8-12 weeks. Transarticular screws are removed at 4-6 months if ORIF was performed (prior to unrestricted activity). Custom orthotics with arch support are used long-term. Return to sport occurs at 6-9 months depending on injury severity and fixation method.
Complications
The most common complication is missed diagnosis, leading to chronic midfoot instability and pain. Post-traumatic arthritis occurs in 20-50% of cases even with anatomic reduction and is more common in ligamentous injuries. Hardware failure (screw breakage) occurs in up to 20-40% of ORIF for ligamentous injuries. Loss of the longitudinal arch produces flatfoot deformity from inadequate reduction or fixation failure. Compartment syndrome of the foot is rare but must be considered in crush injuries.
Key Clinical Pearls
Plantar ecchymosis at the midfoot after a foot injury is pathognomonic for a Lisfranc injury until proven otherwise, and weight-bearing radiographs must always be obtained. Weight-bearing CT has become the gold standard for detecting subtle Lisfranc injuries that are occult on standard radiographs and should be used liberally when clinical suspicion is high. For purely ligamentous Lisfranc injuries, primary arthrodesis of the medial and middle columns produces superior functional outcomes compared to ORIF with screw fixation. The lateral column (fourth and fifth TMT joints) should never be fused because these joints require mobility for normal gait accommodation over uneven surfaces.
References
- Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle. 1986;6(5):225-242.
- Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. J Bone Joint Surg Am. 2006;88(3):514-520.
- Nunley JA, Vertullo CJ. Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med. 2002;30(6):871-878.
- Weatherford BM, Bohay DR, Anderson JG. Open reduction and internal fixation versus primary arthrodesis for Lisfranc injuries. Foot Ankle Clin. 2017;22(1):1-14.