Orthopaedic Surgery - Lisfranc Fracture–Dislocation

Basics

A Lisfranc fracture-dislocation is an injury involving the tarsometatarsal (TMT) joint complex of the midfoot.

The injury may consist primarily of ligament disruption, fracture, joint dislocation, or a combination of these abnormalities.

Lisfranc injuries can occur at any age and may range from subtle low-energy instability to severe high-energy fracture-dislocations associated with extensive soft-tissue damage.

Fractures involving the:

Metatarsal bases, cuneiforms, and cuboid

commonly accompany the ligamentous injury.

Classification

A traditional classification describes the direction and extent of TMT incongruity.

Type A

Type A injuries demonstrate total incongruity of the tarsometatarsal joint complex, with the metatarsals displaced together as a unit.

Type B

Type B injuries show partial incongruity.

Displacement may involve either the:

Medial portion or lateral portion of the TMT complex.

Type C

Type C injuries demonstrate a divergent pattern.

Typically:

The first metatarsal displaces medially, while the second through fifth metatarsals displace laterally.

Epidemiology

Lisfranc injuries represent an important proportion of midfoot trauma.

Historical series suggest that they may account for approximately one-third of midfoot injuries.

The true incidence is probably underestimated because subtle injuries may be overlooked initially.

Risk Factors

Risk is increased with:

Motor vehicle collisions, motorcycle crashes, high-energy trauma, and sports involving axial loading or twisting of a plantarflexed foot.

Etiology

The mechanism ranges from relatively minor twisting to severe crush injury.

Low-Energy Mechanism

A low-energy injury may occur when a plantarflexed forefoot is twisted or axially loaded.

This is common in sports.

High-Energy Mechanism

High-energy Lisfranc injuries may result from:

Motor vehicle collisions, motorcycle crashes, falls from height, or crushing trauma.

These injuries are more likely to be associated with fractures, soft-tissue compromise, and compartment syndrome.

Automobile and Motorcycle Injury

A classic mechanism occurs when the patient braces against a brake pedal with the foot plantarflexed during a collision.

Axial force transmitted through the forefoot may disrupt the Lisfranc complex.

Sports Injuries

Athletic injuries may occur during:

Running, twisting, tackling, jumping, or axial loading of a plantarflexed foot.

Sports-related Lisfranc injuries may be subtle and predominantly ligamentous.

Associated Conditions

Lisfranc injuries may occur with:

Comminuted fractures of the metatarsal bases

Cuneiform fractures

Cuboid fractures

Severe soft-tissue injury

Compartment syndrome

Open fractures

High-energy trauma should prompt careful examination of the entire foot and lower extremity.

Diagnosis

Signs and Symptoms

Typical findings include:

Midfoot pain, swelling, deformity, bruising, and difficulty or inability to bear weight.

Some injuries spontaneously reduce before evaluation, so obvious deformity may be absent.

Plantar Ecchymosis

Bruising on the plantar midfoot is an important clinical clue and should raise strong suspicion for a Lisfranc injury.

Physical Examination

Inspection

Assess for:

Swelling, dorsal or plantar ecchymosis, deformity, skin compromise, blistering, and open wounds.

Palpation

Focal tenderness is often greatest around the first and second TMT joints, particularly over the base of the second metatarsal.

Forefoot Stress

Rotational or abduction-pronation stress applied to the forefoot may reproduce pain at the Lisfranc joint complex.

Pain with this maneuver suggests instability.

Weight Bearing

Patients may have substantial pain during standing or walking.

In subtle injuries, inability to perform a single-leg heel rise or push off normally may be a useful clue.

Neurovascular Examination

A complete distal neurovascular examination should be documented.

Assess:

Pulses, capillary refill, skin temperature, motor function, and sensation.

Compartment Syndrome

High-energy midfoot injuries carry a risk of compartment syndrome.

The patient should be monitored for:

Severe or increasing pain, pain with passive toe movement, tense swelling, sensory changes, and progressive neurologic dysfunction.

Imaging

Plain Radiographs

Standard radiographs should include:

AP, lateral, and oblique views of the foot.

When the patient can tolerate it safely, weight-bearing bilateral radiographs may improve detection of subtle instability.

AP View

On the AP radiograph, the:

Medial border of the second metatarsal base should align with the medial border of the middle cuneiform.

Loss of this relationship suggests TMT displacement.

Oblique View

On the oblique view, the:

Medial border of the fourth metatarsal base should align with the medial border of the cuboid.

Disruption suggests lateral-column injury.

Lateral View

On the lateral radiograph, the dorsal surfaces of the metatarsal bases should align smoothly with their corresponding tarsal bones.

Dorsal displacement of the metatarsals relative to the cuneiforms suggests Lisfranc instability.

Fleck Sign

A small avulsion fragment between the base of the second metatarsal and medial cuneiform is called the fleck sign.

It strongly supports injury to the Lisfranc ligament complex.

Cuboid Compression Injury

Compression or impaction of the cuboid may accompany severe lateral-column injury and should raise suspicion for a broader Lisfranc fracture-dislocation pattern.

Stress Imaging

When plain films appear normal but clinical suspicion remains high, especially after spontaneous reduction, further evaluation may include:

Weight-bearing radiographs, stress fluoroscopy, CT, or MRI.

CT

CT is an important adjunct for defining:

Small fractures, articular impaction, subtle displacement, comminution, and operative anatomy.

Lisfranc injuries may be missed on standard radiographs, particularly when displacement is minimal.

MRI

MRI is useful when a predominantly ligamentous injury is suspected despite nondiagnostic radiographs or CT.

It can evaluate:

The Lisfranc ligament complex, surrounding soft tissues, bone marrow edema, and occult fracture.

Differential Diagnosis

Important alternatives include:

Midfoot contusion, ligament sprain, isolated metatarsal fracture, cuneiform fracture, cuboid fracture, navicular injury, and other tarsometatarsal injuries.

Treatment

General Principles

The main treatment goal is to:

Restore and maintain anatomic alignment of the tarsometatarsal joints so that the ligaments and articular surfaces can heal in a stable position.

Even small residual malalignment may increase the risk of chronic pain and post-traumatic arthritis.

Initial Management

Before definitive treatment, evaluate for:

Compartment syndrome, vascular compromise, open injury, and severe soft-tissue swelling.

Immobilization

The foot should be placed in a well-padded splint and elevated.

Swelling Control

Measures may include:

Ice, elevation, compression when safe, and careful soft-tissue monitoring.

Definitive surgery may be delayed until swelling improves if the soft tissues are severely compromised.

Nonoperative Treatment

Stable, nondisplaced Lisfranc injuries without instability on weight-bearing imaging may be treated nonoperatively.

Management generally involves:

Immobilization and strict protection from weight bearing for several weeks, followed by gradual progression if alignment remains stable.

Close radiographic monitoring is required.

Operative Treatment

Displaced or unstable injuries usually require surgery.

The two principal strategies are:

Open reduction and internal fixation

or

Primary arthrodesis of selected TMT joints.

Open Reduction and Internal Fixation

Surgical exposure is commonly obtained through one or more dorsal longitudinal incisions.

The goal is precise reduction of the TMT joints, especially the:

First and second rays and the Lisfranc interval between the medial cuneiform and second metatarsal base.

Fixation

Fixation may involve:

Screws, plates, bridge plates, or Kirschner wires, depending on the injury pattern and involved columns.

Historically, 3.5-mm cortical screws have been widely used.

Kirschner-Wire Fixation

K-wires may be used for selected lateral-column injuries.

They are usually temporary and can often be removed after several weeks once sufficient stability has developed.

Screw or Plate Fixation

Rigid fixation of the medial and middle columns is commonly maintained longer because these joints contribute importantly to midfoot stability.

Weight bearing is restricted until healing and fixation stability are sufficient.

Primary Arthrodesis

Primary fusion of selected TMT joints is increasingly used for certain injuries, particularly:

Severe purely ligamentous injuries, major articular destruction, or injuries in which reliable joint preservation is unlikely.

The medial and middle columns are the most common fusion targets.

Salvage Arthrodesis

Arthrodesis is also an important salvage procedure for:

Painful post-traumatic midfoot arthritis, chronic instability, or late deformity after failed initial treatment.

Physical Therapy

Postoperative rehabilitation begins with protection of the repair.

Gait Training

Patients usually require training with:

Crutches, walker, or other assistive devices while non-weight bearing.

Edema Control

Therapy may include:

Elevation, compression when appropriate, and active toe movement.

Range of Motion

Motion of the:

Ankle and toes

should be maintained when permitted to reduce stiffness.

Weight Bearing

The timing of weight-bearing progression depends on:

The injury pattern, fixation method, soft-tissue condition, radiographic healing, and surgeon protocol.

Patients are generally kept non-weight bearing initially and then progress to protected weight bearing once healing and stability are adequate.

Follow-Up

Prognosis

The most important predictor of outcome is restoration and maintenance of anatomic alignment.

Patients with accurate reduction generally have better outcomes than those with persistent displacement.

Factors Associated With Poorer Outcome

Results are less favorable with:

Nonanatomic reduction, severe articular damage, delayed diagnosis, extensive soft-tissue injury, or high-energy trauma.

Primary Arthrodesis Outcomes

For selected unstable or predominantly ligamentous injuries, primary arthrodesis may provide outcomes comparable to or better than fixation alone.

The optimal strategy depends on:

Injury pattern, joint destruction, patient activity level, and surgeon judgment.

Complications

Post-Traumatic Arthritis

Post-traumatic arthritis is one of the most common long-term complications.

It results from:

Initial cartilage injury, residual incongruity, or chronic instability.

Fixed Deformity

Malalignment may lead to:

Midfoot collapse, abduction deformity, altered arch height, chronic pain, and difficulty with footwear.

Chronic Instability

Failure of ligament healing or loss of fixation may produce persistent instability and pain during push-off.

Delayed Diagnosis

Lisfranc injuries diagnosed late, particularly after approximately 7–8 weeks, have a worse prognosis because:

Soft-tissue contracture, malalignment, cartilage injury, and early arthritis may already be present.

Late Treatment

Patients with chronic painful deformity or arthritis may be better treated with:

Corrective arthrodesis rather than delayed joint-preserving fixation.

Hardware Problems

Screws, plates, or pins may become:

Prominent, painful, loose, or broken.

Selected implants may require later removal.

Infection

Superficial or deep infection may occur after open injury or operative treatment.

Risk is greater with severe soft-tissue trauma.

Patient Monitoring

Serial follow-up is necessary to ensure the Lisfranc complex remains anatomically aligned.

Radiographs are often obtained at intervals during early healing, historically around monthly, although timing should be individualized.

Monitoring should assess:

Joint alignment, hardware position, fracture healing, midfoot stability, pain, swelling, and progression of weight bearing.

Persistent pain or loss of alignment should prompt reevaluation for instability, nonunion, hardware failure, or post-traumatic arthritis.