Lisfranc Injuries

Summary

Injuries to the Lisfranc joints are uncommon but can be difficult to diagnose. A high degree of suspicion for lisfranc injuries must be maintained for all patients presenting with midfoot pain and swelling and a significant mechanism. X-rays often do not reflect the extent of the injury and CT is necessary to show the significant bony and ligamentous disruption that characterises this injury. Missed lisfranc injuries result in significant post traumatic arthritis.

Classification

There are several classification systems for TMTC injuries.

The most commonly used classification is that developed by Quene and Kuss in 1909:⁴

1. Homolateral: All five metatarsals displaced in the same direction.
2. Isolated: One or two metatarsals displaced from the others.
3. Divergent: Metatarsals are displaced in both the sagittal and coronal planes.

The above system was further modified by Myerson et al. in 1986 to the following which gives much more anatomical detail.¹

• Type A total incongruity of the TMT joint.
• Type B injuries – partial Incongruity
  • Type B1 partial incongruity affecting the first ray in relative isolation (i.e. partial medial incongruity);
  • Type B2 partial incongruity in which the displacement affects one or more of the lateral four MTs (i.e. partial lateral incongruity).
• Type C - Divergent
  • Type C1 Partial displacement
  • Type C2 total displacement.

Classification of tarsometatarsal joint injury. The shaded areas represent the injured or displaced portion of the foot.

• A, Type A, total incongruity, which involves displacement of all five metatarsals (MTs) with or without fracture at the base of the second MT. The usual displacement is lateral or dorsolateral, and the MTs move as a unit. These injuries are “homolateral.”
• B, In type B injuries, one or more articulations remain intact. Type B1 represents partial incongruity with medial dislocation. Type B2 represents partial incongruity with lateral dislocation; the first MT cuneiform joint may be involved.
• C, Type C injuries are divergent, with either partial (C1) or total (C2) displacement. The arrows in C2 represent the forces through the foot leading to a divergent pattern.

Redrawn with permission from Myerson MS, Fisher RT, Burgess AR, Kenzora JE: Fracture-dislocations of the tarsometatarsal joints: End results correlated with pathology and treatment. Foot Ankle1986;6:225–242.

Epidemiology

• First described by Jacques Lisfranc de St Martin (1790-1847), a field surgeon in the Naoleonic army. He described a significant injury to the MTC when a soldier fell off their horse with their foot in the stirrups. This caused a vascular injury, often requiring amputation through this joint.
• Uncommon injuries. Incidence in the USA is 1 per 55,000 people or 0.2% of all fractures (1).
• 1/3 are low velocity injuries – often sports related and involved forced plantarflexion with rotation or forced abduction.
• 2/3 are high velocity injuries with a similar mechanism, and result from motor vehicle and motorbike accidents, and falls from a height.

Presentation

• The Tarsometatarsal complex (TMTC) or lisfranc joint is made up of 9 bones - the 5 metatarsal bases, the proximal articular surfaces of the three cuneiforms and the cuboid laterally. Functionally it is the transition point between the forefoot and midfoot.
• The bases of the middle three metatarsals are trapezoidal in shape. Together with their associated cuneiforms, they form a transverse arch, the keystone of which is the second tarsometatarsal joint. This improves the inherent stability of this joint.
• The lisfranc ligament runs between the second metatarsal base and the medial cuneiform and is the strongest structure supporting the TMT complex. There are other ligamentous complexes that support the joint but the lisfranc ligament is the strongest.

Imaging

• Plain X-rays: AP, lateral and oblique films (with the image taken parallel to the midfoot 1). Up to 20% of injuries to the Lisfranc joint are missed on X-ray.
• Weight bearing views can make the deformity more obvious.
• The AP film shows malalignment of the 1st and 2nd tarsometatarsal joint, whereas the oblique film shows any malalignment at the 3rd and 4th tarsometatarsal joints.
• On the lateral view, the dorsal and plantar aspects of the MTs should correspond with the cuneiform and cuboid. A tangential line drawn through the medial aspect of the medial cuneiform and navicular should intersect the first MT base 1.

Any suspected TMTC injury should be further evaluated by a CT to assess the extent of the fractures and ligamentous injuries, particularly when the injury is sustained via a high energy mechanism. It is not uncommon for CT to show comminution and intraarticular extension of the fracture not seen on X-ray. CT may not show subtle displacement as it is also not a weight bearing test.

MRI will better evaluate the ligamentous and soft tissue injury aspect of the injury and is important in evaluation of the low energy injury subgroup in particular.

ED Management Options

• Adequate analgesia
• High index of suspicion based on clinical presentation and mechanism.
• Foot and ankle X-rays.
• CT if required.
• Orthopaedic consult to decide whether it is an unstable injury requiring an ORIF or a stable injury.
• Unstable Injuries:
  • If any subluxation or ligamentous injury, lisfranc injuries require open reduction and internal fixation.
  • Backslab, non weight bearing. Keep foot elevated. ADMIT for OT.
• Unstable Injuries – this will require immobilisation with a backslab and fixation in the operating theatre. Discharge planning and follow up will be as per the orthopaedic team.
• Stable injuries can be managed in a Cam Boot for 6-10 weeks, weight bearing as tolerated. Relative contraindications for surgical intervention may include insensate feet (e.g. charcot midfoot), inflammatory arthritis, nonambulatory status, and severe medical comorbidity.

Referral and Follow Up Requirements

Stable injuries – discharge in cam boot, weight bearing as tolerated. Follow up in 6 weeks.

Unstable injuries: Will have ORIF to restore anatomic alignment. Follow up to be determined by orthopaedic team.

Potential Complications

• Missed injury (up to 20% of injuries are missed initially).
• Post traumatic arthritis
• Ongoing foot pain and instability. May require salvage arthrodesis.

Patient Advice

• Stable injuries for discharge - weight bear as tolerated.
• Follow up with an orthopaedic surgeon within 2 weeks.
• You may require an MRI to further investigate this injury if you have ongoing pain and swelling.
• Pain from the fracture and restriction of movement is usual for 2-3 weeks and will require regular, then analgesia as required.
• Monitor for compartment syndrome.
• ECI patient factsheets

Further References and Resources

• Burge, A. et al. (2012) Imaging of Sports-Related Midfoot and Forefoot Injuries, Sports Health. 2012 Nov; 4(6): 518–534.
• Medscape -
• OrthoInfo - Lisfranc (Midfoot) Injury.
• Pyklawa T, Andersen,L; Midfoot Trauma, Current Orthopaedic Practice, 19(3), May 2008, p 228–233.
• Watson, T. et al. (2010) Treatment of Lisfranc joint injury: current concepts, J Am Acad Orthop Surg, December, 18(12), 718-28.