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Lisfranc fracture dislocation cover

Lisfranc Fracture Dislocation

Case Introduction

A 17 year old male presents with left foot pain immediately following a football game. He says he was tackling someone and one of his teammates fell onto his left foot. He felt a pop with immediate onset of pain and was unable to bear weight on it. Emergency medical services (EMS) reports significant swelling and deformity on the scene. The team’s trainer applied a splint and ice and transported him to the hospital.
XR Lisfranc Fracture Dislocation Lateral
Lateral radiograph shows dorsal dislocation of the tarsal-metatarsal joint
XR Lisfranc Fracture Dislocation PA
PA radiograph shows complete disruption of the tarsometatarsal joint. Additional cuboid and navicular fractures are seen.
On arrival to the ED, the patient is noted to have a swollen and tender midfoot. There is some bruising already present. The dorsalis pedis pulse is 2+ and he can wiggle his toes. Radiographs are obtained which identify a left Lisfranc fracture-dislocation. There is also a displaced, comminuted fracture-dislocation of the cuboid. Orthopedic surgery is consulted, a hematoma block is performed along with a closed reduction and the patient is admitted to the hospital for surgical management.


Lisfranc injuries, which includes a broad spectrum of injuries from ligament sprain to complex fracture-dislocation, refers to injuries to the so-called lisfranc joint. The lisfranc joint, more appropriately termed the tarsometatarsal joint, is proximally composed of the 3 cuneiforms and cuboid and distally with metatarsals 1 through 5. The lisfranc ligament complex includes the Y-shaped lisfranc ligament which extends from the medial cuneiform to the second metatarsal base as well as a series of dorsal ligaments stabilizing the second through fifth metatarsals.
Ligaments of the lisfranc joint
Ligaments of the Lisfranc joint including the Lisfranc ligament complex, and intermetatarsal and tarsometatarsal ligaments. Only the dorsal ligaments are noted in this drawing.1Tafur, Monica, Zehava Sadka Rosenberg, and Jenny T. Bencardino. "MR imaging of the midfoot including Chopart and Lisfranc joint complexes." Magnetic Resonance Imaging Clinics 25.1 (2017): 95-125.
lisfranc joint bony anatomy
Bones of the Lisfranc joint

Lisfranc injuries are fairly rare, representing 0.2% of all fractures and subsequently, up to 20% of them are missed initially in polytrauma or low-energy mechanisms.1Perron, AD, Brady, WJ, Keats, TE. Orthopedic pitfalls in the ED: Lisfranc fracture-dislocation. Am J Emerg Med. 2001;19:71-75. The vast majority are closed injuries and the average patient is a 20-30 year old male. The mechanism can be from either high energy forces or low energy forces. A review of 2000 cases found that the most common causes were motor vehicle accidents (43%), fall from height (24%), crush injuries (13%) and sports injuries (9.7%).2Lievers, WB, Frimenko, RE, Crandall, JR, Kent, RW, Park, JS. Age, sex, causal and injury patterns in tarsometatarsal dislocations: a literature review of over 2000 cases. Foot (Edinb). 2012;22:117-124. Sports that more commonly encounter lisfranc injuries are gymnastics and horseback riding.

Differential Diagnosis
– Midfoot Sprain
Metatarsal Fracture
Cuboid Fracture
Posterior Tibial Tendon Dysfunction
Lisfranc Injury
– Pes Planus
– Osteoarthritis
Navicular Fracture

lisfranc injury gap sign clinical exam
The ''gap sign'' seen on the right foot is indicative of separation between the great and second toes2Eleftheriou, Kyriacos I., Peter F. Rosenfeld, and James DF Calder. "Lisfranc injuries: an update." Knee Surgery, Sports Traumatology, Arthroscopy 21 (2013): 1434-1446.
lisfranc injury mechanism of action
Lisfranc injury mechanism of injury
History is key as the clinical presentation can vary wildly. It is important to attempt to characterize the exact mechanism if possible, which is most commonly an axial load onto a plantarflexed foot. Most patients have pain, swelling of the midfoot and inability to bear weight. Acutely, pain and swelling may limit the exam. Plantar ecchymosis should raise suspicion even with normal radiographs. Passive range of motion is painful. The so-called positive gap sign is seen when the instability increases the distance between the first and second toes. The piano key test can be used to evaluate the instability of individual metatarsals.
Standard radiographs are the initial imaging study of choice, although they are only 85% sensitive and up to 20% of unstable lisfranc injuries are missed on initial diagnosis.3Rankine, James J., et al. “The diagnostic accuracy of radiographs in Lisfranc injury and the potential value of a craniocaudal projection.” American Journal of Roentgenology 198.4 (2012): W365-W369. Potential findings include loss of alignment between the second metatarsal and medial edge of the middle cuneiform and diastasis between the first and second metatarsal. The fleck sign is a small bony fragment seen in the first intermetatarsal space representing an avulsion fracture of the lisfranc ligament. Weight bearing radiographs with displacement less than 2 mm can be considered stable
Lisfranc fracture on xray and CT
Example of an 11-year-old girl with an acute Lisfranc injury. (a) AP radiograph with widening C1-M2 distance and C1-C2 distance (thick white arrows). (b) Axial and (c) coronal CT images showing a tarsometatarsal malalignment (thick white arrows). (d) The coronal CT imaging with small osseous fleck in the Lisfranc interval from an avulsion injury (thin white arrow)3Sripanich, Yantarat, et al. "Imaging in Lisfranc injury: a systematic literature review." Skeletal Radiology 49 (2020): 31-53.
CT should be obtained if radiographs are inconclusive and can be used for surgical planning. CT does a better job evaluating the metatarsal and tarsal fractures and joint malalignment.4 Preidler, KW, Peicha, G, Lajtai, G, et al. Conventional radiography, CT, and MR imaging in patients with hyperflexion injuries of the foot: diagnostic accuracy in the detection of bony and ligamentous changes. AJR Am J Roentgenol. 1999;173:1673-1677. MRI is useful in subtle lisfranc injuries and best at evaluating soft tissue injuries. In terms of diagnostic value, MRI is 90% sensitive when compared to intraoperative findings.
Management can be non-surgical in stable, nondisplaced injuries. These patients can be placed in a short leg cast and non weight bearing for 6-8 weeks and then weaned into a walking boot or shoe for a further 4-6 weeks. Serial radiographs should be obtained every 2 weeks to confirm there is no delayed displacement or diastasis. Indications for operative management include isolated ligamentous injury, instability, fractures, dislocations and missed or inadequately treated cases. Patients often undergo open reduction and internal fixation although many surgical techniques have been described.
Postoperatively, the patient is typically placed in a cast and made non-weight bearing for the first 6 to 8 weeks. At around 12 weeks, they can go back to a normal shoe with good arch support and begin formal physical therapy. In patients who are managed surgical, outcomes are good to excellent if a high quality reduction is obtained. Patients who can be managed nonoperatively also tend to have excellent outcomes. Predictors of poor outcome include delayed treatment, open injuries, articular comminution, workers comp and purely ligamentous injuries. Complications include acute compartment syndrome, foot osteoarthritis, inability to return to and inability.

Case Conclusion

The next day, the patient underwent open reduction and internal fixation of his lisfranc fracture-dislocation. He had a percutaneous fixation of his 4th and 5th metatarsal fracture. He was discharged on post op day 1, with two week outpatient follow up. On the last visit the patient was doing well and had initiated physical therapy.

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3 Key Points

  1. Lisfranc injuries represent a range of soft tissue and often bony injuries to the lisfranc ligament complex and lisfranc joint
  2. Diagnosis is typically made by on radiographs although CT is useful in the setting of inconclusive radiographs or for surgical planning
  3. Stable injuries can potentially be managed nonsurgically however the vast majority of cases will have some component of instability and require surgical fixation


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