Fracture, Lisfranc
Kenneth M. Bielak
Benjamin D. England
BasicsDescription
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Injury occurs from direct or indirect mechanisms.
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Direct injury occurs with crush injury to the tarsometatarsal joint.
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Indirect injury occurs:
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When the hindfoot is placed in a fixed position, and the forefoot is forcefully abducted, producing lateral displacement of the metatarsals with associated fracture of the second metatarsal base
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From an axially applied force to a plantar flexed foot (“tiptoe” position) causing disruption of the dorsal ligament complex
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From a force applied to the heel in the axis of the foot with the toes in a fixed plantar position
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Synonym(s): Lisfranc fracture; Tarsometatarsal fracture; First-second metatarsal-cuneiform fracture
Epidemiology
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1/50,000–60,000 orthopedic injuries per year; 67% occur in motor vehicle accidents.
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0.2% of all fractures per year
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Rare in the athletic population
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2nd tarsometatarsal joint is most frequently injured.
Risk Factors
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Slips, falls, motor vehicle accidents
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Motorcycle accidents continue to be a source of severe injury, especially to the foot. The most common foot injury is a metatarsal fracture; however, there must be a high index of suspicion for associated injuries (1).
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Although these injuries are associated with a low mortality rate, they require prompt assessment and treatment to limit long-term morbidity and disability.
Commonly Associated Conditions
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Cuneiform and cuboid fracture dislocations
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Compartment syndrome of the foot
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Late recognition and treatment: Posttraumatic arthritis with resulting pes planus and forefoot abduction, which may require tarsometatarsal arthrodesis
DiagnosisHistory
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Is there midfoot pain? A high index of suspicion for these injuries needed. Up to 20% of subtle injuries may be missed on initial examination.
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Was the injury associated with low- or high-velocity trauma? High-velocity trauma usually will have obvious deformity; low-velocity trauma may cause only minor discomfort in the midfoot.
Physical Exam
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Signs and symptoms include:
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Midfoot pain and swelling
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Pain with weight-bearing on involved foot or inability to bear weight
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Plantar ecchymosis
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Physical examination should include the following:
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Evaluate the integrity of the soft tissue, and perform neurovascular examination. Marked swelling and deformity may indicate complete dislocation and risk for compartment syndrome.
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Palpate each articulation for tenderness and swelling. Medial cuneiform-1st metatarsal joint is the most frequent site of pain and swelling.
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Stress 2nd metatarsal joint by elevating and depressing the 2nd metatarsal head relative to the 1st metatarsal head; elicits pain in Lisfranc joint.
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Compression of midfoot from side to side reproduces pain in the interval between the bases of the 1st and 2nd metatarsals.
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Diagnostic Tests & Interpretation
Imaging
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Standard anteroposterior (AP) view:
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Medial shaft of 2nd metatarsal should be aligned with medial aspect of the middle cuneiform.
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Any malalignment indicates Lisfranc dislocation.
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Small fractures in and around the Lisfranc joint should cause suspicion of significant injury in this area.
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“Fleck sign” avulsion fracture in medial cuneiform-2nd metatarsal space represents rupture of Lisfranc ligament.
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Compression fracture of cuboid (“nutcracker” injury) may be apparent.
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30-degree oblique view: Medial shaft of 4th metatarsal should align with the medial aspect of the cuboid. Any malalignment indicates disruption of the joint. Malalignment of 1st metatarsal joint is seen frequently.
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Lateral view: Dorsal or plantar displacement of the metatarsals relative to the tarsal bones
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Weight-bearing lateral (both feet): Flattening of longitudinal arch; seen with subtle Lisfranc injuries
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Weight-bearing AP (both feet): Diastasis >1–2 mm between 1st and 2nd metatarsal bases indicates rupture of Lisfranc ligament.
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Stress views: Valgus stress can be applied to accentuate the injury.
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CT scan may be helpful in defining the extent of injury.
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MRI can show isolated ligamentous injury and bone marrow edema as another important differentiating feature.
Differential Diagnosis
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Lisfranc fracture dislocation
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Tarsometatarsal sprain
P.213
Treatment-
Bulky posterior splint for fracture ± dislocation
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Lisfranc injuries with <2 mm of diastasis on weight-bearing radiographs can be treated without weight-bearing in a short-leg cast or a walking boot for 6 wks (2).
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Lisfranc injuries with more significant displacement or instability require operative intervention.
Pre-Hospital
Immobilize with posterior splint, non-weight-bearing, elevation, and ice/compression
Surgery/Other Procedures
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Any diastasis (>1 mm) or fracture requires operative reduction and screw fixation.
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Primary treatment by open reduction and internal fixation (ORIF) of tarsometatarsal fracture dislocations leads to improved functional results, earlier return to work, and greater patient satisfaction than secondary corrective arthrodesis (remains a useful salvage procedure providing significant relief of pain and improvement in function) (3).
Ongoing CareFollow-Up Recommendations
Early orthopedic referral is indicated for any fracture, dislocation, or instability of the Lisfranc joint.
References
1. Jeffers RF, Tan HB, Nicolopoulos C, et al. Prevalence and patterns of foot injuries following motorcycle trauma. J Orthop Trauma. 2004;18:87–91.
2. Lattermann C, Goldstein JL, Wukich DK, et al. Practical management of lisfranc injuries in athletes. Clin J Sport Med. 2007;17:311–315.
3. Rammelt S, Schneiders W, Schikore H, et al. Primary open reduction and fixation compared with delayed corrective arthrodesis in the treatment of tarsometatarsal (Lisfranc) fracture dislocation. J Bone Joint Surg Br. 2008;90:1499–1506.
Additional Reading
Clanton TO, Porter DA. Primary care of foot and ankle injuries in the athlete. Clin Sports Med. 1997;16:435–466.
Coetzee JC. Making sense of Lisfranc injuries. Foot Ankle Clin. 2008;13:695–704.
Crim J. MR Imaging evaluation of subtle Lisfranc injuries: the midfoot sprain. Magn Reson Imaging Clin N Am. 2008;16:19–27.
Desmond EA, Chou LB. Current concepts review: lisfranc injuries. Foot Ankle Int. 2006;27:653–660.
CodesICD9
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825.24 Fracture of cuneiform bone of foot, closed
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825.25 Fracture of metatarsal bone(s), closed
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825.29 Other fracture of tarsal and metatarsal bones, closed
Clinical Pearls
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Generally, surgically repaired injuries initially are immobilized in a non-weight-bearing cast for 6 wks, followed by progressive weight-bearing in a cast or range-of-motion boot for another 3–6 wks.
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Athletes typically can return to sports at 4–5 mos after injury.