May 30, 2024

Lisfranc Injury is defined as the fracture dislocation of the tarsometatarsal articulation. Lisfranc ligament runs from medial cuneiform to second metatarsal.

Foot swelling following trauma
Foot swelling following trauma

Clinical Features of Lisfranc Injury

Swelling over the dorsum of the foot

Plantar ecchymosis sign

Piano Key test is positive

Stress examination of midfoot

Inability to bear weight

Elevating and depressing 2nd TMT Joint develops PAIN

Lisfranc Injury
Lisfranc Injury

X-ray features of Lisfranc Injury

In Normal foot:

In anteroposterior view: The medial shaft of the 2nd Metatarsal aligns with the medial aspect of the 2nd cuneiform [normal]

In Oblique view: The medial shaft of the 4th Metatarsal aligns with the medial aspect of cuboid

1st Tarsometatarsal Joint should be congruent

‘Fleck Sign’ Avulsion of Lisfranc ligament should be seen at medial cuneiform and 2nd metatarsal space

Navicular cuneiform articulation should be evaluated for subluxation

Loss of the arch and/or loss of alignment between the plantar aspect of 5th MT and medial cuneiform on the lateral view

Classification of Lisfranc (Midfoot) Injuries

Myerson’s classification

https://epos.myesr.org/posterimage/esr/ranzcr2016/135679/mediagallery/677601
References: Dr. Jeffrey Hocking / This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License

Type A

Totally incongruity

Displacement of all metatarsals with /without fracture of base of 2nd MT

Lateral/ Dorsolateral

Type B

Partial incongruity

One or more articulation remains intact

  • B1: Medially displaced (sometimes involving intercuneiform/ navicular-cuneiform )
  • B2: Laterally displaced may involve 1st MT-cuneiform also

Type C

Diversant Injuries

More prone to compartment syndrome

  • C1: Partial
  • C2: Complete

Treatment of Lisfranc (Midfoot) Injuries

Indication for Non-operative management

Non-displaced / Purely ligamentous injury i.e. Malalignment < 1mm, Articular displacement < 2 mm

Intact medial column of the foot (length/ stability)

No major associated midfoot injuries

No vascular or soft tissue compromise

Surgical contraindications

Options:

RICE

  • Rest
  • Immobilization
  • Compression
  • Elevation

Lisfranc foot braces

Lisfranc foot support or Lisfranc shoes

Lisfranc socks or compression socks

Below knee cast

NSAIDs

Enzymes to reduce swellings

Indication for Surgery

Malalignment 1mm

Articular incongruity 2mm

Soft tissue or bone fragment prevents the reduction

  • Avulsion fracture
  • Tibialis anterior tendon
  • Dorsal/ Plantar ligaments

Medial column instability or shortening

Associated multiple midfoot injuries

Associated compartment syndrome

Open fracture

Contraindication to surgery

Compromise soft tissue

General Health condition of the patient

Peripheral vascular disease

Neuropathy

Non-compliance to treatment

Surgical Steps for Management of Lisfranc Injury

  • Under Anesthesia
  • Dorsal incision lateral to EHL tendon over the interval of 1st and 2nd MT
  • Slightly lateral if access to 3rd MT joint is necessary
  • If 4th and 5th MT joint reduction is necessary 2nd incision is given more lateral
  • Locate and incise Inferior extensor retinaculum
  • Dorsalis pedis artery and the deep peroneal nerve is isolated and retracted
  • Lisfranc Joint is visible
  • Remove soft tissue interposition
  • Reduce 1st TMT joint and fix with guide wires
  • Insert a cannulated screw from dorsally 1st metatarsal to medial cuneiform
  • 2nd screw may be kept proximal to distal along 1st TMT joint
  • Another guide wire from medial cuneiform to the base of 2nd MT after reduction
  • Keep 4mm cannulated screw
  • Similarly, intercuneiform screws can be kept from medial –>middle cuneiform
  • Lateral MT cuboid disruption is reduced and fixed with K wires
  • Close skin with interrupted nylon suture

Postoperatively

  • Posterior splint and a bulky dressing
  • Convert lateral into a non-weight-bearing cast after 6-8 weeks
  • Screw removed after 4-5 months
  • Lateral K wire removed after 6-8 weeks

See also: Fifth Metatarsal Fracture

See also: Hammer toe and claw toe