Lisfranc injury involves disruption of the tarsometatarsal (TMT) joint complex of the midfoot, ranging from subtle ligamentous sprains to frank fracture-dislocations. It is misdiagnosed in approximately 20% of cases and is among the most common causes of litigation against emergency physicians and radiologists. [1-3] The majority are caused by low-energy trauma (e.g., simple falls, stepping off a curb), though high-energy mechanisms (MVCs, crush injuries) produce more severe patterns. [4]
1. History
- Mechanism of injury: Axial compression or twisting through a plantarflexed foot (e.g., landing from a jump, foot caught in a stirrup, stepping off a curb, MVC with foot on brake pedal) [5-6]
- Pain localized to the midfoot, worse with weightbearing; often unable to bear weight
- Low-energy mechanisms (tripping, sports pivoting) produce subtle injuries easily mistaken for "midfoot sprains" [7]
- High-energy mechanisms (MVC, fall from height, crush) produce obvious fracture-dislocations
- Ask about timing of swelling onset, ability to ambulate after injury, and prior foot injuries
- Important negative: Isolated hindfoot or forefoot pain without midfoot involvement makes Lisfranc less likely
2. Alarm Features
- Plantar ecchymosis — highly suggestive of Lisfranc injury and should not be dismissed [6]
- Severe, disproportionate midfoot swelling with tense compartments → concern for compartment syndrome [1][8]
- Pain out of proportion to apparent injury, pain with passive toe stretch, paresthesias → compartment syndrome until proven otherwise [9-10]
- Open fracture or neurovascular compromise (absent dorsalis pedis pulse, capillary refill delay)
- Gross deformity of the midfoot
- Inability to bear weight at all after seemingly minor trauma
3. Medications
- First-line: Topical NSAIDs (e.g., diclofenac gel) for mild-moderate pain; oral NSAIDs (ibuprofen 400–600 mg q6–8h, naproxen 500 mg q12h) or acetaminophen for moderate pain [11-12]
- Multimodal analgesia preferred: NSAID + acetaminophen combination reduces opioid need [13]
- Opioids: Reserve for severe pain (fracture-dislocations); short course only. Tramadol is no better than placebo for acute musculoskeletal pain [12]
- Caution: Avoid excessive analgesia (especially regional blocks) in patients at risk for compartment syndrome, as it may mask evolving symptoms [9-10]
- DVT prophylaxis should be considered during prolonged non-weightbearing immobilization per institutional protocol
4. Diet
- No specific dietary triggers or restrictions
- Adequate calcium and vitamin D intake to support bone healing
- Smoking cessation counseling — smoking impairs fracture healing and increases nonunion risk
5. Review of Systems
- Numbness/tingling in the foot (neurovascular compromise, compartment syndrome)
- Ability to move toes (motor function of deep peroneal nerve)
- Any other extremity injuries (polytrauma patients — associated calcaneal, spinal fractures)
- History of neuropathy (diabetic patients may have atypical presentations with minimal pain)
6. Collateral History and Family History
- Witnesses to mechanism (especially in sports injuries or MVCs) — helps clarify energy level
- In diabetic or neuropathic patients, Lisfranc injuries may occur with minimal trauma and present late; collateral from caregivers is valuable
- No significant hereditary component, though Charcot neuroarthropathy in diabetics can mimic or coexist with Lisfranc injury
7. Risk Factors
- Athletes: Football, soccer, basketball, equestrian sports (foot in stirrup) [5][14]
- Motor vehicle collisions (foot on brake pedal at impact)
- Falls from height
- Diabetic neuropathy — increased risk of low-energy Lisfranc injuries with delayed presentation
- Obesity — higher axial loads through the midfoot
- Mean age at injury: 43 years (men), 49 years (women); slight male predominance (54%) [4]
8. Differential Diagnosis
- Midfoot sprain (most common misdiagnosis) — distinguished by persistent pain >10 days, inability to bear weight, and positive imaging [7][15]
- Metatarsal base fracture — isolated fracture without TMT joint disruption; multiple metatarsal fractures should raise suspicion for Lisfranc [6]
- Navicular fracture — tenderness more dorsomedial; different radiographic findings [6]
- Cuboid/cuneiform fracture — may coexist with Lisfranc injury
- Chopart joint injury — more proximal midfoot/hindfoot pain
- Stress fracture of metatarsal — insidious onset, no acute trauma
- Plantar fascia rupture — plantar ecchymosis can overlap; different mechanism
- Charcot neuroarthropathy (in diabetics) — chronic, progressive midfoot collapse
9. Past Medical History
- Prior foot/ankle injuries or surgeries
- Diabetes mellitus (neuropathy risk, Charcot foot)
- Peripheral vascular disease (healing concerns)
- Osteoporosis (fracture risk)
- Previous Lisfranc injury (contralateral foot)
- Anticoagulant use (bleeding risk, compartment syndrome risk) [10]
10. Physical Exam
- Inspection: Midfoot swelling, plantar ecchymosis (pathognomonic), deformity, open wounds [1][6]
- Palpation: Tenderness along the TMT articulations, especially at the base of the 1st–2nd metatarsals and medial cuneiform
- "Lisfranc jut": Bony prominence on the medial border of the 1st TMT joint — suggests subluxation in subtle/missed injuries [7]
- Provocative maneuvers:
- Midfoot squeeze test: Compress forefoot medially and laterally — reproduces midfoot pain [5]
- Piano key test: Dorsiflexion/plantarflexion of individual metatarsals — pain at TMT joint
- Passive abduction/pronation stress: Pain with forefoot abduction while stabilizing the hindfoot
- Neurovascular exam: Dorsalis pedis and posterior tibial pulses, capillary refill, sensation (especially 1st web space — deep peroneal nerve) [6]
- Compartment assessment: Palpate for tense, swollen compartments; pain with passive toe extension [8][10]
11. Lab Studies
- No specific labs are diagnostic for Lisfranc injury
- Pre-operative labs if surgery anticipated: CBC, BMP, coagulation studies
- Consider HbA1c in diabetic patients (wound healing, surgical planning)
- Inflammatory markers if infection is a concern (open fracture)
12. Imaging
- First-line: AP, lateral, and oblique weightbearing radiographs of the foot (bilateral for comparison) [6][16-17]
- Key radiographic findings: [6][18-19]
- M1-M2 diastasis ≥2 mm on AP view
- Fleck sign: Small bony fragment between 1st and 2nd metatarsal bases (avulsion of Lisfranc ligament) — indicates instability [6][20]
- Loss of alignment of 2nd metatarsal base with medial cuneiform (AP view)
- Loss of alignment of 4th metatarsal with cuboid (oblique view)
- Loss of dorsal metatarsal-cuneiform alignment (lateral view)
- CT (without contrast): Obtain when radiographs are negative/equivocal but clinical suspicion remains high; superior for detecting occult fractures, subtle subluxation, and surgical planning [16][21-22]
- MRI: Best for evaluating ligamentous integrity (Lisfranc ligament complex); useful for determining operative vs. nonoperative management in subtle injuries [5][23]
- When imaging is unnecessary: If Ottawa foot rules are negative and there is no midfoot tenderness or suspicion for Lisfranc injury [16]
13. Special Tests
- Nunley-Vertullo Classification (for athletic/low-energy injuries): [14]
- Stage I: No diastasis on WB radiographs, positive bone scan/MRI
- Stage II: Diastasis of 1–5 mm, no arch height loss
- Stage III: Diastasis >5 mm with loss of arch height
- 3D CT signs (Mercedes sign, peeking metatarsal sign, peeking cuneiform sign): Sensitivity 92–97%, specificity 92–93% [21]
- Stability-based classification is increasingly favored over anatomy-based systems for guiding treatment [24]
- Intraoperative stress exam under fluoroscopy remains the gold standard for assessing instability when imaging is equivocal
14. ECG
- Not routinely indicated for isolated Lisfranc injury
- Obtain if high-energy polytrauma or if procedural sedation is planned for reduction
15. Assessment
- Lisfranc injuries exist on a spectrum: ligamentous sprain → subluxation → fracture-dislocation [1][25]
- Stable injuries (nondisplaced, intact ligaments on MRI): Good prognosis with conservative management [5][24]
- Unstable injuries (any displacement, diastasis ≥2 mm, fleck sign): Require surgical intervention; most Lisfranc injuries are unstable [6]
- Complications: Post-traumatic arthritis (most common long-term sequela), chronic pain, midfoot instability, arch collapse, compartment syndrome [3][6]
- Atypical presentations: Diabetic/neuropathic patients may present with minimal pain; low-energy injuries in middle-aged women are frequently misdiagnosed as sprains [4][7]
16. Treatment Plan
ED Management
- Ice, elevation, analgesia (NSAIDs ± acetaminophen)
- Non-weightbearing status with posterior short-leg splint [1]
- Reduce gross dislocations emergently if neurovascular compromise is present
- Consult orthopedic surgery for all confirmed or suspected Lisfranc injuries [1]
Stable, nondisplaced injuries (nonoperative)
- Short-leg non-weightbearing cast/boot for 4–6 weeks, followed by weightbearing cast/boot for 2–4 weeks [6][24]
- Close follow-up with repeat weightbearing radiographs to ensure no interval displacement
- Athletes with stable, nondisplaced injuries and intact ligaments on MRI: return to sport in 6–10 weeks [5]
Unstable/displaced injuries (operative)
- ORIF (most common approach): Bridge plating or screw fixation; consensus trending toward bridge plating [24]
- Suture button fixation: Emerging technique with promising early results, lower reoperation rates in ligamentous injuries [26]
- Primary arthrodesis: May be preferred for comminuted injuries or when joint surfaces are not salvageable; associated with lower rates of post-traumatic arthritis (2.8% vs. 17.3%) and unplanned reoperations (14.7% vs. 38.3%) compared to ORIF [27]
- Return to full weightbearing: 8–12 weeks postoperatively; return to sport: 4–6 months [28]
17. Disposition
- Discharge criteria: Stable injury confirmed on imaging, adequate pain control, non-weightbearing with crutches, reliable follow-up within 1 week, no signs of compartment syndrome [1-2]
- Admission/observation: Gross fracture-dislocation requiring urgent reduction, concern for compartment syndrome, open fracture, neurovascular compromise, polytrauma, inability to maintain non-weightbearing status
- Orthopedic consultation: All Lisfranc injuries should be discussed with orthopedics; urgent consultation for displaced/unstable injuries, open fractures, and neurovascular compromise [1]
18. Follow Up / Return Precautions
- Follow-up: Orthopedic follow-up within 5–7 days for all ED-diagnosed Lisfranc injuries; repeat weightbearing radiographs at 10–14 days if initial films were negative but clinical suspicion was high [15]
- Return precautions — seek immediate care for:
- Increasing pain despite immobilization and elevation
- Numbness, tingling, or inability to move toes
- Color change (pale, blue) of the foot or toes
- Worsening swelling not relieved by elevation
- Cast/splint feels too tight
- Expected recovery: Stable injuries heal in 6–10 weeks; surgical cases require 4–6 months for return to full activity; over 90% of athletes return to sport after appropriate treatment [5][28]
- Counsel patients that even with optimal treatment, some degree of post-traumatic arthritis and chronic midfoot stiffness is common, particularly after high-energy injuries [3][27]
References
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2. Lisfranc Fracture Dislocation: A Review of a Commonly Missed Injury of the Midfoot. — Lau S, Bozin M, Thillainadesan T. Emergency Medicine Journal : EMJ. 2017.
3. Evaluation of the Tarsometatarsal Joint Using Conventional Radiography, CT, and MR Imaging. — Siddiqui NA, Galizia MS, Almusa E, Omar IM. Radiographics : A Review Publication of the Radiological Society of North America, Inc. 2014.
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