01Approach to the Critical Patient/attcp52

Immediate priorities

›Life-threatening presentations requiring urgent escalation

›Compartment syndrome of the foot

›Pain out of proportion to injury severity

›Pain with passive toe extension

›Tense dorsal foot compartments

›Paresthesias in first web space (deep peroneal nerve)

›Delta pressure below 30 mmHg confirms diagnosis

›Neurovascular compromise

›Absent or diminished dorsalis pedis pulse

›Prolonged capillary refill beyond 3 seconds

›Pallor or cyanosis of the toes

›Open fracture-dislocation

›Skin breach over the midfoot

›Gross contamination assessment

›Urgent orthopedic consultation required

›Gross dislocation with vascular compromise

›Emergent reduction of dislocated TMT joints

›Reassess neurovascular status after reduction

Stabilization and monitoring

›Initial stabilization bundle

›Posterior short-leg splint with the foot in neutral position

›Well-padded to prevent pressure sores

›Non-weight-bearing strict instructions

›Elevation of the affected limb above heart level

›Reduces swelling and compartment pressure

›Ice packs wrapped in cloth to the dorsal foot

›IV access for analgesia and potential operative prep

02History/hx59

Mechanism and presentation

›Mechanism of injury

›High-energy mechanisms

›Motor vehicle collision with foot on brake pedal

›Fall from height

›Industrial crush injury

›Typically produces obvious fracture-dislocation

›Low-energy mechanisms

›Athletic injury in football or soccer

›Ballet or equestrian sports axial loading

›Misstep off a curb or stumble

›Often subtle, purely ligamentous, easily missed

›Classic mechanism

›Forceful abduction or twisting of a plantarflexed foot

›Axial loading through a fixed forefoot

›Symptom characterization

›Midfoot pain

›Dorsal and plantar pain distribution

›Weight-bearing worsens pain significantly

›Inability to bear weight

›Key diagnostic clue

›Inability to complete single-leg heel raise

›Swelling

›Rapid progressive dorsal foot swelling

›Delayed presentation possible with low-energy injuries

Risk factors and prior history

›Patient risk factors

›Athletic population

03Physical Exam/exam70

Inspection and palpation

›Inspection findings

›Dorsal foot swelling

›Distribution over TMT joints

›Extent of swelling correlates with energy of injury

›Plantar ecchymosis

›Pathognomonic for Lisfranc injury

›Distinguishes from simple midfoot sprain

›Gross deformity

›Splaying of the forefoot

›Obvious malalignment of the midfoot

›Skin integrity

›Open fracture assessment

›Fracture blisters indicating high-energy injury

›Palpation findings

›Point tenderness at the TMT joint complex

›First and second intermetatarsal space

›Base of second metatarsal (most sensitive location)

›Medial cuneiform region

›Plantar surface tenderness

›Along the Lisfranc ligament course

Provocative maneuvers

›Functional tests

›Single-leg heel raise test

›Inability to perform is a key positive finding

›Pain with attempt is also positive

›Piano key test

›Stabilize the hindfoot and passively dorsiflex and plantarflex individual metatarsals

04Differential Diagnosis/ddx38

Life-threatening and urgent diagnoses

›Urgent diagnoses to exclude

›Compartment syndrome of the foot

›ICD-10 M79.3

›Requires emergent fasciotomy

›Vascular injury to the dorsalis pedis artery

›Loss of foot perfusion

›Requires vascular surgery consultation

›Open fracture with contamination

›ICD-10 S93.325A

›Infection risk without urgent debridement

Musculoskeletal mimics

›Close mimics requiring distinction

›Midfoot sprain without instability

›Most common mimic of Lisfranc injury

›No diastasis on weight-bearing radiographs

›MRI shows intact Lisfranc ligament

›Isolated metatarsal base fractures

›Multiple metatarsal fractures raise suspicion for Lisfranc disruption

›ICD-10 S92.311A through S92.352A depending on location

›Navicular fracture

›Acute or stress type

›Medial midfoot tenderness

›ICD-10 S92.251A

›Cuboid or cuneiform fractures

›Lateral or central midfoot tenderness

›May co-exist with Lisfranc injury

›Jones fracture and proximal fifth metatarsal fractures

05Laboratory Tests/lt36

Pre-operative and baseline labs

›Operative preparation labs

›Complete blood count

›Baseline hemoglobin before surgical intervention

›Platelet count for bleeding risk assessment

›Basic metabolic panel

›Renal function for contrast and anesthetic agents

›Glucose for diabetic patients requiring surgical management

›Coagulation studies

›PT and INR particularly in anticoagulated patients

›Holds and bridging planning with orthopedics

›Type and screen

›Major fracture-dislocation with potential blood loss

›Required before operative intervention

Metabolic and systemic assessment

›Comorbidity-directed labs

›HbA1c in diabetic patients

›Glycemic control critical for wound healing

›Target below 8% preferred before elective surgery

›Poor control associated with higher complication rates

›Inflammatory markers

›ESR and CRP if open fracture or infection concern

›Baseline values useful for post-operative monitoring

›Vitamin D level

›Deficiency impairs fracture healing

›Supplement if deficient

Compartment pressure monitoring

›Intracompartmental pressure measurement

06Diagnostic Tests/dt83

Scoring Systems

›Classification systems for Lisfranc injuries

›Stability-based classification (preferred for treatment planning)

›Stable injuries

›No displacement on weight-bearing radiographs

›Intact ligaments confirmed on MRI

›Nonoperative management appropriate

›Unstable injuries

›Displacement 2 mm or greater on any view

›Positive fleck sign present

›Ligament disruption on MRI

›Surgical intervention required

›Hardcastle and Myerson anatomical classification

›Type A: total incongruity of the entire TMT joint complex

›Type B: partial incongruity of medial or lateral columns

›Type C: divergent pattern with both medial and lateral displacement

›Type C associated with worst outcomes and highest complication rates

›Ottawa Foot Rules (for initial imaging decision)

›Tenderness at the base of the fifth metatarsal

›Tenderness at the navicular

›Inability to bear weight for four steps in the ED

›Negative Ottawa rules do not exclude Lisfranc injury reliably

MRI

›MRI of the foot for Lisfranc injury

›Indications

›Negative or equivocal radiographs with high clinical suspicion

›Purely ligamentous injury evaluation

›Distinguishing stable from unstable injuries

›Athletes where operative versus nonoperative decision is critical

›Protocol considerations

›Non-weight-bearing MRI standard

›Weight-bearing MRI emerging for dynamic instability

›Short tau inversion recovery (STIR) sequences most sensitive for edema

›Findings

›Lisfranc ligament disruption (dorsal and interosseous components)

›Bone marrow edema at the base of second metatarsal and medial cuneiform

›Associated fractures not visible on plain radiographs

›Joint capsule disruption extent

›Performance characteristics

›Superior to CT for ligament assessment

›Best modality for classifying injury stability

›ACR Appropriateness Criteria usually appropriate for equivocal cases

CT

›CT of the foot for Lisfranc injury

›Indications

›Negative radiographs with high clinical suspicion

›Surgical planning for confirmed injuries

›Evaluation of associated fractures not seen on plain films

›Preoperative assessment of comminution

›Protocol

›CT foot with coronal, sagittal, axial reconstructions

›Bilateral comparison CT increases diagnostic sensitivity

›No intravenous contrast required for bone assessment

›Findings

›Subtle subluxation not visible on plain radiographs

›Occult fractures at the metatarsal bases and cuneiforms

›Comminution patterns for surgical planning

›Novel 3D CT signs

›Mercedes sign on 3D reconstruction

›Peeking metatarsal sign

›Peeking cuneiform sign

›Sensitivity 92 to 97% and specificity 92 to 93% for these signs

›ACR Appropriateness Criteria

›Usually appropriate when radiographs negative but clinical suspicion remains

›Preferred over MRI for surgical planning and fracture detail

Ultrasound

›Ultrasound for Lisfranc injury

›Role in the ED

›Not the primary modality for Lisfranc diagnosis

›Useful for soft tissue and tendon assessment

›Doppler for vascular assessment

›Vascular assessment

›Dorsalis pedis artery Doppler

›Posterior tibial artery Doppler

›Triphasic waveform confirms normal perfusion

›Soft tissue adjunct

›Evaluate for dorsal ligament disruption

›Identify hematoma and fluid collections

›Tendon integrity assessment

›Compartment syndrome adjunct

›Real-time fascial thickness assessment

›Not sufficiently validated to replace pressure measurement

›Weight-bearing plain radiographs

›Bilateral views are the most important initial study

›AP, lateral, and 30-degree oblique views

›Fleck sign between first and second metatarsal bases is pathognomonic

›Diastasis 2 mm or greater between medial cuneiform and second metatarsal on AP view is diagnostic

07Disposition/dispo47

Admission criteria

›Indications for admission

›Compartment syndrome confirmed or suspected

›Requires emergent fasciotomy planning

›ICU level monitoring post-operatively

›Open fracture-dislocation

›IV antibiotics and urgent surgical debridement

›Orthopedic team admission

›Neurovascular compromise

›Vascular surgery consultation and monitoring

›Serial vascular checks required

›Gross dislocation requiring urgent operative reduction

›Unable to achieve or maintain acceptable alignment

›Polytrauma

›Trauma team care

›Systemic injuries requiring monitoring

›Inability to manage pain as outpatient

›IV analgesia requirement

›Social factors precluding safe non-weight-bearing at home

Discharge criteria

›Safe discharge criteria

›Neurovascularly intact foot

›Palpable or dopplerable dorsalis pedis pulse

›Intact sensation

›Normal capillary refill

›Adequate pain control with oral analgesics

›Pain manageable on acetaminophen and NSAIDs

›Short-course opioid if needed with clear instructions

08Treatment/t94

Immediate ED management

›Initial treatment bundle

›Ice application to the dorsal foot

›Wrapped in cloth to protect skin

›Fifteen to twenty minutes on, fifteen minutes off

›Elevation above heart level

›Reduces edema and compartment pressure

›Immobilization in posterior short-leg splint

›Foot at 90 degrees of dorsiflexion

›Well-padded over bony prominences

›Strict non-weight-bearing instructions

›Crutch training and fitting

›Single-leg hopping or walker as alternative

›Analgesia

›Multimodal analgesia preferred

›Acetaminophen 1000 mg PO or IV every 6 hours

›Ibuprofen 400 to 600 mg PO every 6 to 8 hours with food

›Ketorolac 15 to 30 mg IV for severe acute pain

›ACP and AAFP guideline supports multimodal approach as first-line

›Opioid adjunct for severe pain

›Short-course oral opioid if multimodal therapy insufficient

›Oxycodone 5 mg PO every 4 to 6 hours as needed

›Minimize dose and duration

›Avoid in patients with prior opioid use disorder

›NSAIDs cautions

›Avoid in renal disease

›Avoid in active GI bleeding

›Caution in significant cardiovascular disease

Nonoperative management

›Stable injury nonoperative protocol

›Eligibility

›No displacement on bilateral weight-bearing radiographs

›Intact Lisfranc ligament on MRI

›Reliable patient for strict compliance

›Phase one: non-weight-bearing immobilization

›Short-leg non-weight-bearing cast or boot for 4 to 6 weeks

›Repeat weight-bearing radiographs at 2 weeks to exclude interval displacement

›Phase two: weight-bearing progression

›Weight-bearing cast or boot for 2 to 4 additional weeks

›Gradual progression with physiotherapy guidance

›Phase three: rehabilitation

›Physiotherapy for range of motion and strengthening

›Custom orthotics for arch support

›Return to sport typically 2.8 months for ligamentous injuries

Operative management

›Surgical indications

›Any injury with diastasis 2 mm or greater

›Class I indication for operative stabilization

›Positive fleck sign with instability

›Ligament disruption with dynamic instability

›Failed nonoperative management with delayed displacement

›ORIF with bridge plating

›Current consensus technique for most unstable injuries

›Anatomical reduction is the single most important determinant of outcome

›Bridge plating across the TMT joint with screws

›Timing

›Ideally within 1 to 2 weeks of injury

›May need to delay for soft tissue swelling to subside

›Fracture blisters must resolve before incision

›Hardware removal

›Required in 19 to 26% of cases due to hardware-related pain

›Typically at 3 to 6 months post-operatively

›Primary arthrodesis

›Indications

›Comminuted injuries where joint surfaces are not salvageable

›Predominantly ligamentous injuries with no bony anatomy to reconstruct

›Outcome comparison to ORIF

›Lower rates of post-traumatic arthritis (2.8% vs 17.3%)

›Lower reoperation rates in some series

›Comparable functional outcomes to ORIF

›Technique

›Fusion of the medial two or three columns

›Lateral column generally not fused to preserve motion

›Suture button fixation

›Emerging technique for purely ligamentous injuries

›Flexible stabilization allows physiological motion

›Promising early results at minimum 5-year follow-up

›May reduce post-traumatic arthritis by preserving joint kinematics

›Selection criteria

›Purely ligamentous injury confirmed on MRI

›No significant bony comminution

›Perioperative DVT prophylaxis

›Consider in non-weight-bearing patients post-operatively

›Low molecular weight heparin per institutional protocol

›Early mobilization of upper extremities

Compartment syndrome treatment

›Foot fasciotomy

›Indication

›Delta pressure below 30 mmHg

›Clinical compartment syndrome regardless of pressure

›Technique

›Medial incision releasing medial and central compartments

›Dorsal incisions between metatarsals releasing interosseous compartments

›Lateral incision releasing lateral compartment if needed

›Post-fasciotomy care

›Delayed primary closure at 48 to 72 hours

›Skin graft if closure not possible

›Meticulous wound care

09Special Populations/sp66

Pregnancy

›Pregnancy considerations for Lisfranc injury

›Physiological ligamentous laxity

›Relaxin-mediated ligament laxity increases injury susceptibility

›Third trimester highest risk due to altered gait and center of gravity

›Weight-bearing changes increase midfoot stress

›Imaging considerations

›Plain radiographs preferred with abdominal shielding

›MRI preferred over CT when advanced imaging needed

›CT reserved for surgical planning if MRI unavailable

›Radiation to foot is distant from uterus and fetal dose is minimal

›Analgesia in pregnancy

›Acetaminophen preferred analgesic (all trimesters)

›NSAIDs avoid in first trimester and after 30 weeks gestation

›Opioids with caution and short duration only

›Regional nerve block consideration for acute pain control

›Operative timing

›Delay elective surgery to second trimester when possible

›Emergency surgery for compartment syndrome proceeds regardless of trimester

›Obstetric consultation for perioperative fetal monitoring

Geriatric

›Older adult considerations

›Injury characteristics

›Low-energy mechanisms predominate (simple fall or misstep)

›Simple fall or tripping accounts for 31% in population registries

›Higher rates of comminution due to osteoporosis

›Delayed presentation due to neuropathy masking pain

›Diagnostic challenges

›Peripheral neuropathy reduces pain perception

›Inability to perform weight-bearing views due to deconditioning

›Higher baseline comorbidity complicates workup

›Surgical risk assessment

›Cardiac and pulmonary clearance often required

›Frailty screening with Clinical Frailty Scale

›Anticoagulation management pre-operatively

›Osteoporosis reduces fixation quality requiring modified technique

›Analgesia considerations

›Reduced renal clearance requiring NSAID dose reduction or avoidance

›Risk of delirium with opioids in older adults

›Acetaminophen preferred first-line

›Fall risk counseling mandatory with any analgesia

›Rehabilitation

›Prolonged non-weight-bearing particularly challenging

›Physiotherapy essential to prevent deconditioning

›Occupational therapy for home adaptation

›DVT prophylaxis mandatory in immobilized older adults

Pediatrics

›Pediatric Lisfranc injury considerations

›Epidemiology in children

›Rare in young children due to ligamentous flexibility

›More common in adolescent athletes

›Physeal injuries co-exist and complicate management

›Diagnostic approach

›Growth plates on radiographs may mimic Lisfranc diastasis

›Contralateral comparison films essential

›MRI preferred over CT for physeal injury assessment

›Adolescent athletes same criteria as adults for instability

›Treatment principles

›Stable injuries managed nonoperatively same as adults

›Unstable injuries generally require ORIF

›Smooth pin fixation may be preferred over screws to avoid physeal damage in younger patients

›Analgesia dosing

›Acetaminophen 15 mg per kg per dose PO every 4 to 6 hours maximum 75 mg per kg per day

›Ibuprofen 10 mg per kg per dose PO every 6 to 8 hours maximum 40 mg per kg per day

›Opioid use in pediatrics requires careful age-appropriate dosing and close monitoring

›Return to sport

›Adolescent athletes require careful rehabilitation before return to sport

›Earlier return to sport in ligamentous injuries (mean 2.8 months)

›Later return in bony injuries or surgical cases

10Background/b79

Epidemiology

›Incidence and population data

›Frequency

›Lisfranc injuries account for approximately 0.2% of all fractures

›Estimated 20% are initially misdiagnosed or overlooked

›True incidence likely higher due to underdiagnosis of subtle injuries

›Swedish Fracture Register data

›2084 Lisfranc injuries analyzed in a large observational study

›Simple fall or tripping was the most common mechanism at 31%

›Obesity present in 40% of surgical cohort in one series

›At-risk populations

›Male sex and athletic populations predominate

›Motor vehicle occupants and athletes are highest risk groups

›Equestrian, football, and soccer athletes at elevated risk

›Long-term morbidity burden

›Post-traumatic arthritis in 37% of surgical series

›Radiographic osteoarthritis in 72% at mean 11-year follow-up

›Chronic pain and gait dysfunction common regardless of treatment

Pathophysiology

›Anatomy and biomechanics

›Lisfranc joint complex (tarsometatarsal joint complex)

›Five TMT joints forming the midfoot

›Transverse arch supported by the Roman arch configuration

›Second metatarsal recessed between medial and intermediate cuneiforms providing inherent bony stability

›Lisfranc ligament

›Runs from the medial cuneiform to the base of the second metatarsal

›Interosseous component is the primary stabilizing ligament

›No direct ligament between the first and second metatarsal bases

›Absence of this ligament explains vulnerability to lateral diastasis

›Injury mechanism

›High-energy: direct crush or forced abduction

›Low-energy: axial load through a plantarflexed foot (e.g., missing a step)

›Ligamentous disruption with or without bony avulsion

›Injury spectrum

›Stable sprains

›Partial ligament tear without displacement

›Intact bony alignment on weight-bearing views

›Unstable ligamentous injuries

›Complete Lisfranc ligament tear

›Displacement on weight-bearing views only

›High risk of missing on non-weight-bearing studies

›Fracture-dislocations

›Bony avulsion plus ligamentous disruption

›Fleck sign represents avulsion from medial cuneiform

›Variable degrees of TMT displacement

›Complications pathway

›Post-traumatic arthritis

›Results from articular cartilage damage at time of injury

›Nonanatomic reduction dramatically increases arthritis risk

›Develops even with optimal anatomic reduction

›Compartment syndrome

›High-energy injuries disrupt dorsal foot vasculature

›Bleeding into closed foot compartments

›Nine anatomical compartments in the foot

Therapeutic Considerations

›Treatment strategy principles

›Stability determines treatment

›Stable injuries: nonoperative management with close follow-up

›Unstable injuries: surgical stabilization to restore anatomy

›Anatomic reduction is the most important determinant of long-term outcome

›Timing of surgery

›Ideally within 1 to 2 weeks

›Allow soft tissue swelling to resolve before definitive fixation

›Emergent surgery for compartment syndrome or vascular compromise

›ORIF versus primary arthrodesis controversy

›ORIF traditionally preferred to preserve joint motion

›Primary arthrodesis may reduce post-traumatic arthritis and reoperation rates

›No high-quality randomized controlled trial definitively favors one approach

›Systematic review and meta-analysis (O'Connor 2024) supports both as acceptable

›Suture button fixation evidence

›Minimum 5-year follow-up data showing satisfactory outcomes

›Avoids hardware removal in many patients

›Risk factor modification

›Smoking cessation

›Tobacco use is independent risk factor for post-traumatic arthritis

›Counsel all patients on cessation before and after surgery

›Glycemic control in diabetic patients

›HbA1c below 8% preferred before operative intervention

›Neuropathy may mask pain and delay presentation

›Weight management

›Obesity associated with higher surgical complication rates

›Increased midfoot stress with obesity

11Patient Discharge Instructions/pdi43

copy discharge instructions

›Lisfranc injury home care instructions

›Non-weight-bearing on the injured foot

›Do not put any weight through the foot until seen by orthopedics

›Use crutches or a walker at all times when moving

›Do not attempt to walk on the injured foot even for short distances

›Splint care

›Keep the splint dry at all times

›Cover with a plastic bag when showering

›Do not remove the splint

›Return immediately if the splint becomes wet, cracked, or causes increased pain

›Ice and elevation

›Keep the foot elevated above heart level as much as possible

›Ice the foot through the splint for 15 to 20 minutes several times daily

›Elevation reduces swelling and pain significantly

›Pain medications

›Acetaminophen every 6 hours as directed

›Ibuprofen with food every 6 to 8 hours if no contraindications

›Take opioids only as prescribed and only if needed

›Do not drive while taking opioid pain medication

›Warning signs to return to ER immediately

›Increasing pain despite medications

›This may be a sign of a serious complication called compartment syndrome

›Do not wait until morning if pain is worsening rapidly

›Numbness, tingling, or coldness in the toes

›Toes turning blue, white, or significantly pale

›Toes becoming cold compared to other toes or the other foot

›Splint feels too tight or is cutting into the skin

12References/r24

Guidelines and key sources

›Key clinical references

›McDermott A et al. High Risk and Low Incidence Diseases: Lisfranc Injury. American Journal of Emergency Medicine. 2024. PMID 39276688

›Lau S et al. Lisfranc Fracture Dislocation: A Review of a Commonly Missed Injury of the Midfoot. Emergency Medicine Journal. 2017. PMID 27013521

›Poutoglidou F et al. Acute Lisfranc Injury Management. The Bone and Joint Journal. 2024. PMID 39615511

›Ahluwalia R et al. Surgical Controversies and Current Concepts in Lisfranc Injuries. British Medical Bulletin. 2022. PMID 36151742

›Juto H et al. Epidemiology Classification and Treatment of 2084 Lisfranc Injuries: An Observational Study from the Swedish Fracture Register. Injury. 2025. PMID 39626601

›Imaging and diagnostic guidelines

›Expert Panel on Musculoskeletal Imaging et al. ACR Appropriateness Criteria Acute Trauma to the Foot. JACR. 2020

›Sripanich Y et al. Imaging in Lisfranc Injury: A Systematic Literature Review. Skeletal Radiology. 2020. PMID 31368007

›Kennelly H et al. Utility of Weight-Bearing Radiographs Compared to CT for Diagnosis of Subtle Lisfranc Injuries in the Emergency Setting. Emergency Medicine Australasia. 2019. PMID 30780193

›Tamir E et al. Lisfranc Injury Diagnosis: Diagnostic Reliability of New Radiographic Signs Using 3D CT. Clinical Orthopaedics and Related Research. 2023. PMID 37078895

›Surgical outcome references

›O'Connor KP et al. Primary Arthrodesis Versus ORIF for Acute Lisfranc Injuries: A Systematic Review and Meta-Analysis. Archives of Orthopaedic and Trauma Surgery. 2024. PMID 39680239

›Dubois-Ferriere V et al. Clinical Outcomes and Development of Symptomatic Osteoarthritis 2 to 24 Years After Surgical Treatment of Tarsometatarsal Joint Complex Injuries. JBJS. 2016. PMID 27147683

›Sinkler MA et al. Complications and Outcomes After Fixation of Lisfranc Injuries at an Urban Level 1 Trauma Center. Journal of Orthopaedic Trauma. 2024. PMID 38294227

›Saito GH et al. Results of Lisfranc Injuries Treated With Interosseous Suture Button Fixation With Minimum 5-Year Follow-Up. Foot and Ankle International. 2025. PMID 40077945

›Pain management guidelines

›Qaseem A et al. Nonpharmacologic and Pharmacologic Management of Acute Pain From Non-Low Back Musculoskeletal Injuries in Adults. Annals of Internal Medicine. 2020

›Hsu JR et al. Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury. Journal of Orthopaedic Trauma. 2019. PMID 30681429

›ICD-10 coding references

›ICD-10 S93.325A dislocation of tarsometatarsal joint of right foot initial encounter

›ICD-10 S93.326A dislocation of tarsometatarsal joint of left foot initial encounter

›ICD-10 M79.3 panniculitis

›SNOMED CT tarsometatarsal dislocation disorder concept

Evidence & Review

Evidence & Review