Physis at base of second metatarsal particularly vulnerable
Radiographic diagnosis complicated by normal physeal lucency mimicking diastasis
Comparison views of contralateral foot essential
Treatment considerations
Conservative management favored for stable injuries in skeletally immature patients
Short-leg non-weightbearing cast for 4 to 6 weeks
Operative fixation reserved for displaced, unstable injuries
Smooth Kirschner wire fixation preferred over screw fixation to avoid physeal damage
Analgesic dosing
Acetaminophen 15 mg/kg per dose orally every 4 to 6 hours; maximum 75 mg/kg/day
Ibuprofen 10 mg/kg per dose orally every 6 to 8 hours; maximum 40 mg/kg/day
Prognosis generally excellent in pediatric patients with appropriate treatment
Background
Epidemiology
Incidence and demographics
Lisfranc injuries occur in approximately 1 per 55,000 persons per year
Misdiagnosed in approximately 20% of cases on initial evaluation
Slight male predominance: 54% of cases
Mean age at injury: 43 years in men, 49 years in women
Swedish Fracture Register study: 2084 Lisfranc injuries analyzed (2025)
Mechanism distribution
Low-energy mechanisms (simple falls, sports, stepping off curb) predominate
High-energy mechanisms (motor vehicle collisions, crush injuries) produce more severe patterns
Athletic injuries increasingly recognized in elite and recreational athletes
Medicolegal significance
Among most common causes of litigation against emergency physicians and radiologists
20% misdiagnosis rate contributes to delayed care and poor outcomes
Delayed diagnosis associated with worse functional outcomes and post-traumatic arthritis
Pathophysiology
Anatomy of the tarsometatarsal joint complex
Lisfranc joint: Tarsometatarsal articulations between all five metatarsal bases and tarsal bones
Medial cuneiform articulates with first and second metatarsal bases
Middle cuneiform articulates with second metatarsal
Lateral cuneiform articulates with third metatarsal
Cuboid articulates with fourth and fifth metatarsal bases
Lisfranc ligament complex
Interosseous Lisfranc ligament: Between medial cuneiform and base of second metatarsal
Strongest ligament in the complex
Primary stabilizer of the medial column
Dorsal Lisfranc ligament: Weaker, often injured first
Plantar Lisfranc ligament: Strongest component; disruption indicates severe instability
No intermetatarsal ligament between first and second metatarsal — Lisfranc ligament only connection
Injury mechanism
Axial compression through plantarflexed foot transmits force along metatarsal shafts to bases
Twisting forces create rotational stress across TMT joint complex
Spectrum of injury: Ligamentous sprain to complete fracture-dislocation
Fleck sign represents avulsion of Lisfranc ligament at second metatarsal base
Complications
Post-traumatic arthritis: Most common long-term sequela
Chronic midfoot pain and instability
Arch collapse and flatfoot deformity
Compartment syndrome: Tight fascial compartments of the foot susceptible after injury
Neurovascular injury to dorsalis pedis artery and deep peroneal nerve
Therapeutic Considerations
Nonoperative versus operative management evidence
Purely ligamentous Lisfranc injuries have worse outcomes with nonoperative management if unstable
Stable, nondisplaced injuries (confirmed on MRI): Nonoperative treatment with good outcomes
Any diastasis 2 mm or greater is indication for operative fixation
Operative technique considerations
Bridge plating trending preferred over transarticular screws to avoid iatrogenic cartilage damage
Suture button fixation advantages
Preserves native joint motion
Lower reoperation rates for ligamentous injuries
Emerging evidence supports equivalence or superiority to screw fixation
Primary arthrodesis vs ORIF debate
Primary arthrodesis: Post-traumatic arthritis rate 2.8% vs 17.3% with ORIF
Primary arthrodesis: Reoperation rate 14.7% vs 38.3% with ORIF
Primary arthrodesis most appropriate for medial column injuries
Return to sport evidence
Over 90% of athletes return to sport after appropriate treatment
Stable injuries: Return to sport 6 to 10 weeks
Operative cases: Return to full activity 4 to 6 months
2024 International Foot and Ankle Sports Consensus provides athlete-specific guidance
Post-traumatic arthritis prevention
Anatomic reduction reduces risk of post-traumatic arthritis
Even with optimal treatment some degree of arthritis common after high-energy injuries
Patient counseling about long-term prognosis and potential arthritis essential
Patient Discharge Instructions
copy discharge instructions
Diagnosis and injury overview
You have been diagnosed with a Lisfranc injury (midfoot injury involving the tarsometatarsal joints)
This injury can range from a ligament sprain to a fracture-dislocation of the midfoot
Your injury was evaluated and determined to be stable at this time
Activity restrictions
Do not bear any weight on your injured foot
Use crutches or a knee scooter for all movement
Keep your foot elevated above the level of your heart as much as possible
Apply ice wrapped in a cloth for 20 minutes several times daily for the first 48 hours
Splint and cast care
Keep your splint or boot dry at all times
Do not remove or adjust the splint
If the splint feels too tight, return immediately to the emergency department — do not wait
Medications
Take ibuprofen or naproxen with food as directed for pain
Take acetaminophen as directed if NSAIDs are not sufficient or not tolerated
Do not take more than the prescribed dose of any medication
Follow-up appointment
You must see an orthopedic surgeon within 5 to 7 days — this appointment is mandatory
Repeat weightbearing X-rays may be taken at your follow-up to confirm the injury has not shifted
Return to the emergency department immediately if you experience any of these warning signs
Severe or increasing pain that is not controlled by medications or elevation
Numbness, tingling, or inability to move your toes
Toes turning pale, blue, or cold
Worsening swelling that does not improve with elevation
Splint or boot feels increasingly tight
Any open wound, drainage, or signs of infection (redness, warmth, foul odor)
Recovery expectations
Stable injuries typically heal in 6 to 10 weeks with proper immobilization
Some injuries require surgery — your orthopedic surgeon will make this determination
Even with proper treatment, some long-term stiffness or discomfort in the midfoot is possible
Smoking significantly impairs bone healing — smoking cessation is strongly advised
References
Guidelines and key sources
McDermott A, Repanshek Z, Koyfman A, Long B. High Risk and Low Incidence Diseases: Lisfranc Injury. American Journal of Emergency Medicine. 2024. PMID 39276688
Comprehensive emergency medicine review; primary grounding source for ED management and disposition
Lau S, Bozin M, Thillainadesan T. Lisfranc Fracture Dislocation: A Review of a Commonly Missed Injury of the Midfoot. Emergency Medicine Journal. 2017. PMID 27013521
Clinical review of mechanism, exam findings, imaging, and treatment
Siddiqui NA, Galizia MS, Almusa E, Omar IM. Evaluation of the Tarsometatarsal Joint Using Conventional Radiography, CT, and MR Imaging. Radiographics. 2014. PMID 24617695
Detailed imaging review including fleck sign, diastasis criteria, and multimodal imaging
Juto H, Mukka S, Wolf O, Moller M. Epidemiology, Classification, and Treatment of 2084 Lisfranc Injuries. Injury. 2025. PMID 39626601
Large Swedish Fracture Register epidemiological study
Semelsberger SD, Boggiano VJ, Webber K, et al. Diagnostic Evaluation and Nonoperative Management of Lisfranc Injuries in Athletes. Knee Surgery Sports Traumatology Arthroscopy. 2025. PMID 41451696
Athletic population management and return to sport evidence
Poutoglidou F, van Groningen B, McMenemy L, Elliot R, Marsland D. Acute Lisfranc Injury Management. Bone and Joint Journal. 2024. PMID 39615511
Current management guidelines including ORIF vs arthrodesis evidence
O'Connor KP, Tackett LB, Riehl JT. Primary Arthrodesis Versus ORIF for Acute Lisfranc Injuries: Systematic Review and Meta-Analysis. Archives of Orthopaedic and Trauma Surgery. 2024. PMID 39680239
Post-traumatic arthritis 2.8% vs 17.3% and reoperation 14.7% vs 38.3% data
Imaging and classification sources
Expert Panel on Musculoskeletal Imaging, Gorbachova T, Chang EY, et al. ACR Appropriateness Criteria: Acute Trauma to the Foot. Journal of the American College of Radiology. 2020
ACR guidance on appropriate imaging modality selection
Tamir E, Essa A, Levi A, et al. Lisfranc Injury Diagnosis: Diagnostic Reliability of New Radiographic Signs Using 3D CT. Clinical Orthopaedics and Related Research. 2023. PMID 37078895
Nunley JA, Vertullo CJ. Classification, Investigation, and Management of Midfoot Sprains: Lisfranc Injuries in the Athlete. American Journal of Sports Medicine. 2002. PMID 12435655
Nunley-Vertullo Classification Stage I to III original publication
Herscovici D, Scaduto JM. The Lisfranc Jut: A Physical Finding of Subtle Lisfranc Injuries. Injury. 2021. PMID 33413925
Description of Lisfranc jut sign for subtle injury detection
Balboni JM, Levine AR, Boggiano VJ, et al. Operative Treatment of Lisfranc Injuries in Elite Athletes: 2024 International Foot and Ankle Sports Consensus. Knee Surgery Sports Traumatology Arthroscopy. 2026. PMID 41649218
International consensus on operative management in athletes
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