Pathophysiology
1. Lisfranc Joint:Tarsometatarsal articulation of foot
  1. First and second metatarsal
  2. First and second cuneiforms
2. Keystone wedging of base of second metatarsal
  1. Articulates with second cuneiform
  2. Straddled by first and third cuneiform
3. Lisfranc joint transfers force from mid to forefoot
  1. Critical to plantar and dorsiflexion
Mechanism
1. Plantar hyperflexion with axial loading
2. Displaces second metatarsal dorsally
Causes
1. Lateral Ankle Sprain
2. High energy injury
  1. Motor vehicle accident
  2. Fall from high height
Symptoms: Persist >5 days after injury
1. Midfoot swelling
2. Difficult weight bearing
Signs
1. Tenderness at tarsometatarsal joint
2. Difficult weight bearing while on tiptoes
Imaging: XRay foot
1. Consider Bone scan or Foot CT if XRay not diagnostic
2. Efficacy: Initial false negative rate approaches 50%
3. Views
  1. Lateral weight bearing foot XRay
  2. Anteroposterior weight bearing foot XRay
  3. Oblique view of foot (30 degrees)
4. Anteroposterior foot xray
  1. Widening of space between first and second metatarsal heads (diastasis)
  2. Avulsed bone fragments (fleck sign)
  3. Malalignment second cuneiform and metatarsal
5. Lateral foot xray: Step-off on dorsal foot surface
  1. Loss of arch height (Stage III injury)
  2. Proximal second metatarsal displaced upward
  3. Middle cuneiform top below metatarsal top
Management: Conservative Management
1. Short-leg walking cast (or CAM walker) for 4-6 weeks
  1. Consider non-weight bearing cast
2. Rehabilitation after cast removal
3. Reassess 2 weeks after starting rehabilitation
  1. Repeat weight bearing XRays to assess for instability
Management: Surgery
1. Indications (controversial)
  1. Displacement greater than 2 mm
2. Timing
  1. Best performed within first 24 hours of injury
  2. Some prefer to wait 7-10 days for less swelling
Complications
1. Post-traumatic arthrosis
Prognosis
1. High risk of morbidity
References
1. Burroughs (1998) Am Fam Physician 58(1):118

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This page was written by Scott Moses, MD. This page was last revised before 5/10/08, prior to consistent tracking of revision date. This page was last published on 6/1/2008. Please send comments and questions to the editor. Contact information may be found on the page About the Family Practice Notebook. These pages are best viewed with Microsoft Internet Explorer 6.0.