Lisfranc Fracture Dislocation

Aka: Lisfranc Fracture Dislocation, Lisfranc Fracture, Lisfranc Injury, Lisfranc Dislocation

1. 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
2. Mechanism
   1. Plantar hyperflexion with axial loading
   2. Displaces second Metatarsal dorsally
3. Causes
   1. Lateral Ankle Sprain
   2. High energy injury
      1. Motor vehicle accident
      2. Fall from high height
4. Symptoms: Persist >5 days after injury
   1. Midfoot swelling
   2. Difficult weight bearing
5. Signs
   1. Tenderness at tarsometatarsal joint
   2. Difficult weight bearing while on tiptoes
6. 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
7. 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
8. 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
9. Complications
   1. Post-traumatic arthrosis
10. Prognosis
    1. High risk of morbidity
11. References
    1. Burroughs (1998) Am Fam Physician 58(1): 118-24