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Lisfranc injury

A Lisfranc injury (also termed a Lisfranc fracture-dislocation), is the most common type of dislocation involving the foot. 

Anatomy

The Lisfranc joint is the articulation of the tarsus with the metatarsal bases, whereby the first three metatarsals articulate respectively with the three cuneiforms, and the 4th and 5th metatarsals - with the cuboid.

The Lisfranc ligament is a strong band attaching the medial cuneiform to the 2nd metatarsal base on the plantar aspect of the foot. Its integrity is crucial to the stability of the Lisfranc joint.

Pathology

Mechanism

Injury mechanisms are varied, and include direct crush injury, or an indirect load onto a plantar flexed foot 3. Tarsometatarsal dislocation may also occur in the diabetic neuropathic joint (Charcot's).

Subtypes

There are two types of Lisfranc fracture-dislocation:

Homolateral

A homolateral injury refers to lateral displacement of the 1st to 5th metatarsals, or of 2nd to 5th metatarsals where the 1st MTP joint remains congruent.

Divergent 

A divergent injury is the lateral dislocation of the 2nd to 5th metatarsals with medial dislocation of the 1st metatarsal.  

Radiographic features

Plain film / CT

These injuries are well demonstrated on the standard views of the foot.

Ancillary imaging techniques are seldom required, although CT examination may demonstrate unsuspected associated fractures. 

Associated fractures most often occur at the base of the second metatarsal. They may also be seen in the 3rd metatarsal, 1st or 2nd cuneiform, or navicular bones. 

Ultrasound

Useful for assessing ligamentous injury. Non-visualisation of the dorsal C1-M2 ligament and a C1-M2 distance > 2.5 mm is indirectly indicative or a Lisfranc ligament tear 5.

Dynamic evaluation with weight bearing may show widening of the space between C1 and M2.

MRI

Again may be useful for assessing ligamentous injury especially when there is strong clinical concern with routine radiographs being inconclusive 7

Complications

The most common complications of ankle and foot fractures are non-union and post traumatic arthritis. Although conventional radiography can usually demonstrate the features of these complications, CT is the better technique for delineating their details.

Etymology

It is named after Jacques Lisfranc De Saint Martin (1790-1847), French surgeon 2.

 

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