Lisfranc injury

Lisfranc injuries, also called Lisfranc fracture-dislocations, are the most common type of dislocation involving the foot and correspond to the dislocation of the articulation of the tarsus with the metatarsal bases.

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.

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

There are several types of Lisfranc fracture-dislocation:

  • homolateral: a homolateral injury is a 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 a lateral dislocation of the 2nd to 5th metatarsals with medial dislocation of the 1st metatarsal
  • isolated: this involves one or two metatarsals that dislocate dorsally in isolation

These injuries are well demonstrated on the standard views of the foot but subtle injuries may be missed and require further imaging such as CT, MRI or radiographic stress views with forefoot abduction. CT is however favored as it will also demonstrate unsuspected associated fractures.

The key finding is malalignment of the second tarsometatarsal joint, such as lateral displacement of the second metatarsal base on AP view and/or dorsal step-off sign on lateral view 10. An additional abnormality is diastasis >2 mm between the first and second metatarsal bases 10.

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

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

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

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

Internal fixation is the most common treatment. 

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.

It is named after Jacques Lisfranc De Saint Martin (1790-1847), the chief of surgery at the Hôpital de la Pitie in Paris 2.

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Article information

rID: 1590
Synonyms or Alternate Spellings:
  • Lisfranc fracture
  • Lisfranc fracture-dislocation

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Cases and figures

  • Figure 1: normal Lisfranc joint alignment
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  • Figure 2: Myerson classification - illustrations
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  • Figure 3: Nunley-Vertullo classification - illustrations
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  • Case 1: homolateral
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  • Case 2
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  • Case 3: homolateral
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  • Lisfranc’s disloc...
    Case 4: with Charcot's foot
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  • Case 5: traumatic homolateral LisFranc fracture dislocation
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  • Case 6
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  • Case 7
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  • Lisfranc injury

    Case 8
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  • Case 9: subtle - arrowed
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  • Case 10
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  • Case 11
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  • Case 12
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  • Case 13
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  • Case 14
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