Lisfranc injury

Lisfranc injuries are disruptions of the tarsometatarsal joint complex of the foot, which can result from both high-energy trauma and low-energy mechanisms. Accurate diagnosis is crucial because untreated injuries can lead to chronic pain, deformity, and impaired function. This article provides a detailed overview of the anatomy, classification, and clinical considerations related to Lisfranc injuries.

Anatomy of the Lisfranc Joint Complex

Bony Anatomy

The Lisfranc joint complex consists of the articulations between the metatarsals and the tarsal bones. The first to third metatarsals articulate with the three cuneiform bones, while the fourth and fifth metatarsals articulate with the cuboid. These articulations form a stable arch that is essential for weight-bearing and walking.

• Metatarsals (first to fifth)
• Cuneiforms (medial, intermediate, lateral) and cuboid
• Articular surfaces contributing to the tarsometatarsal joint

Ligamentous Anatomy

The stability of the Lisfranc joint is primarily maintained by a complex arrangement of ligaments. The Lisfranc ligament, an interosseous ligament connecting the medial cuneiform to the base of the second metatarsal, is the most critical stabilizer. Additional support is provided by the dorsal, plantar, and intermetatarsal ligaments.

• Lisfranc ligament (medial cuneiform to second metatarsal)
• Dorsal and plantar ligaments
• Intermetatarsal ligaments between the bases of metatarsals

Functional Anatomy

The Lisfranc joint complex plays a crucial role in maintaining the transverse and longitudinal arches of the foot. It allows for controlled motion during gait while providing the rigidity needed for weight-bearing. Disruption of this joint can compromise the foot’s structural integrity and impair normal locomotion.

• Maintains foot arches
• Contributes to stability during weight-bearing
• Supports propulsion during walking and running

Classification of Lisfranc Injuries

Hardcastle Classification

The Hardcastle classification categorizes Lisfranc injuries based on the pattern of displacement and incongruity of the tarsometatarsal joints. This system aids in diagnosis and treatment planning.

• Type A: Total incongruity of the tarsometatarsal joint
• Type B: Partial incongruity with displacement of some metatarsals
• Type C: Divergent injuries with medial and lateral displacement of metatarsals

Myerson Modification

Myerson modified the Hardcastle system to provide additional detail for partial incongruity injuries, subdividing them based on the direction and extent of displacement. This modification improves prognostic accuracy and guides surgical decisions.

• Type B1: Partial medial displacement
• Type B2: Partial lateral displacement

Other Classifications

Other classification systems focus on the mechanism and severity of the injury. Injuries may be described as purely ligamentous or as fracture-dislocations. They can also be categorized as low-energy, typically sports-related, or high-energy, often resulting from motor vehicle accidents or crush injuries.

• Pure ligamentous injuries vs fracture-dislocations
• Low-energy vs high-energy mechanisms

Etiology and Mechanism of Injury

Traumatic Causes

Lisfranc injuries often occur due to trauma to the midfoot, which can be classified as direct or indirect. Direct trauma typically involves a crush injury to the foot, whereas indirect trauma occurs when an axial load is applied to a plantar-flexed foot. Both mechanisms can disrupt the tarsometatarsal joint complex and associated ligaments.

• Direct trauma such as crush injuries from heavy objects or machinery
• Indirect trauma including axial load applied to a plantar-flexed foot during falls or sports

Risk Factors

Certain factors increase the likelihood of sustaining a Lisfranc injury. Athletes participating in sports with sudden changes of direction or high-impact forces are at higher risk. Similarly, individuals involved in high-energy accidents or those with pre-existing foot deformities may have increased susceptibility.

• Sports-related activities involving pivoting or jumping
• High-energy accidents such as motor vehicle collisions
• Pre-existing foot deformities that compromise joint stability

Clinical Presentation

History

Patients with Lisfranc injuries typically report acute onset of midfoot pain following a traumatic event. Detailed history should include the mechanism of injury, prior foot injuries, and any activities at the time of trauma. Early recognition of subtle injuries is essential to prevent long-term complications.

• Onset and location of pain
• Mechanism and context of injury
• History of previous foot trauma or deformities

Physical Examination

Clinical examination often reveals swelling and bruising over the dorsum of the midfoot. Palpation may elicit tenderness along the tarsometatarsal joints, especially at the base of the second metatarsal. Specific tests can aid in diagnosis, and assessment of neurovascular status is critical to rule out associated injuries.

• Swelling, ecchymosis, and tenderness at the midfoot
• Positive “piano key” test: pain with dorsal-plantar movement of the metatarsals
• Positive “drawer” test: instability with anterior-posterior translation
• Evaluation of neurovascular function

Diagnostic Evaluation

Imaging Studies

Accurate diagnosis of Lisfranc injuries relies on appropriate imaging techniques. Weight-bearing radiographs are the first-line modality, allowing visualization of subtle displacements that may be missed on non-weight-bearing films. Computed tomography provides detailed assessment of bony structures, while magnetic resonance imaging is valuable for evaluating ligamentous injuries.

• Weight-bearing radiographs (anteroposterior, lateral, and oblique views)
• Computed tomography (CT) scan for detailed bony evaluation
• Magnetic resonance imaging (MRI) for detecting ligamentous and soft tissue injuries

Stress Tests and Special Imaging

In cases where standard imaging is inconclusive, stress tests under fluoroscopy or advanced weight-bearing imaging techniques may be employed. These tests help identify occult instability and guide treatment decisions.

• Fluoroscopic stress views to assess joint stability
• Weight-bearing CT scans for dynamic assessment
• Special MRI protocols for detecting subtle ligamentous tears

Treatment

Non-Surgical Management

Non-operative treatment may be appropriate for stable, non-displaced injuries. Management typically involves immobilization, activity restriction, and structured rehabilitation. Close monitoring is required to detect any late displacement that may necessitate surgical intervention.

• Indications: stable, non-displaced injuries
• Immobilization using cast or boot for 6 to 8 weeks
• Gradual rehabilitation including range-of-motion exercises and strengthening

Surgical Management

Surgical intervention is indicated for displaced or unstable Lisfranc injuries. Open reduction and internal fixation is commonly performed to restore anatomical alignment. In some cases, primary arthrodesis may be preferred, especially in purely ligamentous injuries or when joint surfaces are severely damaged.

• Open reduction and internal fixation (ORIF) to realign bones and ligaments
• Primary arthrodesis for ligamentous or severe joint injuries
• Postoperative care including immobilization, pain management, and gradual weight-bearing

Rehabilitation and Return to Activity

Rehabilitation after Lisfranc injury focuses on restoring strength, flexibility, and proprioception. Weight-bearing is gradually introduced based on stability and healing progress. A structured physiotherapy program helps patients regain normal gait and functional mobility, with return to sports or high-impact activities guided by clinical and radiographic recovery.

• Progressive weight-bearing as tolerated
• Physiotherapy including range-of-motion, strengthening, and balance exercises
• Guidelines for safe return to sports and high-impact activities

Complications

Complications from Lisfranc injuries can be significant, especially if diagnosis or treatment is delayed. Patients may develop persistent pain, instability, and degenerative changes in the midfoot. Awareness of potential complications is essential for monitoring and timely intervention.

• Post-traumatic arthritis leading to chronic midfoot pain
• Chronic instability of the tarsometatarsal joints
• Malunion or nonunion of fractures
• Infection and hardware-related complications following surgery

Prognosis

The prognosis of Lisfranc injuries depends on the severity of the injury, timeliness of diagnosis, and adequacy of treatment. Early recognition and appropriate management are associated with better functional outcomes, whereas delayed or inadequate treatment can result in chronic pain, deformity, and impaired mobility.

• Factors affecting recovery: injury severity, treatment method, patient age, and comorbidities
• Long-term functional outcomes: return to daily activities and athletic performance
• Impact on quality of life: potential for persistent pain and limitation in high-impact activities

Prevention

Preventive strategies focus on minimizing risk factors and protecting the midfoot during high-impact activities. Proper footwear, training, and early recognition of foot injuries are essential to reduce the incidence and severity of Lisfranc injuries.

• Use of protective footwear in sports and occupational settings
• Conditioning and training to strengthen foot and ankle musculature
• Early recognition and management of high-risk mechanisms to prevent injury

References

1. Myerson MS, Fisher RT. The diagnosis and treatment of injuries to the Lisfranc joint complex. J Bone Joint Surg Am. 1986;68(5):647-656.
2. Hardcastle PH, Reschauer R, Kutzner J, et al. Injuries to the tarsometatarsal joint. J Bone Joint Surg Br. 1982;64-B(3):349-356.
3. Ly TV, Coetzee JC. Current concepts review: the diagnosis and management of tarsometatarsal joint injuries. Foot Ankle Int. 2006;27(4):283-293.
4. Nunley JA, Vertullo CJ. Classification, investigation, and management of midfoot sprains. Foot Ankle Int. 2002;23(9):798-801.
5. Wang C, Yu B, Zhang S. Lisfranc injuries: diagnosis, classification, and treatment. Orthop Surg. 2012;4(2):69-76.
6. Johansson M, Wikeroy AK, Wikeroy I. Lisfranc injuries in athletes: epidemiology, diagnosis, and management. Sports Med. 2018;48(8):1783-1795.
7. Fleming JJ, Polat G, Chen A, et al. Weight-bearing CT for evaluation of Lisfranc injuries. Foot Ankle Int. 2017;38(2):146-155.
8. Keenan MA, Mann RA. Long-term results of treatment of Lisfranc injuries. Foot Ankle Int. 1999;20(1):48-54.