Study Guide

Lisfranc Injuries

Key Points:

Tarsometatarsal (Lisfranc) joint consists of ligaments and bones that stabilize the midfoot and forefoot.
Injuries can be bony fractures, purely ligamentous, or fracture dislocations.
Scrutiny of clinical signs and symptoms, as well as radiographic parameters is crucial, as injuries can be missed up to twenty percent of the time.
Treatment goal is anatomic reduction to optimize clinical outcomes. This can be achieved conservatively or surgically.

Description:

Lisfranc injuries can be sprains, fractures, subluxations, or fracture dislocations. Injuries that are at least minimally displaced are commonly classified using the Meyerson classification (Meyerson, 1986):

Type A: (total incongruity) complete dislocation of metatarsals one through five in either the lateral or dorsal plantar direction

Type B: (partial incongruity)

B1: medial dislocation of the first metatarsal joint only
B2: lateral dislocation involving any of metatarsals two through four

Type C: (divergent)

C1: partial displacement of first metatarsal and some of the two through four metatarsals
C2: total displacement of the first metatarsal and all metatarsals two through four

In the pediatrics population, it is also important to note whether the patient has open or closed physis and whether the injury involved the physis. Salter Harris fractures were found in 26% of Lisfranc injuries that involved fractures and a significant association between open versus closed physis and Meyerson classification type (Hill, 2017).

Epidemiology:

Lisfranc injuries are rare in the pediatric population and can often be missed.

Clinical Findings:

Clinical presentation is often midfoot pain and swelling. Plantar ecchymosis has been described as a sign for Lisfranc injuries, but studies have shown this may only be present half the time and usually has associated fractures (Kushare, 2021).

Imaging Studies:

Initial images should include AP, lateral and oblique weight bearing radiographs. Assessment of Lisfranc injuries on radiographs are based on parameters in the adult population. On the AP view, the distance between the first and second metatarsal base and the distance between the second metatarsal base and medial cuneiform should be assessed as widening may suggest injury (Nunley, 2002; Knijnenberg, 2018). On the 30-degree oblique view, the third and fourth tarsometatarsal joints are assessed for congruity. Lateral radiographs may demonstrate flattening of the arch or dorsal displacement of the second metatarsal. Subtle differences in joint space widening or joint incongruity may be difficult to assess due to incomplete ossification in the pediatric population. Obtaining contralateral comparison films or advance imaging can be helpful in diagnosis subtle injuries. Advanced imaging such as CT or MRI is indicated if radiographs are inconclusive or weightbearing views may be too painful to obtain in the acute setting. In the adult literature, CT scans can better detect metatarsal fractures or joint malalignment compared to MRI (Sripanich, 2020).

Treatment:

Nondisplaced injuries are usually treated conservatively. Options include controlled ankle motion (CAM) boot, short leg cast with or without closed reduction, and limited weight bearing status. Surgical indications are not well described in the current literature but factors such as severity of displacement and skeletal maturity are more likely to be treated surgically (Hill, 2017). Operative treatment options include open reduction internal fixation with wires, screws, or non-rigid fixation. Suture button or dynamic fixation is an option and case reports described advantages include early weight bearing, no intended second surgery for hardware removal or less risk for second surgery due to hardware failure, and less iatrogenic damage to cartilage (Cardile, 2021). Due to the rarity of Lisfranc injuries and the wide spectrum of injury characteristics, there are currently no comparative studies evaluating the variety of treatment options. Injury severity and fracture characteristics, skeletal maturity, and discussions with patients and families should all be considered in guiding treatment plans.

Complications:

Broken hardware is the most common complication reported by two case series 1.8% (1 of 56) (Cheow, 2018) and 25% (2 of 8) (Hill, 2017). There is one case of physeal arrest from a severely displaced injury (Hill, 2017).

In the adult population, posttraumatic arthritis is a common sequela of Lisfranc injuries. However, there are no long-term studies in the pediatric population that have estimated the incidence of posttraumatic arthritis or long-term effects of Lisfranc injuries.

References:

Buoncristiani AM, Manos RE, Mills WJ. Plantar-flexion tarsometatarsal joint injuries in children. J Pediatr Orthop. 2001;21(3):324-327.
Cardile C, Cazzaniga C, Manzini B, Marasco R, Ragni P. Lisfranc injuries in adolescents: A case report and literature review. Foot (Edinb). 2021;47:101812. doi:10.1016/j.foot.2021.101812
Cheow X, Lam KY. Midterm functional outcomes in operatively treated adolescent Lisfranc injuries. J Pediatr Orthop B. 2018;27(5):435-442.
Coss HS, Manos RE, Buoncristiani A, Mills WJ. Abduction stress and AP weightbearing radiography of purely ligamentous injury in the tarsometatarsal joint. Foot ankle Int. 1998;19(8):537-541. doi:10.1177/107110079801900806
Faciszewski T, Burks RT, Manaster BJ. Subtle injuries of the Lisfranc joint. J Bone Joint Surg Am. 1990;72(10):1519-1522.
Hardcastle PH, Reschauer R, Kutscha-Lissberg E, Schoffmann W. Injuries to the tarsometatarsal joint. Incidence, classification and treatment. J Bone Joint Surg Br. 1982;64(3):349-356. doi:10.1302/0301-620X.64B3.7096403
Hill JF, Heyworth BE, Lierhaus A, Kocher MS, Mahan ST. Lisfranc injuries in children and adolescents. J Pediatr Orthop B. 2017;26(2):159-163. doi:10.1097/BPB.0000000000000380
Kushare I, Wunderlich N, Elabd A, Attia E. Pediatric and adolescent Lisfranc injuries - Presentation, treatment and outcomes. Foot (Edinb). 2021;46:101737. doi:10.1016/j.foot.2020.101737
Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture Dislocations of the Tarsometatarsal Joints: End Results Correlated with Pathology and Treatment. Foot Ankle. 1986;6(5):225-242. doi:10.1177/107110078600600504
Nunley JA, Vertullo CJ. Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med. 2002;30(6):871-878. doi:10.1177/03635465020300061901
Sripanich Y, Weinberg MW, Krähenbühl N, et al. Imaging in Lisfranc injury: a systematic literature review. Skeletal Radiol 2020; 49(1): 31–53
Wiley JJ. Tarso-metatarsal joint injuries in children. J Pediatr Orthop. 1981;1(3):255-260. doi:10.1097/01241398-198111000-00003

Top Contributors:

Dave Bennett, MD

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