From the Guidelines
Lisfranc injuries should be treated with surgery when fracture fragments are large, articular, or significantly displaced, while simple immobilization is appropriate for small, nonarticular, or minimally displaced fractures. The diagnosis of a Lisfranc injury is based on a history of trauma and focal pain on palpation, and is confirmed with radiographic studies, including a typical three-view radiographic study of the foot (anteroposterior [AP], oblique, and lateral), and an AP view with 20 craniocaudal angulation can be added 1. Treatment depends on the severity of the injury, with non-displaced injuries often managed conservatively with 6-8 weeks of non-weight bearing in a cast or boot, followed by gradual return to activities using supportive footwear.
Key Considerations
- Displaced injuries typically require surgical intervention with internal fixation using screws or plates to realign the bones, followed by 6-12 weeks of protected weight bearing 1.
- Pain management includes NSAIDs like ibuprofen (400-600mg every 6-8 hours) or naproxen (500mg twice daily), with stronger prescription medications for severe pain.
- Physical therapy is essential for recovery, focusing on range of motion, strength, and proprioception.
- These injuries require prompt treatment as they can lead to chronic pain, arthritis, and altered gait if not properly addressed, as noted in the diagnosis and treatment guidelines 1.
Radiographic Evaluation
- Radiography should be the initial imaging modality in the setting of a suspected Lisfranc injury 1.
- The mechanism typically involves forced plantar flexion of the foot, such as stepping in a hole or from a direct crushing injury, causing disruption of the tarsometatarsal joint complex that maintains the arch of the foot.
From the Research
Definition and Classification of Lisfranc Injury
- Lisfranc injuries are a spectrum of midfoot and tarsometatarsal (TMT) joint trauma, ranging from purely ligamentous injuries to bone fracture-dislocations 2.
- The severity of the injury exists on a spectrum, from minor subluxations to fractures and dislocations involving the TMT joint complex 3.
- Lisfranc injuries can be caused by high- or low-energy trauma to the TMT joint complex 3.
Diagnosis of Lisfranc Injury
- A quick and careful diagnosis is crucial to optimize management and treatment, reducing complications and improving functional outcomes in the middle and long-term 2.
- Clinically, Lisfranc injuries present with evident swelling of the midfoot and pain, often associated with joint instability of the midfoot, and plantar region ecchymosis is highly peculiar 2.
- The first level of examination is X-Ray performed in 3 projections, while CT scan is useful to detect nondisplaced fractures and minimal bone sub-dislocation, and MRI is the gold standard for ligament injuries 2.
- Delay in diagnosis has a negative impact on outcome, and if a Lisfranc injury is suspected and plain radiographs are inconclusive, computed tomography and if necessary magnetic resonance imaging are indicated 4.
Treatment of Lisfranc Injury
- The major current controversies in literature concern the management and treatment of Lisfranc injuries 2.
- In stable lesions and in those without dislocation, conservative treatment with immobilization and no weight-bearing is indicated for a period of 6 weeks 2, 4.
- Displaced injuries have worse outcomes and require surgical treatment with the two main objectives of anatomical reduction and stability of the first three cuneiform-metatarsal joints 2.
- Different surgical procedures have been proposed, including closed reduction and percutaneous surgery, open reduction and internal fixation (ORIF), and primary arthrodesis (PA) 2, 5.
- A systematic review and meta-analysis found that primary arthrodesis (PA) may have better functional outcomes and increased cost-effectiveness compared to ORIF, but further research is needed to confirm this 5.