From the Guidelines
A Lisfranc fracture is a serious injury to the midfoot where the metatarsal bones are displaced from the tarsus, requiring prompt diagnosis and treatment to prevent long-term complications such as chronic pain, arthritis, and altered gait. This injury typically occurs when excessive force is applied to the foot, such as during a fall from height, motor vehicle accident, or sports injury. The fracture is named after French surgeon Jacques Lisfranc de St. Martin who first described it. Symptoms include severe pain, swelling, bruising on the bottom of the foot, and inability to bear weight.
Diagnosis and Treatment
Treatment depends on severity but often requires surgical intervention with internal fixation using screws and plates to realign the bones, followed by 6-12 weeks of non-weight bearing and protective boot use 1. Early diagnosis through X-rays, CT scans, or MRI is crucial for proper management and to prevent long-term complications. According to the American College of Radiology, weightbearing radiographs are recommended when possible because non-weightbearing radiographs are not reliable for detection of subtle injuries 1.
Imaging Modalities
MRI has been advocated as a sensitive diagnostic test in evaluation of Lisfranc ligamentous complex, especially if the patient is not able to bear weight 1. CT scans are also useful in demonstrating the multiple metatarsal and cuneiform fractures that can be associated with a ligamentous Lisfranc injury 1. Ultrasound (US) may hold promise as an alternative method to accurately evaluate for a significant Lisfranc injury, providing direct and indirect assessment of the Lisfranc ligamentous complex as well as dynamic evaluation with weightbearing 1.
Key Considerations
It is essential to note that a high clinical suspicion of an acute Lisfranc injury warrants imaging of the foot, and radiography should be the initial imaging modality in this setting 1. The inclusion of both feet on AP radiographs can help in the detection of subtle malalignment when compared with the uninjured side 1. In the patient with a suspected Lisfranc injury and normal radiographs, further advanced imaging by MRI and CT is supported by the literature 1.
From the Research
Definition of Lisfranc Fracture
- A Lisfranc fracture is an injury to the joints in the middle of the foot, specifically the tarsometatarsal joints 2.
- It can range from a mild sprain to a fracture-dislocation, and is often misdiagnosed due to its complexity and rarity 2.
Causes and Symptoms
- Lisfranc injuries can occur due to various mechanisms, including high or low energy trauma 3.
- Typical signs and symptoms include pain, swelling, and the inability to bear weight, with swelling primarily over the midfoot region 2.
- Pain is elicited with palpation along the tarsometatarsal articulations, and force applied to this area may elicit medial or lateral pain 2.
Diagnosis
- Radiographs showing diastasis of the normal architecture confirm the presence of a severe sprain and possible dislocation 2.
- Negative standard and weight-bearing radiographs do not rule out a mild or moderate sprain, and reevaluation may be necessary if pain and swelling continue for 10 days after the injury 2.
- Computed tomography (CT) and magnetic resonance imaging (MRI) may be indicated if plain radiographs are inconclusive 4.
Treatment
- Stable injuries generally have good outcomes with nonoperative management, most reliably treated with immobilization and non-weightbearing for six weeks 5.
- Displaced or comminuted injuries require surgical intervention, with open reduction and internal fixation (ORIF) being the most common approach 5.
- Primary arthrodesis may offer benefits such as lower rates of post-traumatic arthritis and hardware removal, but is currently niche for the treatment of acute injuries 5.
- Novel fixation techniques, including suture button fixation, aim to provide flexible stabilization and improve midfoot biomechanics, with promising functional outcomes reported in some studies 6, 5.
Complications
- Delay in diagnosis can have a negative impact on outcome, and untreated Lisfranc injuries can lead to posttraumatic osteoarthritis and chronic pain 6, 3.
- Early complications, such as infection or hardware failure, can occur in up to 18% of cases 3.
- Long-term complications, such as C2M2 osteoarthritis, can occur in up to 45% of patients, even with proper treatment 3.