What is the diagnosis and treatment for a Lisfranc (midfoot) fracture?

From the Guidelines

Lisfranc fractures are serious injuries that require prompt medical attention, and treatment typically involves immobilization for minor injuries or surgical intervention for displaced fractures, with the goal of minimizing morbidity, mortality, and improving quality of life. A Lisfranc fracture is a serious injury to the midfoot where the metatarsal bones connect to the tarsal bones, often involving fracture and dislocation of these joints. The diagnosis is based on a history of trauma and focal pain on palpation, and is confirmed with radiographic studies, including weightbearing radiographs when possible, as recommended by the American College of Radiology 1.

Diagnosis and Treatment

• The initial imaging modality should be radiography, with an AP view with 20 craniocaudal angulation added to the typical three-view radiographic study of the foot (anteroposterior [AP], oblique, and lateral) 1.
• Weightbearing radiographs are recommended when possible, as they can increase the abnormal alignment at the Lisfranc joint, making it easier to identify a Lisfranc injury 1.
• Treatment depends on the severity of the injury, but typically requires immobilization for minor injuries or surgical intervention for displaced fractures.
• For non-surgical cases, a non-weight bearing cast is applied for 6-8 weeks, followed by a walking boot for 4-6 weeks and physical therapy.
• Surgical treatment involves open reduction and internal fixation with screws or plates to realign the bones, followed by similar post-operative immobilization and rehabilitation.

Pain Management and Recovery

• Pain management typically includes NSAIDs like ibuprofen (400-800mg every 6-8 hours) or naproxen (500mg twice daily), with stronger opioid medications sometimes needed initially after surgery.
• Complete recovery takes 3-6 months, and complications can include post-traumatic arthritis, chronic pain, and altered foot biomechanics.
• These injuries require prompt medical attention as delayed treatment can lead to permanent disability, as noted in the American College of Foot and Ankle Surgeons guidelines 1.

Key Considerations

• The mechanism of injury typically involves excessive force to the midfoot, such as from a fall from height or a motor vehicle accident, causing disruption of the strong ligaments that maintain the arch structure of the foot.
• Prompt and accurate diagnosis, followed by appropriate treatment, is crucial to minimize morbidity, mortality, and improve quality of life in patients with Lisfranc fractures.

From the Research

Diagnosis of Lisfranc (Midfoot) Fracture

• The diagnosis of Lisfranc fractures is crucial to optimize management and treatment, reducing complications and improving functional outcomes in the middle and long-term 2.
• Clinical presentation includes 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.

Treatment of Lisfranc (Midfoot) Fracture

• Conservative treatment with immobilization and no weight-bearing is indicated for a period of 6 weeks in stable lesions and in those without dislocation 2, 3.
• 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, 3.
• Different surgical procedures have been proposed, including:
  • Closed reduction and percutaneous surgery with K-wire or external fixation (EF) 4, 5.
  • Open reduction and internal fixation (ORIF) with transarticular screw (TAS) or dorsal plate (DP) 2, 3.
  • Primary arthrodesis (PA) 2, 3.
• The choice of surgical technique depends on the severity of the injury and the surgeon's preference, with no superiority of one technique over the other, but anatomical reduction is the main determinant of post-operative outcomes 2.
• Closed reduction and percutaneous fixation (CRPF) with suspensory fixation is a minimally invasive technique that offers several benefits over traditional surgical techniques, including minimized soft-tissue trauma and reduced risk of postoperative complications 5.