What is the treatment for a suspected Lisfranc (Lisfranc joint injury) fracture?

Treatment of Suspected Lisfranc Fracture

For suspected Lisfranc fractures, obtain weight-bearing radiographs (AP, lateral, and oblique views) as the initial diagnostic step, and if clinical suspicion remains high despite normal radiographs, proceed directly to CT or MRI for definitive diagnosis before determining whether operative or non-operative management is appropriate. 1, 2

Initial Diagnostic Approach

First-Line Imaging

• Obtain three-view weight-bearing radiographs (anteroposterior, oblique, and lateral) as the cornerstone of diagnosis, specifically looking for diastasis between the first and second metatarsal bases and the "fleck" sign. 2, 3
• Add an AP view with 20° craniocaudal angulation to improve visualization of the Lisfranc joint. 2
• Bilateral comparison views are essential to detect subtle malalignment when compared to the uninjured side. 2
• Non-weight-bearing radiographs are unreliable and should not be used to rule out injury—up to 20% of Lisfranc injuries are missed on initial evaluation. 2, 4

Advanced Imaging When Radiographs Are Normal or Equivocal

• CT is the primary imaging technique for acute hyperflexion injuries, high-energy polytrauma, patients unable to bear weight, and for preoperative planning, as it detects 25% of midfoot fractures overlooked on radiographs in polytrauma patients. 1, 2
• MRI shows high correlation with intraoperative findings for unstable Lisfranc injuries and is particularly valuable for purely ligamentous injuries without diastasis, with 3-D volumetric acquisitions superior to standard sequences. 1, 2
• Both CT and MRI are appropriate next steps when radiographs are normal but clinical suspicion remains high. 1

Treatment Algorithm

Non-Operative Management (Limited Indications)

• Reserved exclusively for stable, non-displaced injuries confirmed on weight-bearing radiographs. 4, 5
• Immobilization in a non-weight-bearing cast for 6 weeks, followed by graduated weight-bearing. 5
• Critical pitfall: Multiple studies demonstrate poor outcomes with non-operative treatment of displaced or unstable injuries. 6, 5

Operative Management (Most Cases)

For Purely Ligamentous Unstable Injuries

• Closed reduction and percutaneous fixation (CRPF) with suspensory fixation is preferred for low-energy, purely ligamentous Lisfranc injuries, ideally performed within 10-14 days of injury. 6
• This technique minimizes soft-tissue trauma, reduces complications (wound breakdown, infection, complex regional pain syndrome), and allows earlier rehabilitation compared to open procedures. 6
• Growing evidence supports primary arthrodesis for unstable purely ligamentous injuries, showing better functional outcomes, increased cost-effectiveness, and reduced return-to-theatre rates. 5

For Bony Injuries with Fractures

• Open reduction and internal fixation (ORIF) with transarticular screws or dorsal plates (when metatarsals or cuneiform bones are comminuted) remains the preferred approach. 4
• The two critical surgical objectives are: (1) optimal anatomic reduction, which directly influences outcomes, and (2) stability of the first, second, and third cuneiform-metatarsal joints. 7, 4
• Failure to achieve anatomic reduction leads to post-traumatic arthritis (occurring in approximately 25% of cases despite anatomic reduction), foot deformities, and significant disability. 7, 4

Surgical Timing and Perioperative Care

• Administer prophylactic antibiotics (such as cefazolin) prior to incision. 7
• Perform fluoroscopic stress examination intraoperatively to identify all components of instability. 7, 6
• Postoperatively: non-weight-bearing for 6 weeks in a splint (first 2 weeks) then boot, followed by partial progressive weight-bearing weeks 6-12 with arch support, progressing to full weight-bearing. 6
• Physical therapy initiated after K-wire removal at 6-8 weeks post-surgery. 7
• Return to full activity expected at 12-16 weeks postoperatively. 6

Critical Pitfalls to Avoid

• Never rely solely on non-weight-bearing radiographs—this is the most common cause of missed diagnosis. 2
• Do not delay advanced imaging when clinical suspicion is high despite normal radiographs, as purely ligamentous injuries are particularly challenging to diagnose. 2
• Special attention required for neuropathic patients who may bear weight despite fractures. 2
• If closed reduction cannot be achieved, convert immediately to open procedure to debride obstruction. 6
• Ensure reduction clamp does not interfere with guidewire path during percutaneous procedures. 6

Comparative Outcomes

• CRPF with suspensory fixation versus PRIF with screw fixation: both provide comparable stability and clinical outcomes at 1 year, but CRPF avoids screw-related complications (breakage, metal irritation, need for removal) and allows increased range of motion. 6
• CRPF patients demonstrated significantly better AOFAS midfoot scores (81 vs 74 points) and VAS scores (3.1 vs 4.6 points) at 6 months compared to PRIF with screws. 6