What is the initial management of a Lisfranc injury in the emergency department?

Initial Management of Lisfranc Injury in the Emergency Department

All patients with suspected Lisfranc injuries should be made strictly non-weight-bearing, placed in a below-knee splint or boot, and have orthopedic surgery consultation arranged for definitive management. 1, 2

Immediate Assessment and Stabilization

Clinical Recognition

• Maintain high clinical suspicion in any patient presenting with midfoot pain, swelling, or plantar ecchymosis following foot trauma, as up to 20% of Lisfranc injuries are initially missed 2, 3
• Examine specifically for:
  • Midfoot tenderness over the tarsometatarsal (TMT) joint complex
  • Plantar ecchymosis (highly suggestive finding)
  • Inability to bear weight
  • Gross deformity or instability 2

Emergency Complications to Rule Out

• Assess immediately for compartment syndrome, neurovascular compromise, and open fractures, as these require urgent surgical intervention 2, 4
• Document neurovascular status including dorsalis pedis and posterior tibial pulses, capillary refill, and sensation 2

Pain Management

Provide adequate analgesia with opioids as the primary agent, using caution in patients with renal dysfunction 5

• Administer parenteral opioids for acute pain control 5
• Add scheduled acetaminophen unless contraindicated 5
• Avoid NSAIDs in patients with renal impairment (GFR <60 mL/min/1.73m²), which is present in approximately 40% of trauma patients 5
• Consider regional nerve blocks (femoral or fascia iliaca) if trained personnel are available, though this is more commonly described for proximal injuries 5

Imaging Protocol

Initial Radiographic Evaluation

Obtain a three-view radiographic series (AP, oblique, and lateral) as the initial imaging study 5, 6

• Add an AP view with 20° craniocaudal angulation to improve visualization of the Lisfranc joint 5, 6
• Weight-bearing radiographs are essential when the patient can tolerate them, as non-weight-bearing films are unreliable for detecting subtle injuries 5, 6
• Include bilateral foot imaging on AP views to compare with the uninjured side for subtle malalignment 5, 6

Key Radiographic Findings to Identify

• Diastasis between the first and second metatarsal bases (>2mm is abnormal) 6
• The "fleck" sign (small avulsion fracture fragment) 6
• Loss of alignment between the medial border of the second metatarsal and medial border of the middle cuneiform 6
• Associated metatarsal base fractures, particularly at the second metatarsal base (present in ~50% of cases) 7

Advanced Imaging Indications

When radiographs are normal but clinical suspicion remains high, obtain CT imaging before discharge 5, 6, 2

• CT is superior for detecting nondisplaced fractures and evaluating the true extent of osseous injury 5, 6
• In polytrauma patients, approximately 25% of midfoot fractures are missed on plain radiographs but identified on CT 6
• MRI is indicated for purely ligamentous injuries when both radiographs and CT are negative but clinical suspicion persists, though this is typically arranged on an outpatient basis 6, 8

Immobilization and Weight-Bearing Status

Place all patients with confirmed or suspected Lisfranc injuries in strict non-weight-bearing status with a below-knee splint or boot 1, 2

• Provide crutches or other assistive devices 1
• Weight-bearing forces worsen instability and increase displacement at the TMT joints, potentially converting a reducible injury into one requiring more extensive reconstruction 1
• This is critical even for subtle injuries, as small subluxations can result in significant long-term morbidity including post-traumatic arthritis and foot deformities 2, 3

Orthopedic Consultation

All Lisfranc injuries, regardless of severity, require orthopedic surgery consultation to determine definitive management 2

• Stable, non-displaced injuries may be managed conservatively with immobilization and non-weight-bearing 3
• Displaced or unstable injuries require surgical intervention, typically within 10-14 days to avoid scar tissue formation that complicates reduction 9

High-Energy Injuries Requiring Urgent Intervention

For high-energy Lisfranc fracture-dislocations (Type A homolateral or Type C divergent patterns), consider temporary K-wire stabilization in the ED if orthopedic surgery is immediately available and the patient has associated complications 4

• This staged approach is appropriate when there is gross instability, compartment syndrome risk, or need for damage control 4
• Definitive fixation is performed once soft tissues recover and the patient is optimized 4

Discharge Instructions (When Appropriate)

Patients discharged from the ED must understand that non-compliance with non-weight-bearing status can worsen displacement and compromise surgical outcomes 1

• Arrange orthopedic follow-up within 3-5 days 2
• Prescribe adequate analgesia for home use 5
• Provide written instructions emphasizing strict non-weight-bearing and elevation to minimize swelling 8
• Counsel on smoking cessation if applicable, as nicotine increases surgical complications 1

Common Pitfalls to Avoid

• Never rely solely on non-weight-bearing radiographs when the patient can tolerate weight-bearing views, as this leads to missed diagnoses 5, 6
• Do not discharge patients to weight-bearing status even with "normal" radiographs if clinical suspicion is high—obtain CT first 2
• Do not miss purely ligamentous injuries that show no fracture on imaging but have positive stress examination findings 6, 3
• Avoid assuming patients with neuropathy (diabetics) cannot have significant injuries simply because they can bear weight—they require special attention 6