Diagnosis and Management of Lisfranc Injuries

Diagnosis and Management of Lisfranc Injuries: A High-Yield Review for Orthopaedic Surgical Learners

High-Yield Executive Summary

• Lisfranc injuries involve disruption of the tarsometatarsal (TMT) joint complex, often subtle but with high morbidity if missed; maintain a high index of suspicion in midfoot trauma.
• Weight-bearing radiographs are essential; CT and MRI are adjuncts for occult injuries and preoperative planning.
• Displacement >2 mm or instability mandates surgical fixation; purely ligamentous injuries may require more aggressive fixation than previously thought.
• Open reduction and internal fixation (ORIF) remains the gold standard; primary arthrodesis is increasingly favored in purely ligamentous or severely comminuted injuries.
• Meticulous restoration of the medial column alignment and stable fixation of the second metatarsal-cuneiform articulation (“keystone”) are critical for optimal outcomes.

Clinical Fundamentals

Anatomy & Biomechanics:
The Lisfranc joint complex comprises the articulation between the first, second, and third metatarsals and the three cuneiforms, plus the cuboid and fourth/fifth metatarsals laterally. The second metatarsal base is recessed and locked by the “Roman arch” configuration of the cuneiforms, making it the keystone of midfoot stability. The Lisfranc ligament, a strong interosseous ligament from the medial cuneiform to the base of the second metatarsal, is the primary stabilizer preventing diastasis.

Epidemiology:
Lisfranc injuries are uncommon but often underdiagnosed, representing 0.2% of fractures. They occur in high-energy trauma (e.g., motor vehicle accidents) and low-energy mechanisms (e.g., twisting injuries in athletes). Missed injuries lead to chronic pain, deformity, and post-traumatic arthritis.

Classification & Diagnosis

Classification Systems:

• Myerson Classification (most clinically relevant):
• Type A: Total incongruity (all metatarsals displaced in one direction)
• Type B: Partial incongruity (one or two metatarsals displaced)
• Type C: Divergent (metatarsals displaced in different directions)

This classification guides surgical approach and fixation strategy.

Diagnostic Pearls:

• Weight-bearing AP, lateral, and 30° oblique foot radiographs are mandatory; non-weight-bearing films underestimate displacement.
• Look for >2 mm diastasis between the first and second metatarsal bases or malalignment of the medial cuneiform and second metatarsal on AP view.
• Fleck sign (small bony fragment at Lisfranc ligament insertion) is pathognomonic.
• CT scans delineate fracture patterns and subtle displacement; MRI is superior for purely ligamentous injuries and chronic cases.
• Pitfall: Non-weight-bearing films and failure to obtain contralateral comparison can miss subtle injuries.

The Decision-Making Algorithm

Non-Operative Management:

• Indicated only for stable injuries without displacement (<2 mm) and no evidence of ligamentous disruption on advanced imaging.
• Requires strict non-weight-bearing immobilization for 6–8 weeks with serial imaging.

Operative Management:

• Displacement >2 mm or any instability mandates surgery.
• Open injuries require emergent debridement and staged fixation.
• Purely ligamentous injuries have worse prognosis and often benefit from primary arthrodesis rather than ORIF.
• Comminuted fractures or delayed presentations with arthritis may also be candidates for primary fusion.

Surgical Approach & Implant Choice:

• Dorsal longitudinal incision centered over the second TMT joint provides optimal exposure.
• Fixation options:
• Transarticular screws (3.5 or 4.0 mm cortical screws) for medial and middle columns.
• Bridge plating for lateral column to preserve motion.
• Primary arthrodesis involves fusion of the medial two or three TMT joints, especially in ligamentous injuries.

Surgical Mastery & Pearls

Stepwise Technique:

1. Exposure: Dorsal longitudinal incision; protect dorsal neurovascular structures.
2. Reduction: Achieve anatomic reduction of the second metatarsal base to the medial cuneiform first; confirm alignment in all planes.
3. Temporary fixation: Use K-wires to maintain reduction.
4. Definitive fixation: Insert transarticular screws from metatarsal bases into cuneiforms; lateral column fixed with low-profile plates to preserve motion.
5. Check stability: Stress under fluoroscopy to confirm no residual diastasis or subluxation.
6. Closure: Layered closure with attention to soft tissue.

Intraoperative Red Flags:

• Persistent diastasis after fixation suggests missed injury or inadequate reduction.
• Overcompression of joints can cause iatrogenic cartilage damage; avoid excessive screw torque.
• Failure to restore the second metatarsal “keystone” alignment leads to poor outcomes.

Evidence-Based Synthesis

Recent randomized controlled trials and meta-analyses have shifted the paradigm toward primary arthrodesis in purely ligamentous Lisfranc injuries, demonstrating superior functional outcomes and lower reoperation rates compared to ORIF. However, fracture-dislocation patterns with large bony fragments still benefit from ORIF to preserve joint motion. The role of bridge plating in the lateral column is supported by biomechanical studies showing improved stability without sacrificing mobility.

Controversy remains regarding the timing of surgery in low-energy injuries and the optimal fixation construct. Emerging evidence supports early weight-bearing protocols post-fusion but not after ORIF, highlighting the need for individualized rehabilitation plans.

Pro-Tip: Surgical Excellence in Lisfranc Injuries

• Prioritize anatomic reduction of the second metatarsal-cuneiform joint; this is the cornerstone of midfoot stability.
• Use intraoperative fluoroscopy judiciously—oblique and lateral views are critical to confirm reduction in all planes.
• Avoid transarticular screws in the lateral column; use bridge plating to maintain physiological motion and reduce hardware failure.
• In ligamentous injuries, consider primary arthrodesis early to prevent chronic instability and secondary procedures.
• Postoperative protocols should be tailored: prolonged non-weight-bearing after ORIF, but accelerated rehabilitation may be safe after fusion.
• Always reassess for compartment syndrome in high-energy injuries—early recognition can be limb-saving.

This synthesis equips the orthopaedic surgical learner with a focused, evidence-driven framework to diagnose, classify, and manage Lisfranc injuries with surgical precision and confidence.

Last Updated on January 26, 2026 by OrthoNet AI