Definition and Clinical Spectrum
Lisfranc injuries involve the tarsometatarsal (TMT) joint complex, ranging from
isolated ligamentous disruptions
to complex fracture–dislocation patterns.
The injury spectrum is broad and may include
subtle instability with preserved alignment
overt displacement with associated fractures.
Concomitant soft tissue injury is common and has a direct impact on treatment planning and timing.
Missed or delayed diagnosis is frequent, particularly in low-energy injury patterns, and may lead to long-term functional impairment.
Historical Background
The injury is named after Jacques Lisfranc, a French surgeon during the Napoleonic era.
Lisfranc described amputations through the TMT level in cavalry soldiers
whose feet were trapped in stirrups during falls from horses.
Similar injury mechanisms continue to be observed in modern trauma.
Lisfranc Joint Complex – Anatomical Components
The Lisfranc joint complex consists of:
Osseous structures
Tarsometatarsal joints
Intertarsal joints
Ligamentous structures
Surrounding soft tissues
Joint capsule
Tendons
Osseous Architecture and Midfoot Stability
The base of the second metatarsal plays a central role in midfoot stability.
It functions as a keystone within the transverse arch.
The transverse arch configuration resembles a Roman arch, allowing effective load transfer.
The mortise-like configuration between the second metatarsal base and cuneiforms contributes to:
vertical load transmission
transverse stability of the midfoot.
Ligamentous Structures and Stabilization
Ligamentous structures provide secondary stability to the Lisfranc complex.
These include:
Interosseous ligaments
Plantar ligaments
Dorsal ligaments
Among these:
Interosseous and plantar ligaments are the primary contributors to stability.
Dorsal ligaments are comparatively weaker and are commonly involved in dorsal displacement patterns.
The Lisfranc ligament:
connects the medial cuneiform to the base of the second metatarsal
represents the strongest ligamentous structure of the complex.
Disruption of the Lisfranc ligament results in:
loss of the keystone mechanism
collapse of the transverse arch.
Three-Column Concept of the Midfoot
The Lisfranc joint complex can be described using a three-column framework:
Medial column
First TMT joint and first metatarsal
Middle column
Second and third TMT joints
Second and third metatarsals
Lateral column
Fourth and fifth TMT joints
Fourth and fifth metatarsals
This conceptual separation is useful for:
understanding injury patterns
surgical planning
fixation strategies.
Mechanism of Injury – Overview
Lisfranc injuries may result from:
Low-energy mechanisms
commonly sports-related
twisting or axial load applied to a plantar-flexed foot
High-energy mechanisms
motor vehicle collisions
crush injuries
falls from height
Injury mechanism influences:
stability
associated fractures
soft tissue condition
urgency and type of surgical intervention.
Clinical Presentation and Diagnostic Challenges
Clinical presentation varies according to:
injury mechanism (low-energy vs high-energy),
degree of instability,
associated fractures and soft tissue injury.
Common clinical findings include:
midfoot pain,
swelling,
inability or difficulty with weight bearing,
localized tenderness over the tarsometatarsal joints.
Plantar ecchymosis is a notable clinical finding and should raise suspicion for a Lisfranc injury.
Symptoms may be disproportionate to initial radiographic findings, particularly in:
low-energy injuries,
purely ligamentous patterns.
Subtle injuries are frequently misdiagnosed as:
midfoot sprain,
ankle sprain,
soft tissue contusion.
Imaging Strategy in Lisfranc Injuries
Plain Radiographs
Initial evaluation includes:
anteroposterior (AP),
lateral,
oblique foot radiographs.
Key alignment relationships to assess on AP view:
medial border of the second metatarsal base relative to the medial border of the middle cuneiform.
On oblique view:
alignment between the third metatarsal and lateral cuneiform should be preserved.
Lateral view may demonstrate:
dorsal subluxation of the metatarsal bases.
Weight-Bearing Radiographs
Weight-bearing radiographs improve detection of subtle instability.
Comparison with the contralateral foot is recommended.
Stress views may be required when:
clinical suspicion is high,
non–weight-bearing radiographs are inconclusive.
Single-limb weight-bearing views may further accentuate instability.
Fleck Sign
The fleck sign represents:
a small bony avulsion fragment from the base of the second metatarsal.
It reflects avulsion of the Lisfranc ligament.
Presence of the fleck sign is considered diagnostic of a Lisfranc injury, even when gross displacement is absent.
Computed Tomography (CT)
CT is useful for:
identifying occult fractures,
evaluating fracture morphology,
assessing articular involvement.
CT assists in:
preoperative planning,
detection of associated midfoot injuries.
Subtle fractures not visible on plain radiographs may be detected.
Magnetic Resonance Imaging (MRI)
MRI may be helpful in:
suspected purely ligamentous injuries,
cases with persistent symptoms and normal radiographs.
MRI allows assessment of:
Lisfranc ligament integrity,
associated soft tissue injury.
MRI findings should be interpreted in conjunction with clinical and radiographic data.
Classification Systems of Lisfranc Injuries
Multiple classification systems have been described for Lisfranc injuries.
These systems differ in:
injury mechanism,
degree of displacement,
clinical context.
Classification systems are primarily used to:
describe injury patterns,
facilitate communication,
assist in treatment stratification.
No single system has demonstrated consistent ability to predict long-term clinical outcomes.
Myerson Modification of Hardcastle Classification
Expands the Hardcastle system.
Incorporates:
fracture–dislocation patterns,
more detailed displacement descriptions.
Type A
Total incongruity of the TMT joints.
Type B
Partial incongruity.
B1: medial displacement.
B2: lateral displacement.
Type C
Divergent displacement.
C1: partial divergent.
C2: total divergent.
Commonly used in:
high-energy injuries,
fracture–dislocation patterns.
Less applicable to:
subtle,
purely ligamentous injuries.
Nunley and Vertullo Classification
Designed for low-energy Lisfranc injuries, particularly in athletes.
Based on:
clinical findings,
weight-bearing radiographs,
advanced imaging.
Stage I
No diastasis on radiographs.
MRI or bone scan may demonstrate ligamentous injury.
Symptoms present despite preserved alignment.
Stage II
Diastasis between the first and second metatarsals on weight-bearing radiographs.
No loss of longitudinal arch height.
Stage III
Diastasis with loss of longitudinal arch height.
Represents more advanced instability.
This classification is useful for:
identifying subtle instability,
guiding treatment in low-energy injury patterns.
Descriptive Classification: Ligamentous vs Fracture–Dislocation
Lisfranc injuries may be broadly categorized as:
purely ligamentous injuries
fracture–dislocations.
This distinction is clinically relevant because:
injury patterns,
fixation strategies,
and outcomes may differ between groups.
Summary of Classification Systems
Hardcastle and Myerson classifications:
emphasize displacement patterns,
are more applicable to high-energy injuries.
Nunley and Vertullo classification:
focuses on low-energy, subtle injuries,
incorporates advanced imaging.
Classification systems should be interpreted in conjunction with:
clinical findings,
imaging studies,
injury mechanism.
General Treatment Considerations
Treatment decisions are influenced by:
degree of displacement,
stability of the TMT joints,
soft tissue condition,
energy of injury.
Anatomic reduction is associated with improved functional outcomes.
Timing of surgery is commonly influenced by:
severity of soft tissue swelling,
presence of skin compromise.
Nonoperative Management
Nonoperative treatment may be considered in:
injuries without displacement on weight-bearing radiographs,
absence of bony injury on CT.
Typically applied to:
stable,
low-energy injury patterns.
Management consists of:
immobilization,
protected or non–weight-bearing.
Close clinical and radiographic follow-up is required to monitor for:
delayed displacement,
progressive instability.
Operative Management
Operative treatment is indicated in the presence of:
displacement on radiographs,
instability on stress or weight-bearing views,
associated fractures involving the TMT joints.
Surgery is often delayed until:
soft tissue swelling has subsided,
skin condition permits safe incision.
Open reduction is frequently required to:
achieve accurate joint alignment,
address interposed soft tissue.
Closed reduction with percutaneous fixation may be insufficient in:
complex fracture–dislocation patterns.
Fixation Strategy and Column-Based Approach
Fixation strategy is guided by involvement of the midfoot columns.
Medial and Middle Columns
Include:
first, second, and third TMT joints,
intercuneiform joints.
Stabilization methods include:
transarticular screw fixation,
dorsal plate fixation.
Dorsal plating:
reduces intra-articular hardware placement,
may decrease iatrogenic cartilage injury.
Fixation is typically performed:
from proximal to distal,
from medial to lateral.
Lateral Column
Includes:
fourth and fifth TMT joints.
Represents a more mobile segment.
Temporary fixation with:
Kirschner wires
is commonly used.
Hardware is generally removed after:
approximately 6 weeks.
Primary Arthrodesis
Primary arthrodesis is an alternative treatment option.
Commonly considered in:
purely ligamentous injuries,
chronic or delayed presentations.
Reported characteristics include:
reduced need for secondary procedures,
lower rates of hardware removal.
Comparative studies have demonstrated:
no consistent difference in patient-reported outcomes when compared with ORIF.
Complications
Potential complications include:
post-traumatic midfoot arthritis,
chronic pain,
progressive planovalgus deformity.
Missed diagnosis or inadequate reduction increases the risk of:
long-term functional impairment.
Salvage procedures may involve:
midfoot arthrodesis.
Arthrodesis of the fourth and fifth TMT joints is infrequently required.