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Lisfranc fractures and fracture-dislocations represent a challenging and frequently missed category of midfoot injuries that can lead to significant long-term morbidity if not promptly recognized and appropriately managed. Such injuries commonly occur following low-energy athletic trauma or high-energy mechanisms, including motor vehicle collisions, and are frequently misdiagnosed as simple sprains on initial presentation. Given the critical role of the tarsometatarsal joint complex in foot stability and gait, delayed or inadequate treatment may result in chronic pain, deformity, and posttraumatic arthritis. This activity for healthcare professionals is designed to sharpen learners' skills in evaluating and managing Lisfranc injuries. Participants will gain deeper insights into the condition's etiology, risk factors, pathophysiology, clinical presentation, and evidence-based diagnostic and therapeutic approaches. Greater proficiency will foster interprofessional collaboration, optimize treatment decisions, and support patient-centered recovery, ultimately improving functional outcomes for patients with Lisfranc injuries. Objectives: Identify clinical and radiographic findings that distinguish Lisfranc fractures and fracture-dislocations from benign midfoot sprains. Apply evidence-based criteria to guide the selection of nonoperative versus operative management for Lisfranc injuries. Improve patient awareness of immobilization adherence, gradual return to activity, physical therapy participation, and early recognition of complications to support optimal functional outcomes after initiating treatment for a Lisfranc injury. Collaborate with orthopedic surgeons, radiologists, and physical therapists to coordinate diagnostic evaluation, treatment planning, and rehabilitation for patients with Lisfranc injuries. Access free multiple choice questions on this topic.

The Lisfranc joint consists of the articulation between the metatarsal (M1–M5) and tarsal (cuneiforms C1–C3 and cuboid) bones. The Lisfranc ligament is a 3-part structure connecting the medial cuneiform (C1) to the 2nd metatarsal (M2).[1] The Lisfranc joint may be disrupted by sprain, subluxation, joint widening with or without fracture, dislocation, or crush injury (see Image. Lisfranc Dislocation).[2][3][4] Lisfranc injuries are uncommon, affecting approximately 1 in 55,000 individuals in the U.S. These injuries are frequently misdiagnosed or mismanaged, with up to 20% initially missed.[5] Improper management can result in disabling complications, including midfoot arthritis, chronic pain, and functional foot instability.[6]

Lisfranc dislocations result from both high- and low-energy trauma to the tarsometatarsal joint complex.[7][8] High-energy mechanisms account for approximately 1 in 5 cases and include motor vehicle collisions, motorcycle crashes, direct crush injuries, and falls from heights greater than 4 feet. These events typically produce severe injury patterns, including fracture-dislocations, involvement of multiple rays, and associated injuries such as neurovascular compromise, concomitant foot fractures, and non-foot fractures.[9] Low-energy mechanisms are more common and include athletic injuries, ground-level twisting injuries, simple falls, and falls from less than 4 feet. These injuries more often result in isolated, primarily ligamentous injuries that spare the lateral column.[10] Certain anatomical variations increase susceptibility to Lisfranc injuries and their complications. A study demonstrated that the ratio of M2 length to overall foot length was significantly lower in more than 50% of patients with Lisfranc injuries. Another study indicated that a shorter 2nd tarsometatarsal joint height substantially increased the risk of developing an unstable Lisfranc injury.[11]

Lisfranc dislocations have an overall incidence of approximately 9 to 22 per 100,000 person-years, with variation influenced by geographic location, detection methods, and case definitions, ie, whether studies include only imaging-confirmed cases or all suspected injuries. A recent 10-year analysis of 21,964 cases in the U.S. reported an overall incidence of 22.4 per 100,000 person-years. Age distribution follows a normal curve, peaking at 33.6 per 100,000 person-years in patients aged 40 to 44 years. Lisfranc injuries occurred at equal rates between male and female individuals in this large U.S. dataset. Although U.S. data indicate equal sex distribution, other studies report a slight male predominance. The injury affects all adult age groups, with peak incidence in the 4th and 5th decades of life. The bimodal distribution reflects high-energy trauma in younger patients and low-energy mechanisms, particularly falls, in middle-aged and older adults.[12]

Lisfranc dislocations result from hyperplantarflexion, axial loading, or rotational forces that disrupt the tarsometatarsal joint complex, overcoming the inherent bony and ligamentous stability of the midfoot.[13] The typical mechanism involves an axial force applied to the heel while the forefoot is hyperextended and plantarflexed, such as during landing from a jump or stepping off a curb, causing displacement of the metatarsals from the tarsus. The M2 base, recessed between C1 and C2 in a "keystone" configuration, provides intrinsic bony stability. Disruption of this configuration, combined with ligamentous failure, produces midfoot instability.[14] Common clinical findings include midfoot pain, swelling, and ecchymosis, with plantar ecchymosis being highly suggestive of Lisfranc injury.

On history, midfoot pain develops after an acute injury, worsening during weightbearing or the push-off phases of walking and running. High- or low-energy mechanisms may be identified as the cause of damage. Injury severity is frequently underestimated at the time of impact, and delayed consultation is common until complications arise. A Lisfranc injury should be strongly suspected when midfoot pain persists beyond 5 days and is accompanied by swelling and altered foot mechanics.[15] On physical examination, swelling localizes primarily to the midfoot region, particularly along the medial border of the 1st tarsometatarsal joint. Plantar ecchymosis strongly suggests Lisfranc injury and warrants immediate consideration. Palpation along the tarsometatarsal articulations elicits pain. The "squeeze test," which applies medial-lateral compression to the midfoot, reproduces pain and indicates instability.[16] A bony prominence or "jut" along the medial border of the 1st tarsometatarsal joint represents a specific finding in subtle, chronic Lisfranc injuries initially misdiagnosed as sprains.[17] This sign indicates subluxation and necessitates standing radiographs. Inability to bear weight is common, although patients with subtle injuries may ambulate with pain. Neurovascular assessment is essential, as compartment syndrome and neurovascular compromise may complicate these injuries. The combination of an appropriate mechanism, midfoot tenderness, plantar ecchymosis, and weightbearing inability should prompt immediate imaging evaluation. Approximately 20% of Lisfranc injuries are initially misdiagnosed.

The American College of Radiology recommends weightbearing radiographs as the initial imaging study for suspected Lisfranc injuries, with magnetic resonance imaging (MRI) or computed tomography (CT) reserved for cases in which radiographs are normal or equivocal.[18] Weightbearing radiographs are preferred because nonweightbearing views are unreliable for detecting subtle injuries. Bilateral weightbearing radiographs provide superior diagnostic accuracy compared to unilateral views, as side-to-side comparison enhances the detection of subtle instability.[19] The standard radiographic series includes anteroposterior, oblique, and lateral views of the foot. An additional anteroposterior view with 20° craniocaudal angulation may be obtained when clinical suspicion of acute Lisfranc injury is high. This specialized view improves the detection of subtle malalignment (see Image. Lisfranc Dislocation on Bilateral Weight-Bearing X-Ray).[20] Radiographic findings of a Lisfranc injury include the following: Misalignment of the medial edges of the C2 and M2 on the anteroposterior view Misalignment of the medial edges of the cuboid and M4 on the medial oblique view Presence of a bone fragment in the 1st intermetatarsal space (M1–M2), known as the fleck sign, indicating Lisfranc ligament avulsion from the M2 base Diastasis greater than 2 mm between the C1 and M2 bases or a difference exceeding 1 mm relative to the contralateral foot on the anteroposterior view Dorsal or plantar displacement of metatarsal bases on the lateral view Plain radiography is typically the initial imaging modality for Lisfranc injuries. However, sensitivity is limited to approximately 84%, resulting in nearly 20% of injuries remaining undiagnosed. Three-dimensional CT has emerged as a valuable diagnostic tool, demonstrating excellent sensitivity (92%–97%) and specificity (92%–93%) for Lisfranc injuries. Novel 3-dimensional CT signs include the Mercedes, peeking metatarsal, and peeking cuneiform signs, all exhibiting high interobserver and intraobserver reliability.[21] CT is particularly useful when weightbearing radiographs cannot be obtained in the acute setting, surgery is planned for confirmed injuries, and occult fractures or minimal osseous subluxation is not visible on radiographs.

Plain radiography is typically the initial imaging modality for Lisfranc injuries. However, sensitivity is limited to approximately 84%, resulting in nearly 20% of injuries remaining undiagnosed. Three-dimensional CT has emerged as a valuable diagnostic tool, demonstrating excellent sensitivity (92%–97%) and specificity (92%–93%) for Lisfranc injuries. Novel 3-dimensional CT signs include the Mercedes, peeking metatarsal, and peeking cuneiform signs, all exhibiting high interobserver and intraobserver reliability.[21] CT is particularly useful when weightbearing radiographs cannot be obtained in the acute setting, surgery is planned for confirmed injuries, and occult fractures or minimal osseous subluxation is not visible on radiographs. MRI evaluates the extent of soft tissue and ligamentous injury. Sagittal, long axial, and oblique coronal planes should be obtained using T1-weighted and fluid-sensitive sequences.[22] MRI demonstrates superior detection of ligamentous abnormalities, allowing direct visualization of Lisfranc ligament integrity and associated soft tissue injuries. The 2024 International Foot and Ankle Sports Consensus specifically recommends CT or MRI for the assessment of low-grade instability in athletes. Ultrasonography can evaluate the dorsal Lisfranc ligament and measure the C1–M2 distance. However, the accuracy of this modality for diagnosing Lisfranc instability remains unproven, and routine clinical use is not recommended.

Treatment of Lisfranc dislocations is guided by a stability-based classification system. Stable injuries are managed nonoperatively, whereas unstable or displaced injuries require surgical intervention. Early diagnosis and accurate stability assessment using weightbearing radiographs and advanced imaging are essential to optimize outcomes and prevent long-term complications, including posttraumatic arthritis and chronic pain. Treatment objectives focus on restoring midfoot stability, minimizing long-term sequelae, and achieving normal foot function and mobility. Conservative Approach Nonoperative treatment is indicated for anatomically stable, nondisplaced injuries on weightbearing radiographs, midfoot sprains without evidence of bony injury, stable, nondisplaced injuries with intact ligaments on MRI, and surgical intolerance. The 2024 International Foot and Ankle Sports Consensus achieved unanimous agreement that these injuries may be managed conservatively. Conservative management involves reduction, immobilization with a short-leg cast or boot, and elevation of the injured foot. Repeat evaluation and radiography after 2 weeks are essential to exclude diastasis that would necessitate surgical intervention. The recommended protocol includes 6 weeks of immobilization and nonweightbearing, followed by a gradual return to activity under close radiographic surveillance to ensure maintenance of reduction. In athletes with stable ligamentous injuries, 96.8% successfully returned to sport at a mean of 2.8 months, with minimal complications using nonoperative management. Clinical outcomes may be comparable to those achieved with surgical management when indications for conservative treatment are appropriately determined.[23] Symptom resolution and radiographic evidence of improvement after 6 weeks indicate readiness to begin weightbearing on the injured limb and initiation of rehabilitation. Gradual resumption of physical activity should occur using a full-length orthosis to distribute forces along the medial longitudinal arch. Surgical Treatment Displaced, unstable, or comminuted Lisfranc injuries require surgical intervention to restore anatomical alignment and prevent long-term dysfunction. Primary surgical options include open reduction and internal fixation (ORIF), primary arthrodesis, and emerging techniques, such as suture button fixation.

Surgical Treatment Displaced, unstable, or comminuted Lisfranc injuries require surgical intervention to restore anatomical alignment and prevent long-term dysfunction. Primary surgical options include open reduction and internal fixation (ORIF), primary arthrodesis, and emerging techniques, such as suture button fixation. Operative management of Lisfranc injuries has been debated extensively. ORIF remains the most commonly employed approach, particularly when joint surfaces are salvageable. Recent evidence supports dorsal bridge plating over transarticular screw fixation, as dorsal plating may achieve superior reduction quality while minimizing additional articular damage.[24] Swedish registry data indicate that 39% of Lisfranc injuries underwent operative treatment, with plate fixation representing the predominant method in 51% of operative cases. Primary arthrodesis has emerged as a viable alternative, particularly for severe injuries and 1st tarsometatarsal joint dislocations. A randomized controlled trial comparing ORIF to primary arthrodesis for 1st tarsometatarsal joint dislocations demonstrated that primary arthrodesis produced significantly higher AOFAS (American Orthopedic Foot and Ankle Society) midfoot scores (p<0.01), FAAM (Foot and Ankle Ability Measure) Sports subscale scores (p<0.01), and lower VAS (Visual Analog Scale) pain scores (p<0.01) at a mean follow-up of 37.8 months.[25] Meta-analyses confirm that primary arthrodesis yields superior patient-reported outcomes (AOFAS effect size 0.41, p=0.004), lower rates of posttraumatic arthritis (2.8% vs 17.3%), and fewer reoperations (17.6% vs 64.1%).[26] When planned hardware removals are excluded, unplanned reoperation rates were 14.7% after primary arthrodesis versus 38.3% after ORIF (p<0.001). Systematic reviews support primary arthrodesis over ORIF for adult Lisfranc injuries based on superior or equivalent outcomes across all measured parameters.[27]

Primary arthrodesis has emerged as a viable alternative, particularly for severe injuries and 1st tarsometatarsal joint dislocations. A randomized controlled trial comparing ORIF to primary arthrodesis for 1st tarsometatarsal joint dislocations demonstrated that primary arthrodesis produced significantly higher AOFAS (American Orthopedic Foot and Ankle Society) midfoot scores (p<0.01), FAAM (Foot and Ankle Ability Measure) Sports subscale scores (p<0.01), and lower VAS (Visual Analog Scale) pain scores (p<0.01) at a mean follow-up of 37.8 months.[25] Meta-analyses confirm that primary arthrodesis yields superior patient-reported outcomes (AOFAS effect size 0.41, p=0.004), lower rates of posttraumatic arthritis (2.8% vs 17.3%), and fewer reoperations (17.6% vs 64.1%).[26] When planned hardware removals are excluded, unplanned reoperation rates were 14.7% after primary arthrodesis versus 38.3% after ORIF (p<0.001). Systematic reviews support primary arthrodesis over ORIF for adult Lisfranc injuries based on superior or equivalent outcomes across all measured parameters.[27] Suture button fixation is an emerging technique that provides flexible stabilization and may improve midfoot biomechanics. In elite athletes with unstable ligamentous injuries, suture button fixation produced higher AOFAS scores (95.5 vs 89.4), lower complication rates (10.9% vs 18.2%), zero failures (0% vs 4.9%), and fewer secondary procedures (0% vs 30.5%) compared with ORIF, with 93.5% of ORIF reoperations involving hardware removal. The 2024 International Foot and Ankle Sports Consensus achieved unanimous agreement that elite athletes with unstable ligament injuries should undergo fixation rather than fusion, with suture button fixation demonstrating particular promise.[28] For fracture-dislocation patterns, ORIF is preferred when joint surfaces are salvageable, whereas primary arthrodesis is indicated when long-term joint preservation is not feasible. Complication rates (30.8% vs. 35.5%) and failure rates (13.8% vs 12.9%) were similar between ORIF and primary arthrodesis in fracture-dislocations, although secondary procedures occurred more frequently after ORIF (90.2% vs 22.6%).

Several conditions can mimic the clinical presentation of Lisfranc injury. These conditions must be considered in the differential diagnosis. A common misdiagnosis of Lisfranc injury is a simple midfoot sprain. Both conditions present with midfoot pain, swelling, and difficulty bearing weight following a twisting or axial loading mechanism. Distinguishing features of Lisfranc injury include plantar ecchymosis, which is highly specific, tenderness localized to the tarsometatarsal articulations, and a positive "squeeze test" result, eliciting pain with medial–lateral compression of the midfoot. Unremarkable standard or weightbearing radiograph findings do not exclude mild (grade I) or moderate (grade II) Lisfranc sprains, and reevaluation is warranted if pain and swelling persist for 10 days after injury. Isolated fractures of tarsal bones, including the navicular, cuneiforms, and cuboid, can present with similar midfoot pain and swelling. Tenderness to palpation of the dorsomedial foot should raise suspicion for a navicular fracture. Fractures of tarsal bones adjacent to the tarsometatarsal joint indicate the potential for a more extensive Lisfranc injury and require careful evaluation for associated ligamentous disruption. Multiple metatarsal fractures further increase suspicion for Lisfranc joint involvement. Lateral ankle sprains are considerably more common than Lisfranc injuries and may present with overlapping symptoms of foot pain and swelling following an inversion mechanism. The key distinguishing feature is the location of maximal tenderness. Ankle sprains produce tenderness over the lateral malleolus and anterior talofibular ligament, whereas Lisfranc injuries produce tenderness over the tarsometatarsal articulations and medial midfoot. Proximal M5 fractures, including Jones and avulsion fractures, occur through similar mechanisms, such as landing on the lateral aspect of the foot or applying an adduction force while plantarflexed, and may present with lateral midfoot pain. Tenderness localizes to the proximal M5 rather than the tarsometatarsal joint complex. Standard foot radiographs allow clear differentiation of these injuries.[29]

Myerson Classification The most widely accepted classification of Lisfranc injuries is the Myerson system, which categorizes injuries based on the pattern and extent of tarsometatarsal incongruity and displacement.[30] The classification is as follows: Type A: Total lateral or dorsoplantar incongruity, with all 5 metatarsal bases displaced in the same direction Type B: Isolated incongruity B1: Medial displacement of M1 B2: Lateral displacement of at least 1 of the lateral 4 metatarsals Type C: Divergent incongruity C1: Partial divergence C2: Total divergence Type D: Lisfranc distance-based classification D1: Distance between C1 and M2 of or less than 2 mm; does not require operative fixation D2: Distance between C1 and M2 exceeding 2 mm; requires surgical intervention D2L: Purely ligamentous D2B: Associated with bone avulsion The Myerson classification guides treatment selection by delineating injury severity, displacement patterns, and the need for operative intervention. Advantages include improved interobserver reliability and clearer prognostic stratification. Stability-Based Classification System Current evidence supports a stability-based classification system for Lisfranc injuries rather than purely anatomic schemes. Stable injuries demonstrate no displacement on weightbearing radiographs and intact ligaments on MRI, whereas unstable injuries show displacement, diastasis, or subluxation on weightbearing imaging. This system has greater clinical utility, as stable injuries typically achieve favorable outcomes with nonoperative management, while displaced or comminuted injuries necessitate surgical intervention. Weightbearing radiographs and CT serve as essential diagnostic tools to assess stability and guide treatment decisions. Columnar Classification An alternative classification approach categorizes Lisfranc injuries according to involvement of the medial, middle, and lateral midfoot columns. Injuries affecting all 3 columns are associated with significantly worse functional outcomes (Foot Function Index p = 0.004, AOFAS score p = 0.036). Sagittal displacement, whether dorsal or plantar, does not predict outcomes, indicating that column involvement, rather than sagittal displacement, is the primary determinant of injury severity and long-term functional prognosis.[31]

The strongest predictor of outcome is the quality of anatomical reduction, independent of the classification system used. The stability-based classification is increasingly preferred because it directly informs treatment. Stable injuries may be immobilized and managed conservatively, whereas unstable injuries require orthopedic referral for surgical fixation. High-energy injuries carry a poor prognosis and are associated with worse functional outcomes. Surgical delays exceeding 6 months correlate with reduced recovery. Type B injuries demonstrate a poorer prognosis than types A and C due to frequent delayed diagnosis. Among surgical techniques for Lisfranc joint repair, primary arthrodesis offers the most favorable prognosis, as it avoids the need for follow-up procedures or implant removal, and allows faster return to activity compared with ORIF.[32]

Lisfranc injuries can produce both early and late complications, with posttraumatic arthritis representing the most common long-term sequela, occurring in approximately 37% of cases.[33] Other significant complications include chronic pain, progressive arch collapse, hardware-related issues, infections, and the requirement for secondary procedures. Early complications comprise compartment syndrome, neurovascular compromise, and open fractures necessitating urgent intervention. Deep infections develop in approximately 8% to 9% of cases, with open injuries carrying a markedly higher risk. Wound healing complications and superficial infections occur in roughly 3.8% of acute postoperative cases.[34]

Patients presenting to the emergency department with severe midfoot pain following a high-energy injury require evaluation for emergent conditions, including compartment syndrome. Consultation with a surgeon specializing in foot and ankle injuries, such as an orthopedic or podiatric surgeon, is indicated once emergent conditions have been excluded. Lisfranc injuries subsequently necessitate structured rehabilitation and physical therapy.

Individuals engaged in activities that increase the risk of Lisfranc joint disruption should receive counseling in the following areas: Wearing proper footwear: Lisfranc injuries related to sports or occupational activities may be prevented by footwear that provides adequate midfoot support and protection. Increasing training intensity gradually: Gradual progression of training allows proper conditioning, strengthening, and flexibility of the feet and ankles, reducing injury risk. Using proper movement techniques: Training in correct movement patterns minimizes falls and awkward foot positions that predispose to injury. Warming up and stretching adequately before physical activity: These measures prepare muscles, tendons, and ligaments for movement, reducing the likelihood of injury. Ensuring environmental safety: Identification and mitigation of environmental hazards, combined with adherence to workplace safety guidelines, help prevent Lisfranc injuries. Maintaining strength and flexibility: Exercises targeting foot and ankle strength, stability, and flexibility optimize foot dynamics and reduce injury risk. Coaches, trainers, and healthcare providers should actively promote these preventive measures and encourage immediate evaluation following any suspected injury.

Key points in the management of Lisfranc injuries include the following: Mechanism of injury: Lisfranc injuries frequently result from high- or low-energy trauma. Clinical presentation: Disruption of the Lisfranc joint produces variable signs and symptoms, complicating diagnosis. Imaging: Radiography is typically the initial modality. However, nearly 20% of injuries are missed on x-rays alone. CT and MRI improve diagnostic accuracy. Treatment selection: Management may be nonoperative or operative, depending on injury characteristics and patient status. Surgical indications include joint instability and the presence of emergent conditions such as compartment syndrome. Primary arthrodesis is associated with superior outcomes among surgical techniques. Timing of intervention: Prompt diagnosis and treatment reduce the risk of complications and long-term disability. Rehabilitation: Structured rehabilitation is critical to restore strength, mobility, and function. Close follow-up is necessary to monitor healing and address residual deficits. Complications: Inadequate management may result in chronic pain, instability, posttraumatic arthritis, or long-term foot dysfunction. Individualized care: Each case requires a tailored treatment plan based on injury severity, patient characteristics, and functional goals.[42][43] Understanding these principles allows healthcare professionals to optimize outcomes for patients with Lisfranc injuries.

The management of Lisfranc dislocations requires a coordinated interprofessional approach to ensure accurate diagnosis, effective treatment, and optimal functional recovery. Emergency medicine physicians play a critical role in initial recognition, as subtle findings on plain radiographs frequently lead to missed diagnoses. Advanced imaging should be obtained when clinical suspicion remains high despite normal radiography results, and all Lisfranc injuries should be discussed with orthopedic surgery to determine definitive management. Orthopedic surgeons provide expertise in surgical decision-making, selecting between ORIF, primary arthrodesis, and suture button fixation based on injury pattern, stability, and patient activity level. Radiologists contribute essential diagnostic expertise by interpreting weightbearing radiographs, CT, and MRI to classify injury severity and guide treatment planning. Physical therapists are integral to rehabilitation, as biomechanical studies demonstrate that Lisfranc injuries produce reductions in plantar flexor and dorsal extensor strength, altered postural control, and abnormal plantar pressure distribution. Early initiation of physiotherapy is preferred, with structured guidance on rehabilitation protocols optimizing functional recovery. Nurses and advanced practice providers support patient education, wound care, and coordination of follow-up appointments. Athletic trainers and sports medicine specialists provide sport-specific rehabilitation and return-to-play guidance for athletes, following consensus protocols. Integration of an interprofessional rehabilitation team during acute care hospitalization optimizes management, with early evaluation—ideally within 48 hours—enabling proactive rehabilitation programs that minimize functional decline. Effective communication between healthcare providers and patients is critical, particularly regarding treatment options, expected recovery timelines, the likelihood of secondary surgery, and the risk of posttraumatic arthritis. Implementation of specialized clinical skills, evidence-based treatment strategies, ethical informed consent, clearly defined professional responsibilities, structured interprofessional communication, and coordinated care transitions supports patient-centered management, enhances functional outcomes, and improves patient satisfaction in Lisfranc dislocation management.