Lisfranc Fracture Dislocation

• Named after Jacques Lisfranc, a field surgeon in Napoleon’s army, who described a new technique for an amputation used to treat frostbite of the forefoot in soldiers on the Russian front
• Used today to describe fractures and dislocations that occur at the junction between the tarsal bones of the midfoot and the metatarsals of the forefoot
  
  
• Causes
  
  
• Mechanism involves severe plantar flexion of the foot
• May occur from sports-related injuries
• Motor vehicle accidents
• Falling from a height, down stairs or off a curb
• Ligamentous injuries alone, even without fracture or dislocation, may result in instability on weightbearing
• Lisfranc ligament diagonally connects the 1^st (medial) cuneiform with the base of the 2^nd metatarsal
• If it remains intact, either an avulsion of the lateral border of the 1^st cuneiform or an avulsion of the base or medial border of the 2^nd metatarsal occurs
• If it tears, these fractures may not occur
  
  
• Clinical findings
  
  
• Pain at tarsal-metatarsal joints
• Ecchymosis
• Instability
  
  
• Types
  
  
• Two basic types
  
  
• Homolateral
• All of the metatarsals are dislocated to the same side
• More common than divergent
• Usually involves the 2^nd through 5^th dislocated laterally
• May involve all 5 metatarsals
• Divergent
• Usually more severe than homolateral
• May be associated with a fracture of the 1^st cuneiform
• Usually involves medial displacement of the 1^st metatarsal and lateral displacement of 2^nd-5^th metatarsals
• Occasionally may involve only medial displacement of only the 1^st metatarsal
• Fractures associated with Lisfranc dislocations
• Base of 2^nd metatarsal
• Cuboid
• Fractures of shafts of metatarsals
• Dislocations of the 1^st (medial) and 2^nd (middle) and cuneonavicular joints
• Fractures of the tarsal navicular
  
  
• Imaging
  
  
• Conventional radiographs are usually sufficient to demonstrate the injury
• Normal alignment of the cuneiforms and the bases of the metatarsals (see chart below)
• Lateral border of 1^st metatarsal is aligned with lateral border of 1^st (medial) cuneiform on AP view
• Medial border of 2^nd metatarsal is aligned with medial border of 2^nd (intermediate or middle) cuneiform on AP view
• Medial and lateral borders of the 3^rd (lateral) cuneiform should align with medial and lateral borders of 3^rd metatarsal on oblique view
• Medial border of 4^th metatarsal aligned with medial border of cuboid on oblique
• Lateral margin of the 5^th metatarsal may project lateral to cuboid by as many as 3mm on oblique
• On lateral, a line drawn along long axis of talus should intersect long axis of 5^th metatarsal

• Stress views of the foot with the patient sedated will usually demonstrate any instability
• Lisfranc dislocations may be missed in up to 20% of cases
• Suspect it is present if there is a gap of more than 5 mm between bases of 1^st and 2^nd metatarsals or 1^st (medial) and 2^nd  (middle or intermediate) cuneiforms
• On lateral view, bones of the midfoot will be subluxed or dislocated in a plantar direction
  
  

  Lisfranc Fracture-Dislocation. The bases of all of the metatarsals are dislocated laterally in this homolateral Lisfranc dislocation. There was a fracture of the base of the 2nd metatarsal. Lateral view of Lisfranc dislocation. Notice how the bones of the midfoot are dislocated towards the plantar aspect of the foot.

Lisfranc Dislocation. There is lateral dislocation of all of the metatarsals on their corresponding tarsal bones (red arrows).

• Treatment
  
  
• Sprains with an otherwise stable tarsal-metatarsal joint can be managed with immobilization
• Nonanatomic alignment requires open reduction and internal fixation