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Lisfranc Injury

Fracture-Dislocation of the Midfoot

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Updated October 09, 2013

The foot is separated into three primary parts. The forefoot area consisting of the toes; the midfoot made up of the small bones called the navicular, cuneiform, and cuboid; and the hindfoot consisting of the talus (lower ankle) and calcaneus (heel). The Lisfranc joint is the junction of the bones of the forefoot and midfoot.

A Lisfranc injury is an injury to the ligaments that connect these bones of the midfoot and forefoot. Sometimes, the injury is a simple dislocation (ligament injury), and sometimes a broken bone occurs-- a fracture/dislocation. A dislocation occurs when there is a separation of the normal joint alignment between the forefoot and midfoot. When there is also a fracture, the broken bone usually occurs in the midfoot bones.

The Lisfranc injury is named for the French surgeon Jacques Lisfranc in Napoleon’s army.  The original injury described by Lisfranc usually occurred when a soldier fell from his horse, but his foot did not release from the stirrup--or so the story goes... Today, most injuries to the midfoot occur due to an awkward step on uneven surfaces, sports injuries, or motor vehicle collisions.

Lisfranc Diagnosis

It is important to have a high suspicion for Lisfranc injury whenever there is pain and swelling in the midfoot.  These injuries can be difficult to diagnose, and without proper treatment, there are often poor results.  Any patient with symptoms of a Lisfranc injury should be evaluated by a doctor.

Common symptoms of a Lisfranc injury include

  • Pain in the middle of the foot
  • Swelling and bruising
  • Pain with walking/standing

Lisfranc injuries can be quite subtle on x-ray appearance. In order to better clarify the injury, sometimes it is necessary to apply a force to the foot in order to emphasize the abnormal alignment. Also common is to perform an x-ray view of the normal foot as well as the abnormal foot in order to better define the injury.  If there is a question of the injury, further testing including a CT scan or MRI may be recommended.

Unfortunately, many of these injuries are not noticed without obtaining the appropriate test.  Many Lisfranc injuries are misdiagnosed as a foot sprain.

Treatment of Lisfranc Injuries

Most often the treatment of a Lisfranc injury is surgical, although some minor injuries can be treated non-surgically. If there is minimal separation of the bones, a stiff walking cast applied for approximately eight weeks is an appropriate alternative. However, the more common treatment is to secure the fractured and dislocated bones with either internal (screws) or external (pins) fixation.

Surgery is aimed at restoring the normal alignment of the joints, and then securing the bones in this proper position.  The strongest fixation is usually with multiple metal screws, placed through different bones to secure the midfoot to the forefoot in proper alignment.  Normal recovery involves 6-8 weeks with no weight on the foot.  The foot is usually protected in a walking boot for several more weeks, and the screws are typically removed after 4-6 months.  Complete recovery usually takes 6-12 months, and with more severe injuries may lead to permanent foot problems.

The most common complication of the Lisfranc injury is arthritis of the foot. Post-traumatic arthritis mimics wear-and-tear arthritis, but its course is accelerated because of an injury to the joint cartilage. Arthritis can lead to chronic pain in the injured joint.  If there is chronic pain as a result of post-traumatic arthritis, a surgical procedure called a fusion may become necessary.

Another possible complication of a Lisfranc injury is called compartment syndrome. The compartment syndrome occurs when an injury causes severe swelling in a contained part of the body. If the pressure from the swelling is raised sufficiently within a restricted area, the blood supply to that area may become limited, and can lead to serious complications.

Watson TS, et al. "Treatment of Lisfranc Joint Injury: Current Concepts" J Am Acad Orthop Surg December 2010 ; 18:718-728.

 

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