John W. Munz
Ryan Taylor

Lisfranc Injury
- A Lisfranc injury is any osseous or ligamentous pathology involving the tarsometatarsal (TMT) joint complex of the midfoot ranging from subtle instability to frank dislocations.
- May involve the medial or lateral columns, or both, depending on the mechanism of injury.
- Lower-energy Lisfranc injuries are often misdiagnosed as foot sprains and may be missed altogether with a delayed posttraumatic diagnosis.
- Missed Lisfranc injuries can lead to chronic midfoot instability and degeneration.
Anatomy
- The Lisfranc joint articulations include the base of the metatarsals with the three cuneiforms (1st through 3rd) and the cuboid (4th and 5th).
- The first three metatarsal bases are configured in a Roman arch–style pattern with the 2nd metatarsal head residing the most dorsally and proximally.
- In general, the 1st through 3rd tarsometatarsal articulations are relatively immobile and firmly fixed, while the 4th and 5th TMT articulations are more mobile.
- The depth from dorsal to plantar of the metatarsal bases varies with the 1st metatarsal head being the largest with an average dorsal to plantar depth of approximately 30 mm. The 2nd metatarsal has the shortest dorsal to plantar depth being approximately 22 mm. The 3rd metatarsal base is approximately 26 mm from dorsal to plantar.
- The Lisfranc ligament originates from the plantar aspect of the medial cuneiform and inserts on the plantar aspect of the base of the 2nd metatarsal. On occasion, an avulsion of the Lisfranc ligament from the base of the 2nd metatarsal (a.k.a. “fleck sign”) may be the only radiographic marker of this injury.
- Interosseous ligaments link the 2nd through 5th metatarsals. There is no intermetatarsal ligament that connects the 1st metatarsal base to the 2nd metatarsal base.
- Secondary stabilizers of the Lisfranc articulation include the plantar fascia, the peroneus longus, and the foot intrinsics.

Preoperative Imaging

Radiographs
- Three views of the foot are necessary to fully evaluate the tarsometatarsal joints. The most common views are the AP, the internal rotation oblique, and the lateral.
- Each view has characteristic relationships that must be evaluated to properly assess for the presence or extent of an injury (Fig. 26-1).
- Oftentimes, injuries are not so obvious, and comparison views of the uninjured side are helpful for diagnosing subtle injuries.
- Bilateral weight-bearing views are also helpful in identifying subtle instability.
Relationships
- On the AP view, the medial border of the 2nd metatarsal base should be in line with the medial border of the middle cuneiform (red arrow Case A below). Note the two extremes of Lisfranc injuries depicted below with Case B showing a divergent TMT dislocation of the medial column (navicular-cuneiform, intercuneiform, and TMT joints) and lateral dislocation of the 2nd to 5th TMT articulations (Fig. 26-2).
- On the oblique view, the medial border of the 3rd metatarsal base should be in line with the medial border of the lateral cuneiform (left red arrow Case A above), the medial border of the 4th metatarsal base should be in line with the medial border of the cuboid (right red arrow Case A above), and the 5th metatarsal base should articulate with the lateral cuboid. Again, note the two extremes of Lisfranc injuries depicted above with Case B showing a divergent TMT dislocation with lateral dislocation of the 2nd to 5th TMT articulations disrupting the radiographic lines (Fig. 26-3).
- On the lateral view, the dorsal surface of the 1st metatarsal base should be in line with the dorsal surface of the navicular (thin solid red arrow below). In addition, a straight and parallel line (dashed arrow below) should traverse from the midportion of the talus through the middle of the navicular, medial cuneiform, and 1st metatarsal (a.k.a. Meary’s line). The 2nd metatarsal base is more proximal and can be seen through the midportion of the medial cuneiform. Note, on this lateral view, the dorsal subluxation of the base of the 2nd metatarsal associated with a Lisfranc injury (blue arrow) (Fig. 26-4).

Advanced Imaging

After the diagnosis is made, advanced imaging in the form of computed tomography (CT) is often helpful in delineating the extent of the injury. Minimally displaced fractures, mildly subluxated joints, and midfoot comminution are often not apparent on plain radiographs.
Magnetic resonance imaging (MRI) is usually only indicated if there is high suspicion of ligamentous injury and all other imaging modalities are negative.

Intraoperative Positioning

Intraoperative positioning is crucial to obtaining and maintaining adequate fluoroscopic views of the Lisfranc joint.
The patient should be positioned supine on a radiolucent table with or without an extension. A small bump under the ipsilateral hip prevents the lower extremity from externally rotating.
Prior to prepping and draping, ensure that adequate imaging can be obtained without the interference of radiopaque components of the table or the contralateral limb (lateral images).
Once prepped and draped, a radiolucent triangle can be used to bring the plantar aspect of the foot parallel to the bed with a stack of towels under the foot providing a stable base to work on. This position also facilitates imaging without having to manipulate the foot (Figs. 26-5 and 26-6).