Fracture-dislocations of the midfoot will forever be linked to the Napoleonic-era surgeon Jacques Lisfranc, who described midfoot amputation as a treatment of the injury we now refer to as a Lisfranc. Injuries to the tarsometatarsal (TMT) joint occur in less than 1% of all fractures, with a frequency of 1 in 55,000 persons.¹ The clinical results of missed or inappropriately treated TMT fracture-dislocations are poor. Chronic joint instability can lead to persistent pain, deformity, and midfoot arthritis.²

The indications for open reduction and internal fixation (ORIF) of the TMT joint are injuries with displacement and instability.³ Midfoot arthritis has been reported as a frequent result of significant TMT joint injury and instability. The contraindications to ORIF of the TMT joint include active infection and vascular insufficiency. A delayed ORIF should be considered when there is massive edema to the midfoot. Approximate reduction and provisional fixation can be used in the form of external fixation or percutaneous pinning to reduce any tenting of the skin from the fracture and to allow soft tissue to recover before definitive fixation (Figure 1).

VIDEO 82.1 Open Reduction and Internal Fixation of an Unstable Midfoot Injury. Terrence M. Philbin, DO; Gregory C. Berlet, MD (1 min)

The most common mechanism of injury to the midfoot is an axial load to a hyper-plantarflexed foot. A recent study reviewing front-end motor vehicle accidents with airbag deployment revealed that 38% of the injuries involved the foot and ankle.⁴ Up to 20% of TMT joint injuries are missed or misdiagnosed, potentially leading to long-term sequelae.⁵ A plantar ecchymosis sign can be pathognomonic for a high-grade midfoot injury (Figure 2).

Preoperative imaging should always start with AP, lateral, and oblique radiographs, weight bearing if possible. On the AP view, the first and second TMT joints are assessed for fracture and diastasis. The oblique view is best to assess the alignment of the lateral column. Non-weight-bearing radiographs have a 50% rate of misdiagnosis of unstable midfoot injuries⁶ (Figure 3). A fleck sign (small bone avulsion) can be a clue that an unstable injury is present (Figure 4). If radiographic results are not diagnostic, several options are available for diagnostic imaging. Stress radiographs under anesthesia are very useful to delineate any diastasis or displacement at the TMT joints. CT is helpful in diagnosing associated fractures and quantifying the extent of joint injury (Figure 5). MRI is most useful in identifying the soft-tissue component of the injury, a Lisfranc ligament tear⁷ (Figure 6).