orthopedic pitfalls in the ed--lisfranc fracture-dislocation

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Orthopedic Pitfalls in the ED:Lisfranc Fracture-Dislocation

ANDREW D. PERRON, MD, WILLIAM J. BRADY, MD, AND THEODORE E. KEATS, MD

Lisfranc fracture-dislocation of the foot is an injury that carries a highincidence of chronic pain and disability. Its emergency department pre-sentation can be subtle, and more frequent than previously believed.This review article examines the clinical presentation, historical factors,diagnostic techniques, and management options applicable to the emer-gency practitioner. (Am J Emerg Med 2001;19:71-75. Copyright © 2001 byW.B. Saunders Company)

The articulation between the tarsal and metatarsal bonesin the foot is named after Jacques Lisfranc, a French phy-sician and field surgeon in Napoleon’s army who was thefirst to described amputations through this joint. Injuries to

this region commonly result from falls and motor vehicle orindustrial accidents, ranging from mild sprains to severedislocations and fracture-dislocations. Because Lisfranc joint fracture-dislocations and sprains carry such a high risk of chronic pain and functional disability if they go unrec-ognized and hence untreated,1-4 emergency physiciansshould maintain a high index of suspicion for these injuries.Historically, Lisfranc injuries were thought to be a rareproblem accounting for less than 1% of all orthopedictrauma; the overall incidence, however, is increasing andmore common than initially recognized.1,5-6

The complex bony and ligamentous anatomy of this jointand the multiple patterns and mechanisms of injury makeradiographic interpretation challenging and diagnosis diffi-

cult. It is estimated that the diagnosis is missed on initialpresentation to the emergency department in approximately20% of cases.1,5-8 Emergency physicians should be familiarwith the presentation of Lisfranc injuries. Early recognitionand timely orthopedic referral is essential for optimal treat-ment and outcome.

ILLUSTRATIVE CASES

Case 1

A 30-year-old man presented to the emergency depart-ment with a complaint of left foot pain. He related that hehad jumped from a boat to a dock from a height of approx-imately 8 feet. He landed primarily on the left foot, and had

no other complaints.

Examination of the left foot revealed moderate swellingover the dorsum of the midfoot, and exquisite tenderness topalpation. He could weight-bear only with significant pain.The skin was intact, and his neurovascular examination wasnormal.

Radiographic evaluation showed an oblique fracture inthe midportion of the second metatarsal that extended to thearticular surface (Fig 1). Fractures were also noted to extendhorizontally through the base of the third and fourth prox-imal metatarsal heads. The first through the fifth proximalmetatarsal heads are all shifted laterally with respect to theassociated cuneiforms (Fig 2), indicating a Lisfranc type

dislocation in addition to the fractures.Orthopedic consultation was obtained, and the patientwas taken to the operating room the following day for openreduction, internal fixation of the fracture/dislocation. At1-year follow-up the patient was pain free and had returnedto his usual activities.

Case 2

A 22-year-old weightlifter was transferring a 100-lbweight plate from a barbell to a rack when he lost his gripand the plate fell onto the dorsum of his left foot. Thepatient had immediate pain and swelling, and could not bearweight.

Examination showed impressive swelling throughout theleft foot, with diffuse pain. Pain was maximal with palpa-tion of the proximal second and third metatarsal heads. Hisneurovascular examination was normal.

Radiographs were obtained which showed a divergentLisfranc dislocation. Metatarsals 2 through 5 are displacedlaterally, whereas the first metatarsal is medially shifted (Fig3). Dorsal dislocation of the proximal second metatarsal isevident on the lateral radiograph (Fig 4). No fractures areseen.

The patient was consulted to orthopedic surgery, and heunderwent open reduction, internal fixation of the foot thatsame evening. At 2 years out from his injury, he continuedto have pain with ambulation and occasional swelling in the

foot.

PATHOPHYSIOLOGY

Lisfranc injuries can be caused by either direct or indirecttrauma. Direct or crush injuries to the dorsum of the foot arerare and are often complicated by contamination, vascularcompromise, and compartment syndrome.5 The displace-ment of the metatarsal bases may occur in either the plantaror dorsal direction depending on the direction of force at thetime of injury; and no distinctive pattern of injury exists forthis mechanism. Indirect forces constitute the vast majorityof injuries, resulting from either a rotational force applied to

From the Department of Emergency Medicine, and the Depart-ment of Radiology, University of Virginia Health System, Charlottes-ville, VA.

Manuscript received May 3, 2000, accepted June 6, 2000. Address reprint requests to Andrew D. Perron, MD, Assistant

Professor of Emergency Medicine, Department of Emergency Med-icine, Box 800699, University of Virginia Health System, Charlottes-ville, VA 22908. E-mail: [email protected]

Key words: Lisfranc injury, fracture-dislocation.Copyright © 2001 by W.B. Saunders Company0735-6757/01/1901-0019$10.00/0doi:10.1053/ajem.2001.19990

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the forefoot with a fixed hindfoot or axial loading on a

plantar flexed, fixed foot. The longitudinal force results in

metatarsal dislocation dorsally at the site of least resistance

while the rotational force causes dislocation medially or

laterally. In that tremendous energy is required for disloca-

tion, these injuries are frequently associated with multiple

fractures and significant soft tissue injury.9 Common causes

of indirect trauma include falls from a height, motor vehicle

accidents or motorcycle accidents, equestrian accidents, andathletic injuries.1-3,6

Lisfranc injuries range from mild, undetectable subluxa-tions to obvious fracture-dislocations. The clinical presen-

tations are as varied as the patterns of injury. For thisreason, the emergency physician should always maintain ahigh index of suspicion whenever evaluating an injuredfoot. After a significant tarsometatarsal injury, patients gen-erally present with complaints of midfoot pain, swelling,and difficulty with weight bearing. In milder injuries, thepatient may be able to bear weight acutely and be surpris-ingly active despite the pain. Tenderness along the Lisfranc joint is common and passive pronation with abduction of theforefoot with the hindfoot held fixed will elicit pain; thismaneuver is specific for tarsometatarsal injuries.9 The footmay appear normal or markedly deformed depending on theseverity of the injury. Intense swelling of the foot may mask

a deformity. Plantar ecchymosis may also be noted, and if

found should prompt aggressive search for Lisfranc joint

injury.10 If the mechanism of injury is severe or deformity is

obvious, manipulation of the foot should be kept to a

minimum to prevent further displacement. A broadened

foot, shortening in the anteroposterior plane, or a pathologic

range of motion suggest severe fracture dislocation.7 Vas-

cular compromise at the level of the Lisfranc joint rarelyresults in ischemic injury to the foot, but severe fracture

dislocations can damage vessels or cause vascular spasm at

the level of the ankle (posterior tibial artery), jeopardizing

the foot. Serial vascular examinations are important when

this injury is suspected. Tense swelling of the foot with

diminished pulses suggests compartment syndrome and in

these cases immediate surgical intervention is necessary to

save the extremity.5,9 In a multiply injured, unconscious

patient, the injury is easily missed because more life-threat-

ening issues preclude full evaluation of the extremities.

After the patient’s condition has improved, stability of the

tarsometatarsal joint should be evaluated.

FIGURE 1. Patient 1. Internal oblique view of the foot. Spiralfracture of the proximal second metatarsal, with transverse frac-tures extending horizontally through the base of the third andfourth proximal metatarsals.

FIGURE 2. Patient 1. AP view of the foot. The proximal secondmetatarsal does not line up with the medial edge of the secondcuneiform. A small piece of bone, the “fleck sign” is noted wherethe second metatarsal normally articulates with the second cunei-form.

72 AMERICAN JOURNAL OF EMERGENCY MEDICINE s Volume 19, Number 1 s January 2001



DIAGNOSIS

Proper radiographic evaluation and interpretation of thefoot is the key to diagnosis of Lisfranc injuries. A knowl-edge of the normal anatomic relationships at the Lisfranc joint is vital to radiographic interpretation (see Fig 5).Similarly, familiarity with the mechanism of Lisfranc injuryand common radiologic presentation will help the clinicianin making the diagnosis (see Fig 6). The tarsometatarsaltrauma series should include accurate radiographs withthree views of the injured foot—anteroposterior (AP), lat-eral, and oblique views. Comparison radiographs of the

contralateral foot may be helpful in detecting subtle injuries.Major fracture/dislocations are easily recognized and rarelymissed on roentgenogram.11 Sprain injuries without dislo-cation, however, are difficult to diagnose radiographicallyeven though physical examination findings are highly sug-gestive of tarsometatarsal involvement. Weight-bearingfilms (AP and lateral) should be obtained if the diagnosis issuspected but the plain film series is not diagnostic.1,6,12-13

Radiographs of the tarsometatarsal joint may be daunting atfirst glance because of confusion caused by overlappingbony articulations. The second metatarsal base should al-ways be carefully evaluated for fracture, avulsions anddisplacement. On AP and oblique radiographs, the medial

border of the second metatarsal base and the middle cune-

iform and the medial border of the fourth metatarsal base

and cuboid should form a straight, unbroken line. Any

disruption of these lines or fracture fragments around thebase of the second metatarsal or along the lateral border of the cuboid is indicative of significant tarsometatarsal injury.Other consistently normal findings include a straight lineformed by the lateral border of the base of the third meta-tarsal and lateral border of the lateral cuneiform. On thelateral film, a metatarsal shaft should never be more dorsalthan its respective tarsal bone.6 A fracture of the cuboid,cuneiforms, navicular or metatarsal shafts is suggestive of disarticulation of the tarsometatarsal joint. In minor sublux-ation injuries, the key to diagnosis is the mortise configu-

FIGURE 3. Patient 2. AP view of the foot. A divergent Lisfrancdislocation. The first metatarsal is shifted medially, while thesecond through fifth metatarsals are shifted laterally.

FIGURE 4. Patient 2. Lateral view of foot. Dorsal displacementof the proximal second metatarsal is clearly evident.

73PERRON, BRADY, AND KEATS s ORTHOPEDIC PITFALLS: LISFRANC INJURY



ration of the second metatarsal. Separation between the baseof the first and second metatarsal or between the medial andmiddle cuneiforms is strongly suggestive of subluxation.7,9

Widening can also occur between the second and thirdmetatarsal or middle and lateral cuneiforms. A minor dis-placement of the three lateral metatarsal bones may bemissed on AP and lateral films but are often obvious on30-degree oblique views.7 If plain films and weight-bearingfilms do not yield the diagnosis, magnetic resonance imag-

ing or computed tomography can be used to definitively rulein or out the diagnosis.12-14

Displacement of a Lisfranc injury is described as homo-lateral or divergent. The homolateral type has lateral dis-placement of the first through fifth metatarsal heads. In thedivergent type, the first metatarsal (and occasionally thesecond metatarsal) dislocates medially or stays fixed inplace, while the more lateral metatarsals are displaced lat-erally.15

TREATMENT

Early diagnosis of a Lisfranc joint injury is imperative forproper management and the prevention of a poor functional

outcome.1-4,6,8 The definitive treatment of these fracturesusually involves surgical intervention, although there issome controversy in the literature in this regard.2,9,16 Thephysician’s responsibility in the emergency department is tosuspect the diagnosis, confirm the injury radiographically,and to recognize the potential compartment syndrome,which may be associated with the fracture. If orthopedicconsultation is not immediately available, the emergency

physician can attempt closed reduction by hanging the footby the toes using finger traps. If reduced, a bulky compres-sive dressing is then applied with a posterior splint. Theseinjuries almost always warrant acute orthopedic evaluation.The goal in treating this injury is to reestablish a painless,stable, and functional joint. To do this, precise anatomicreduction is necessary.3,7,16

KEY POINTS FOR LISFRANC FRACTURE/DISLOCATION

● Any foot with pain and swelling following trauma mustbe suspected of having a Lisfranc fracture/dislocation.

● The anatomic relationship of the tarsal/metatarsal joint

should be examined carefully in any patient with asuspicious history and/or physical examination

FIGURE 5. Dorsal AP view of the foot, showing the Lisfranc joint complex. Note the alignment of the second metatarsal withthe second cuneiform, and its “keystone” wedging into the 3cuneiforms. Illustration by Marsha J. Dohrman. Reprinted with

permission from Burroughs KE, Reimer CD, Fields KB: LisfrancInjury of the Foot: A Commonly Missed Diagnosis. Am Fam Phys1998;58:118-124.1

FIGURE 6. Common mechanism for Lisfranc fracture-disloca-tion. An axial load is placed on the plantar-flexed foot, with dorsaldislocation of the proximal second metatarsal head. Illustration byMarsha J. Dohrman. Reprinted with permission from BurroughsKE, Reimer CD, Fields KB: Lisfranc Injury of the Foot: A Com-monly Missed Diagnosis. Am Fam Phys 1998;58:118-124.1

74 AMERICAN JOURNAL OF EMERGENCY MEDICINE s Volume 19, Number 1 s January 2001



● A fracture at the base of a metatarsal bone shouldheighten the suspicion for a Lisfranc joint injury.

● A delay in the diagnosis or treatment of a Lisfrancfracture/dislocation can result in long-term morbidityof pain, arthrosis, and disability.

REFERENCES

1. Burroughs KE, Reimer CD, Fields KB: Lisfranc injury of the foot: A commonly missed diagnosis. Am Fam Phys 1999;58:118-124

2. Buzzard BM, Briggs PJ: Surgical management of acute tarso-metatarsal fracture dislocation in the adult. Clin Orthop 1998;353:125-133

3. Mulier T, Reynders P, Sioen W, et al: The treatment of Lisfrancinjuries. Acta Orthop Belg 1997;63:82-90

4. Rabin SI: Lisfranc dislocation and associated metatarsopha-langeal joint dislocations. A case report and literature review. Am JOrthop 1996;25:305-309

5. Arntz CT, Hansen ST: Dislocations and fracture dislocations ofthe tarsometatarsal joints. Orthop Clin North Am 1987;18:105-114

6. Englenhoff G, Anglin D, Hutson HR: Lisfranc fracture disloca-tion: A frequently missed diagnosis in the emergency department.

Ann Emerg Med 1995;26:229-2337. Goosens M, DeStoop N: Lisfranc’s fracture dislocations: Eti-

ology, radiology, result of treatment. Clin Orthop 1983;176:154-62

8. Vuori JP, Aro HT: Lisfranc joint injuries: Trauma mechanismsand associated injuries. J Trauma 1993;35:40-45

9. Myerson M: The diagnosis and treatment of injuries tothe Lisfranc joint complex. Orthop Clin North Am 1989;20:655-664

10. Margolis M, McLennan MK: Radiology rounds. Tarsometatar-sal fracture dislocation. Can Fam Physician 1994;40:1103, 1108-1110

11. Potter HG, Deland JT, Gusmer PB, et al: Magnetic resonance

imaging of the Lisfranc ligament of the foot. Foot Ankle Int 1998;19:438-446

12. Lu J, Ebraheim NA, Skie M, et al: Radiographic and com-puted tomographic evaluation of Lisfranc dislocation: a cadaverstudy. Foot Ankle Int 1997;18:351-355

13. Ross G, Cronin R, Hauzenblas J, et al: Plantar ecchymosissign: A clinical aid to diagnosis of occult Lisfranc tarsometatarsalinjuries. J Orthop Trauma 1996;10:119-122

14. Wartella J, Cohen R, Schwartz DT: The Foot, in Schwartz DT,Reisdorff E (eds): Emergency Radiology. New York, McGraw-Hill,2000, pp 135-156

15. Rosenberg GA, Patterson BM: Tarsometatarsal (Lisfranc’s)fracture-dislocation. Am J Orthop 1995;7-16 (suppl)

16. Preidler KW, Peicha G, Lajtai G, et al: Conventional radiog-raphy, CT, and MR imaging in patients with hyperflexion injuries ofthe foot: Diagnostic accuracy in the detection of bony and ligamen-tous changes. Am J Roentgenol 1999;173:1673-1677

75PERRON, BRADY, AND KEATS s ORTHOPEDIC PITFALLS: LISFRANC INJURY

orthopedic pitfalls in the ed--lisfranc fracture-dislocation

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