What Is A Lisfranc Fracture?

Overview

There is a cluster of tarsal bones (small foot bones) in the midfoot, which creates the arch on the top of your foot where the metatarsal bones (five long bones which act as bridges to your toes) connect them to the remaining bones of your foot (forefoot). These bones are held in place and bound together by very strong ligaments and tendons together, forming the Lisfranc joint complex. This keeps your foot’s arch stable and facilitates proper movement of the foot. 

The Lisfranc joint is also known as the tarsometatarsal (TMT) joint.¹ The movements permitted between the tarsal and metatarsal bones are limited to a slight gliding of the bones against each other.

During walking, the force produced by the contraction of the calf muscles is transferred into the forefoot through the midfoot. An injury to the Lisfranc joint complex may result in instability of the midfoot arch, which in turn might cause flattening of the foot arch, abnormal force transference and improper movement. 

Midfoot injuries are named after the French surgeon and gynaecologist Jacques Lisfranc de St. Martin, who first described the injury in the 1800s.²

Causes of a lisfranc fracture

Almost all cases of Lisfranc Injury are caused by trauma. Types of trauma are classified into two groups based on intensity: those caused by high-energy trauma, which produces multiple fractures or joint dislocations of the midfoot, and those caused by low-energy trauma, which results in subtle injuries or sprains. 

Lisfranc injuries can be direct or indirect depending on the mechanism of trauma. Direct injury is often due to high-energy impact and is related to the significant blunt trauma crushing the surrounding structures such as soft tissue, blood vessels or nerves. 

On the other hand, indirect injuries can happen due to high- or low-energy trauma. High-energy indirect injuries are often associated with motor vehicle accidents or falls from a height, whereas low-energy indirect injuries are typically sports injuries. These types of sports injuries are most commonly seen in football and soccer players as well as ballet dancers and gymnasts.⁴

Signs and symptoms of lisfranc fracture

Physical signs indicating a lisfranc fracture

The most common signs indicative of Lisfranc injury include:

• Swelling and pain on touching the upper part of the foot 
• Bruising on both the top and bottom of the foot. Bruising on the bottom of the foot is highly indicative of Lisfranc injury
• Deformity of the foot, such as widening of the midfoot or a flattening of the forefoot¹ 

Common symptoms experienced by individuals with Lisfranc fractures

Typical Lisfranc injury symptoms include the following:

• Pain in the midfoot, which worsens upon standing, walking or pushing off on the injured foot
• Occasionally, pain can result in the inability to bear weight, which in turn might cause difficulty walking or standing

Diagnosis of lisfranc fractures and injuries

It is easier to diagnose high-energy injuries as they are commonly associated with foot deformities. On the other hand, diagnosing low-energy injuries can be difficult because patients usually present without deformity and can walk.³

Physical examination and medical history review

After questions about your symptoms and the mechanism of the injury, your doctor will examine your foot and ankle. During the physical examination, your doctor will perform some tests involving grasping different parts of the affected foot and moving them. 

The tests might elicit pain; however, they will not cause any worsening of the injury. Your doctor will also look for bruising on the bottom of your foot and palpate along your midfoot to detect any tenderness. 

Imaging techniques for diagnosing Lisfranc fractures

As the first stage of imaging, your doctor will order X-rays from different angles. A change in alignment between the tarsal and metatarsal bones, detachment of the Lisfranc ligament, as well as separation and displacement of the metatarsal bones can be indicative of Lisfranc injuries. Although a standard X-ray is enough to make a diagnosis in most cases, approximately 20% of the cases cannot be diagnosed with an X-ray.  

If the diagnosis cannot be made using X-rays, the next stage of diagnostic imaging will be Computed Tomography (CT). CT, compared to X-ray, is more successful at detecting subtle dislocations or fractures that do not produce easily observable displacements. 

Additionally, a three-dimensional (3-D) CT scan can enable a complete assessment of the lesion that helps in the decisions regarding treatment and management. 

Magnetic resonance imaging (MRI) is the imaging method of choice if X-ray and CT scans are not sufficient to make a diagnosis. An MRI scan is the gold standard for the detection of ligament injuries and is also useful for excluding other possible conditions.⁴  

Management and treatment for a lisfranc fracture

Treatment decisions for Lisfranc injuries will be made depending on the severity and nature of the injury.

Non-surgical treatment approaches

Non-surgical treatment can be the treatment of choice in a stable injury without a fracture or dislocation in the joint and without a completely torn ligament. In this case, you will be treated with a boot and crutches and told not to put weight on the leg for six weeks.

During this period, you must be very careful about not applying your weight to your injured foot. If your pain has disappeared in the midfoot following that period, your doctor may suggest a gradual return to activity using an orthopaedic insole.

If the pain persists after six weeks, you might need to use an orthopaedic boot while weight-bearing for another four weeks.³

During the course of the treatment, your doctor will arrange regular follow-ups and order additional X-rays to monitor your progress. If the X-ray shows any displacement in the bones, you might need surgery to return them to an alignment that is functional.

Surgical treatment options

Surgery is recommended for patients with displaced fractures or severe injuries that are unstable. This surgery aims to restore the stability of your midfoot by putting the fractured fragments back together into their normal position and realigning the joints.

There are mainly two surgical techniques used:

• Open reduction internal fixation (ORIF) – This procedure involves repositioning the displaced bones through a cut made on top of the foot by the surgeon (open reduction) followed by stabilisation and then placement of various hardware such as screws or plates (internal fixation). Later, the hardware may be removed in another operation 
• Primary arthrodesis or joint fusion: – The movements permitted between the tarsal and metatarsal bones are limited to slight gliding of the bones upon each other. Because there is only limited motion in the midfoot joint, arthrodesis can be a suitable option to alleviate pain and restore stability of the midfoot. This procedure involves realigning and compressing the displaced bones together by using hardware to promote a fusion during healing so that eventually, the bones completely fuse, and then all the joint movement disappears. Afterwards, since the bones are fused together, there is no need to remove the hardware afterwards.⁴

Apart from traditional hardware fixation with screws or plates, there are also flexible fixation methods with no need for subsequent surgery for hardware removal and less possibility of joint injury during hardware placement. However, there is still no consensus in the literature regarding the best surgical method to repair a Lisfranc injury.⁵

Rehabilitation

During rehabilitation after the surgery, you will be recommended a period of non-weight bearing in a cast or boot for approximately 6-8 weeks. If the follow-up X-ray is satisfactory after that period, weight bearing can be recommended. Your surgeon will decide the amount of weight you can put on your foot and the activities you can do.

After the injury, you might experience pain and swelling in your foot for 3-6 months. Swelling might get worse at the end of the day as gravity pulls fluid down, causing swelling in your foot and ankle. You can alleviate the pain and swelling by taking painkillers, elevating your foot, and applying cold packs to it. 

Potential complications associated with Lisfranc fractures

There may be potential complications following Lisfranc injury due to the injury itself or produced by the treatment. The most common complication following ORIF is osteoarthritis, which is due to the trauma to the joints.⁴ One relevant article shows that imaging evidence of osteoarthritis is found in 72.1% of patients and osteoarthritis symptoms in 54.1% of patients.⁶

Other possible complications include:

• Screw problems (breakage etc.)
• Loss of reduction
• Spontaneous fusion of adjacent joints
• Damage to the surrounding nerves, vessels and other structures
• Skin issues and wound complications 
• Compartment syndrome
• Implant infection
• Complex regional pain syndrome
• Deep vein thrombosis (blood clot formation in a vein)^4,5

Compartment syndrome is a serious surgical emergency in which the blood flow to a muscle is restricted due to increased pressure of swollen tissues inside. In the presence of a high suspicion of compartment syndrome, an emergency procedure called fasciotomy to relieve the built-up pressure is necessary.⁴ 

FAQs

How can I prevent a Lisfranc fracture?

Because Lisfranc injuries happen as a result of unexpected accidents, the best way to prevent them is to take some precautions and be careful. You can arrange your home and workplace to be free from any dangers which might cause you or others to fall or trip. You can also make sure you use appropriate equipment before playing any sports. If you need personalised advice, you can contact a healthcare professional, such as an orthopaedic doctor, sports medicine specialist, or registered physiotherapist, physical therapist, or podiatrist.

How common is a lisfranc fracture?

Lisfranc injuries only account for approximately 0.2% of all fractures, which means only 2 out of 1000 fractures are Lisfranc injuries. Although Lisfranc injuries are not common, 20% of cases remain undiagnosed, especially low-energy subtle injuries.

Most of the Lisfranc injuries (87.5%) are closed injuries due to indirect trauma and are more frequently seen in athletes.³

Who is at risk of a lisfranc fracture?

Although Lisfranc injuries can affect anyone, certain factors can put you at increased risk for it such as:

• Activities and sports involving a risk of falls or foot trauma 
• Activities or sports with repetitive overuse of the feet
• Diabetes or nerve damage (because it makes it more difficult to recognise the early symptoms of the injury)
• Structural variations in foot anatomy (a shallow second TMT joint mortise in which the base of the second metatarsal is recessed)⁷ 

Lisfranc injuries are more commonly seen in people assigned male at birth, possibly due to more frequent participation in high-speed sports and activities, and they are more common in the third decade of life.³

How long does it take for a Lisfranc fracture to heal?

The duration of recovery depends on the individual, the severity of the injury, and the type of treatment. The treatment aims to achieve a pain-free, stable midfoot, allowing the resumption of all pre-injury activities.  

Generally, non-surgical treatment takes around 6 to 8 weeks, and surgery takes up to 3 months to recover from when following the advice from a physical therapist. For some patients, it may be 6 months to 1 year for the full recovery. 

However, some athletes may never regain their pre-injury levels of activity and performance. Furthermore, there may be long-term complications such as persistent midfoot pain and arthritis despite successful surgery.

When should I see a doctor?

It is very important to see your healthcare provider without delay if you have symptoms potentially of Lisfranc injuries such as pain, swelling, bruising, and limited mobility of your foot, especially following a trauma. Lisfranc injuries can be challenging to diagnose and may be mistaken for less severe injuries such as a sprain. It is very unlikely for a Lisfranc injury to get better on its own, and if neglected, it can lead to long-term problems such as persistent pain or foot deformities.

Summary

A Lisfranc injury is a type of foot injury that involves damage to the integrated cluster of bones and ligaments in the middle foot. Almost all of the cases are due to trauma and present with symptoms of midfoot pain, swelling and difficulty bearing weight on the injured foot. 

Diagnosis includes a medical history review, physical examination and imaging with an X-ray as a first step. A CT scan or an MRI scan can be used in more complex cases or when the diagnosis is unclear. 

Non-surgical treatment with a plaster boot or surgery can be a treatment option, depending on the severity and type of the injury. As early treatment is crucial to minimise long-term complications and improve recovery outcomes, it is very important to seek help from a healthcare professional without delay.