Anatomy
The Lisfranc joint complex includes the tarsometatarsal joints and intermetatarsal stabilisers. The second metatarsal base is recessed between the cuneiforms and acts as a keystone.
The Lisfranc ligament runs from the medial cuneiform to the base of the second metatarsal and is a major stabiliser.
Mechanisms
- high-energy crush or motor-vehicle trauma
- lower-energy twisting injury in sport
Purely ligamentous injuries may look deceptively benign but can be highly unstable.
Examination
Look for:
- midfoot swelling
- plantar ecchymosis
- tarsometatarsal tenderness
- pain with forefoot stress
- inability to bear weight
Always assess skin and neurovascular status in high-energy injuries.
Imaging
Weight-bearing radiographs are valuable when the patient can safely tolerate them. Compare alignment of:
- first metatarsal with medial cuneiform
- second metatarsal with intermediate cuneiform
- fourth metatarsal with cuboid
CT defines occult fractures and joint incongruity. MRI may help in selected subtle ligamentous injuries.
Weight-bearing radiographs are valuable when safe and tolerated.
Look for:
- malalignment between metatarsal bases and cuneiforms/cuboid
- widening between first and second rays
- avulsion “fleck” sign
- dorsal displacement on lateral view
CT defines fractures and subtle malalignment. MRI can demonstrate ligament injury when radiographs are equivocal.
Treatment
Stable, truly nondisplaced injuries may be treated non-operatively with strict follow-up.
Unstable injuries require restoration of tarsometatarsal alignment. Operative options include:
- open reduction and internal fixation
- primary arthrodesis of selected medial-column joints, particularly in some purely ligamentous patterns
The decision is based on joint damage, instability, patient factors and surgeon experience.
Stable nondisplaced injuries may be treated with immobilisation and protected weight bearing.
Unstable injuries require restoration of anatomic alignment, using:
- ORIF
- primary arthrodesis in selected patterns, especially severe purely ligamentous injury or joint destruction
Complications
- missed instability
- post-traumatic midfoot arthritis
- chronic pain
- arch collapse
- hardware symptoms
The most important preventable error is failure to recognise an unstable injury early.
- missed instability
- midfoot collapse
- post-traumatic arthritis
- chronic pain
- hardware symptoms
- non-union after fusion
Anatomy and mechanism
The Lisfranc complex stabilises the tarsometatarsal joint. The second metatarsal base is recessed between the cuneiforms and acts as a keystone.
Injury may be:
- high-energy with obvious displacement
- low-energy athletic injury with subtle ligament disruption
The latter is commonly missed.
Clinical clues
- midfoot pain and swelling
- plantar ecchymosis
- pain with forefoot stress
- inability to bear weight
- tenderness around first/second TMT region
Plantar bruising is particularly concerning for significant midfoot injury.
Stability
The critical distinction is stable versus unstable injury.
A purely ligamentous unstable injury can have a worse prognosis than a simple bony avulsion because healing and post-traumatic arthritis are less predictable.
FRCS synthesis
The key is recognition of subtle instability under load. A normal non-weight-bearing radiograph does not exclude a clinically important Lisfranc injury.