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ACEP Now: Vol 36 – No 12 – December 2017Figure 5: Normal three-column anatomy of Lisfranc complex. A shows the AP view.
Dr. Anton Helman/Emergency Medicine Cases
Identify and Treat Lisfranc Injuries
B shows the oblique view.
C shows the lateral view.
Diagnostic Imaging for the Emergency Physician. Elsevier 2011
X-Ray Findings Suspicious for Lisfranc Injuries
- On the AP view, widening of >2 mm between the base of the first and second metatarsal indicates instability (See Figure 4).1
- “Fleck sign” is pathognomonic for a Lisfranc injury. This is a small bony fragment avulsed from the second metatarsal base or medial cuneiform (see Figure 6).1
Management
Stable dislocation/fracture injuries are defined as having less than 2 mm of displacement between the first metatarsal and medial cuneiform. These can be managed non-operatively with reduction and casting.5 The patient should be placed in a non-weight-bearing below-the-knee cast for six weeks and have outpatient orthopedic follow-up in two weeks.6
For unstable fractures and dislocations, immediate orthopedic consultation is needed for surgical intervention with internal fixation.5 After surgery, immobilization and non-weight-bearing status is recommend for eight to 12 weeks.7 The screws may then be removed at 12 weeks.7 Full weight-bearing is typically not permitted until all hardware is removed.
Dr. Paez Perez is an emergency medicine resident at St. Joseph’s Regional Medical Center in Paterson, New Jersey.
References
- Siddiqui NA, Galizia MS, Almusa E, et al. Evaluation of the tarsometatarsal joint using conventional radiography, CT, and MR imaging. Radiographics. 2014;34(2):514-531.
- Lau S, Bozin M, Thillainadesan T. Lisfranc fracture dislocation: a review of a commonly missed injury of the midfoot. Emerg Med J. 2017;34(1):52-56.
- Caswell F, Brown C. Identifying foot fractures and dislocations. Emerg Nurse. 2014;22(6):30-34.
- Englanoff G, Anglin D, Hutson HR. Lisfranc fracture-dislocation: a frequently missed diagnosis in the emergency department. Ann Emerg Med. 1995;26(2):229-233.
- Anderson RB, Hunt KJ, McCormick JJ. Management of common sports-related injuries about the foot and ankle. J Am Acad Orthop Surg. 2010;18(9):546-556.
- Buzzard BM, Briggs PJ. Surgical management of acute tarsometatarsal fracture dislocation in the adult. Clin Orthop Relat Res. 1998;(353):125-133.
- Harwood MI, Raikin SM. A Lisfranc fracture-dislocation in a football player. J Am Board Fam Pract. 2003;16(1):69-72.
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