Original article
Lisfranc Injury: Imaging Findings for this Important but Often-Missed Diagnosis

https://doi.org/10.1067/j.cpradiol.2007.08.012Get rights and content

The Lisfranc injury is a popular topic in the radiology, orthopedic surgery, and emergency medicine literature, primarily due to the subtleties of the radiographic findings and potentially dire consequences of missed diagnoses. The purpose of this article is to help readers understand the anatomy of the tarsometatarsal joint, identify a systematic approach for the evaluation of the joint, and demonstrate how a multimodality approach can be used in both straightforward and more complex cases. Specifically, the utility of lateral and weight-bearing radiographs as well as computed tomography and magnetic resonance will be addressed. The dorsoplantar radiograph is often the first radiological examination performed, after initial history and physical examination. An understanding of the anatomy of the normal Lisfranc joint and subtle findings in the abnormal joint is essential in making an accurate diagnosis. Lateral and weight-bearing radiographs can be very useful in evaluating for subtle dislocation and minimizing the effects of overlapping structures at the tarsometatarsal joint. Computed tomography is particularly helpful in the delineation of anatomy and identification of small fractures. The strength of magnetic resonance lies in its ability to show isolated ligamentous injury and bone marrow edema. At the end of the article, the reader should be able to describe the normal anatomy of the tarsometatarsal joint, identify findings of Lisfranc injury on all three modalities, and understand the specific indications for the use of each modality.

Section snippets

Anatomy of the Tarsometatarsal Joint

Knowledge of the anatomy of the tarsometarsal (TMT) joint can be very helpful in making the diagnosis of a Lisfranc fracture–dislocation as well as understanding potential complications of this injury and evaluating posttreatment imaging for adequacy of repair. The TMT joint represents the junction of the midfoot and forefoot and the osseous structures include the five metatarsal bases, three cuneiforms (medial, intermediate, and lateral, respectively), and the cuboid.6 The cuneiforms are named

Mechanism of Injury

The most common mechanisms of the Lisfranc fracture–dislocation involve axial load or forced supination or pronation on a plantar flexed foot. This leads to fractures of the metatarsals and tarsal bones as well as ligamentous injuries.18 These indirect mechanisms are much more common than direct mechanisms (such as crush injuries) in causing Lisfranc fracture–dislocations.

Examples of the indirect mechanism of injury include the “bunk bed” fracture in which children leaping from the top bunk of

Classification of Injury

Classification of the displaced Lisfranc injury was described by Myerson and coworkers14 based on segmental patterns of injury. Type A describes a completely incongruent tarsometatarsal joint complex with medial or lateral dislocation of the forefoot. Type B characterizes a partially incongruent injury with further subclassifications of B1 and B2, describing medial dislocation of the first metatarsal and lateral dislocation of the second to fifth metatarsals, respectively. Divergent injuries

Radiographic Findings

As radiographic findings may be subtle and patients frequently present with polytrauma, a systematic approach should be utilized when interpreting conventional radiographs for possible Lisfranc injury. There are three key anatomic relationships to analyze when examining a dorsoplantar view of the foot. First, the medial margins of the second metatarsal and the middle cuneiform should be well aligned.24, 25 Second, the lateral margin of the first metatarsal should also be aligned with the

Role of CT and MRI

CT is useful in the diagnosis of subtle midfoot malalignments and fractures as it allows for imaging in various planes and allows for visualization of unobscured anatomy. Tarsometatarsal malalignment, subtle fractures, and joint space fracture fragments are better appreciated than with conventional radiography (FIG 6, FIG 7, FIG 8). CT also allows detection of interposed bone fragments and tendons, which may impede adequate reduction27 (Fig 9). CT is advantageous as patient positioning is not

Conclusions

Although relatively rare injuries, fractures and dislocations at the Lisfranc joint are important to recognize due to the potential for chronic morbidity with missed initial diagnosis or improper treatment. Multiple factors contribute to the relatively high initial miss rate including unfamiliarity with appropriate tarsometatarsal anatomy, difficulty in obtaining adequate radiographs of the midfoot due to suboptimal positioning and bony overlap, as well as low clinical suspicion, especially in

References (30)

  • M.S. Aronow

    Treatment of the missed Lisfranc injury

    Foot Ankle Clin North Am

    (2006)
  • C.T. Arntz et al.

    Dislocations and fracture dislocations of the tarso-metatarsal joints

    Orthop Clin North Am

    (1987)
  • T. Philbin et al.

    Complications of missed or untreated Lisfranc injuries

    Foot Ankle Clin North Am

    (2003)
  • E.A. Desmond et al.

    Current concepts review: Lisfranc injuries

    Foot Ankle Int

    (2006)
  • W.H. Cassebaum

    Lisfranc fracture-dislocations

    Clin Orthop

    (1963)
  • A.P. Aitken et al.

    Dislocation of the tarsometatarsal joint

    J Bone Joint Surg Am

    (1963)
  • T.A. English

    Dislocations of the metatarsal bone and adjacent toe

    J Bone Joint Surg Br

    (1964)
  • A.K. Sands et al.

    Lisfranc injuries

    Injury Int J Care Injured

    (2004)
  • J.D. Kaplan et al.

    Lisfranc's fracture-dislocation: A review of the literature and case reports

    J Am Podiatr Med Assoc

    (1991)
  • M. Goosens et al.

    Lisfranc's fracture-dislocations: Etiology, radiology, and results of treatment—A review of 20 cases

    Clin Orthop

    (1983)
  • R.M. Chesbrough

    Strategic approach fends off charges of malpractice: Program provides tips for avoiding litigation

    Diagn Imaging

    (2002)
  • J. Calder et al.

    Effect of compensation claims on isolated Lisfranc injuries

  • J.F. Norfray et al.

    Subtleties of Lisfranc fracture-dislocations

    AJR

    (1981)
  • K.W. Priedler et al.

    Tarsometatarsal joint: Anatomic details on MR images

    AJR

    (1996)
  • M. Myerson et al.

    Fracture dislocations of the tarsometatarsal joints: End results correlated with pathology and treatment

    Foot Ankle Int

    (1986)
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