Identify and Treat Lisfranc Injuries

By Yenisleidy Paez Perez, DO | on January 4, 2018 | 0 Comment

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ACEP Now: Vol 36 – No 12 – December 2017

Figure 5: Normal three-column anatomy of Lisfranc complex. A shows the AP view.
Dr. Anton Helman/Emergency Medicine Cases

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.

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Dr. Paez Perez is an emergency medicine resident at St. Joseph’s Regional Medical Center in Paterson, New Jersey.

References

1. 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.
2. 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.
3. Caswell F, Brown C. Identifying foot fractures and dislocations. Emerg Nurse. 2014;22(6):30-34.
4. 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.
5. 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.
6. Buzzard BM, Briggs PJ. Surgical management of acute tarsometatarsal fracture dislocation in the adult. Clin Orthop Relat Res. 1998;(353):125-133.
7. Harwood MI, Raikin SM. A Lisfranc fracture-dislocation in a football player. J Am Board Fam Pract. 2003;16(1):69-72.