The Lisfranc joint complex, named after French surgeon Jacques Lisfranc de St. Martin, refers to the tarsometatarsal articulation in the midfoot — the junction between the tarsal bones and the five metatarsal bones. Injuries to this region, collectively termed Lisfranc fractures or fracture-dislocations, represent a clinically significant and frequently underdiagnosed group of injuries. Although they account for only 0.2% of all fractures, the consequences of mismanagement can be devastating, leading to chronic pain, progressive deformity, and long-term disability. Understanding the anatomy, classification, and evolving treatment landscape is essential for optimal patient outcomes.
Anatomy and Mechanism of Injury
The stability of the Lisfranc joint depends on a combination of bony architecture and ligamentous support. The second metatarsal base is recessed between the medial and lateral cuneiforms, acting as a keystone that provides inherent bony stability. Ligamentous support is provided by plantar, dorsal, and interosseous ligaments, with the Lisfranc ligament — connecting the medial cuneiform to the base of the second metatarsal — being the most critical stabiliser. Notably, there is no direct ligamentous connection between the first and second metatarsal bases, making this interval particularly vulnerable to injury.
Lisfranc injuries typically occur via two mechanisms: direct trauma, such as a heavy object falling on the foot, or indirect trauma, such as a forced plantarflexion or twisting injury. The latter is common in athletes, particularly footballers, gymnasts, and equestrians. Motor vehicle accidents and falls from height represent the more severe end of the spectrum, often producing high-energy, comminuted fracture-dislocations.
Diagnosis
Diagnosis begins with a careful clinical assessment. Patients typically present with midfoot pain, swelling, and an inability to bear weight. A hallmark sign is the “plantar ecchymosis sign” — bruising on the plantar surface of the midfoot — which, though not universally present, is highly specific for Lisfranc injury when seen. Palpation of the tarsometatarsal joints and a pronation-abduction stress test can help identify instability.
Plain radiographs, taken weight-bearing where possible, remain the primary imaging tool. Key radiographic findings include widening of the space between the first and second metatarsal bases (greater than 2mm), loss of alignment between the medial border of the second metatarsal and the medial border of the middle cuneiform, and the presence of the “fleck sign” — a small avulsion fracture at the Lisfranc ligament insertion. However, plain films may appear normal in up to 50% of purely ligamentous injuries, making computed tomography (CT) scanning invaluable for bony detail. Magnetic resonance imaging (MRI) is the gold standard for identifying ligamentous disruption in suspected occult injuries and is particularly useful in the athletic population.
Classification
The most widely used classification system is that of Myerson, a modification of the original Quénu and Küss system. It categorises injuries into three types based on the direction of displacement: Type A (total incongruity), Type B (partial incongruity, either medial or lateral), and Type C (divergent pattern). While useful anatomically, this classification has limited prognostic value. More clinically relevant is the distinction between stable and unstable injuries, as this directly drives treatment decisions.
Non-Operative Treatment
Truly stable, non-displaced Lisfranc injuries — a minority of presentations — may be managed conservatively. This is generally reserved for injuries with less than 2mm of diastasis on stress radiographs and intact ligamentous structures confirmed on MRI. Treatment consists of non-weight-bearing in a short-leg cast or removable boot for six weeks, followed by a graduated return to weight-bearing. Even in these cases, patients must be counselled regarding the risk of late displacement and the need for close radiographic follow-up at two weeks. Conservative management carries inherent risks: missed instability, late collapse of the midfoot arch, and development of post-traumatic arthritis.
Operative Treatment
The vast majority of Lisfranc injuries — all unstable fracture-dislocations and purely ligamentous injuries with instability — require surgical intervention. The goals of surgery are anatomic reduction, stable fixation, and preservation of the longitudinal arch.
Open Reduction and Internal Fixation (ORIF) has long been the standard operative approach. Access is typically gained through one or two dorsal longitudinal incisions, with careful soft tissue handling to protect the dorsalis pedis artery and deep peroneal nerve. Reduction is achieved under direct vision, and fixation is accomplished using solid or cannulated screws across the medial three tarsometatarsal joints. Transarticular screws, while biomechanically sound, damage the articular cartilage and must be removed at three to five months. To avoid this, bridge plating across the joints has gained favour, preserving articular surfaces while providing stable fixation. The lateral two tarsometatarsal joints (fourth and fifth) are more mobile and are typically stabilised with Kirschner wires rather than rigid screws.
Primary Arthrodesis has emerged as a compelling alternative, particularly for purely ligamentous Lisfranc injuries, where the articular cartilage is intrinsically damaged even at the time of acute injury. Randomised controlled trials, including the landmark study by Ly and Coetzee (2006), have demonstrated superior functional outcomes with primary arthrodesis compared to ORIF in purely ligamentous injuries. By fusing the medial three tarsometatarsal joints — which have minimal physiological motion — primary arthrodesis avoids the morbidity of hardware removal, reduces the risk of post-traumatic arthritis, and offers more durable long-term results. The lateral two joints, which contribute to forefoot flexibility, are not fused.
Rehabilitation and Outcomes
Regardless of the surgical technique employed, postoperative management involves a period of non-weight-bearing (typically six to eight weeks) followed by progressive weight-bearing in a boot. Physical therapy focuses on restoring range of motion, strength, and proprioception. Return to sport or heavy labour typically takes six to twelve months.
Outcomes depend critically on the quality of reduction achieved. Even with perfect surgical technique, post-traumatic arthritis develops in a significant proportion of patients — reported in up to 25–50% of cases following ORIF. Secondary arthrodesis may ultimately be required in those with persistent pain and radiographic arthritis.
Lisfranc injuries occupy a challenging intersection of anatomical complexity, diagnostic subtlety, and demanding surgical technique. Prompt recognition, accurate assessment of stability, and appropriate treatment selection — whether conservative management, ORIF, or primary arthrodesis — are the cornerstones of a good outcome. As the evidence base grows, primary arthrodesis is assuming an increasingly prominent role, particularly in ligamentous injuries. Continued refinement of fixation techniques and rehabilitation protocols will be essential to reducing the long-term burden of this frequently underestimated injury.