ORTHOP ED IC S & REHA B ILITATIO N

Diagnosis and Management of Lisfranc Injuries and Metatarsal Fractures

HEATHER E. GOTHA, MD; CRAIG R. LAREAU, MD; TODD A. FELLARS, MD

A BST RA C T from heights).2,3 Overall, it still remains difficult to quantify

Forefoot and midfoot injuries are relatively common and the exact incidence of these injuries as nearly 20% are not
can lead to chronic disability, especially if they are not accurately diagnosed on initial radiographic assessment.4
promptly diagnosed and appropriately treated. A focused
history and physical examination must be coupled with Anatomy and Biomechanics
a thorough review of imaging studies to identify the cor- The forefoot is comprised of five metatarsal bones and the
rect diagnosis. Subtle radiographic changes can represent phalanges of each toe. The midfoot consists of five bones:
significant ligamentous Lisfranc injury. Midfoot swelling three cuneiforms (medial, middle and lateral), the cuboid,
in the presence of plantar ecchymosis should be consid- and navicular.
ered to be a Lisfranc injury until proven otherwise. While The Lisfranc joint consists of the articulations between
most metatarsal fractures can be treated with some form the metatarsals and the three cuneiforms and cuboid. Its
of immobilization and protected weight-bearing, this ar- osseous architecture and soft-tissue connections are critical
ticle will distinguish these more common injuries from to the stability of the foot. The Lisfranc articulation can be
those requiring surgical intervention. We will review rel- divided into three longitudinal columns.5 The medial col-
evant anatomy and biomechanics, mechanisms of inju- umn consists of the medial cuneiform and first metatarsal.
ry, clinical presentation, imaging studies, and diagnostic The middle column is composed of the middle and lateral
techniques and treatment. cuneiforms and the second and third metatarsals. The lat-
K E YWORD S: Lisfranc joint injury, metatarsal fracture eral column is made up of the cuboid and fourth and fifth

Figure 1. Coronal computed tomography (CT) image demonstrating the

Roman arch

INTRO D U C T I O N
Injuries to the midfoot and forefoot can result from both
high- and low-energy trauma and can lead to chronic dis-
ability. A thorough history and physical examination as well
as careful interpretation of imaging studies are necessary to
make the appropriate diagnosis. Plain radiographs are not al-
ways diagnostic because of multiple overlapping bones in
the foot, particularly on the lateral view. This article will
provide an overview of common traumatic foot injuries, fo-
cusing on Lisfranc joint injuries and metatarsal fractures.
We will review relevant anatomy and biomechanics, mech-
anisms of injury, clinical presentation, imaging studies, and
diagnostic techniques.

LISFRA N C I N JUR I E S
Injuries to the Lisfranc, or tarsometatarsal (TMT), joint com-
plex occur in 1 in 55,000 persons each year in the United
States, approximately 0.2% of all fractures.1 Low-energy trau-
ma, including falls from standing and athletic injuries, ac- Med Cun = medial cuneiform
Mid Cun = middle cuneiform
counts for approximately one-third of Lisfranc injuries. The Lat Cun = lateral cuneiform
remaining two-thirds occur as a result of high-energy trau- Cub = cuboid
ma (eg, motor vehicle collision, industrial accidents and falls 5th MT = fifth metatarsal

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metatarsals. There is limited motion in the medial and Figure 2. Anteroposterior foot x-ray demonstrating Lisfranc injury (the
middle column, but the lateral column exhibits significantly medial border of the second metatarsal does not line up with that of the
more motion. The cuneiforms are trapezoidal, wider dorsally middle cuneiform)
than plantarly, providing stability similar to a “Roman arch”
(Figure 1). The second metatarsal is recessed proximally
, serving as the “keystone” of the Lisfranc joint.
Soft tissue support of the TMT articulation consists pri-
marily of capsular and ligamentous structures. The Lisfranc
ligament is the most important and runs from the plantar
medial cuneiform to the base of the second metatarsal.
While the second through fifth metatarsals are intercon-
nected by inter-metatarsal ligaments, there is no inter-meta-
tarsal connection between the first and second metatarsals.
Thus, the Lisfranc ligament effectively connects the me-
dial column to the lateral four metatarsals. Injury to this
ligament can destabilize the entire forefoot as well as the
Lisfranc articulation.6

Mechanism of Injury
Lisfranc injuries result from both indirect and direct trauma.
Direct injuries, including crush injuries and other high-en-
ergy mechanisms, are frequently associated with significant
soft-tissue trauma, vascular compromise, and compartment
syndrome. Therefore, one should have a high suspicion
for Lisfranc injuries and these other entities in patients
presenting with a history of crush injury to the foot.
There are two common indirect mechanisms of Lisfranc
injury: forced external rotation, or twisting of a pronated
foot and axial loading of the foot in a fixed equinus posi-
tion. In a twisting injury, forceful abduction of the forefoot
causes dislocation of the second metatarsal and lateral dis- anteroposterior (AP) foot radiograph – a “positive gap sign.”
placement of the lateral metatarsals. This type of injury is Tenderness to palpation and inability to bear weight on the
in sports involving use of a stirrup, such as at equestrian tiptoes also suggest injury to the TMT complex.6,7
events. Associated “nutcracker” cuboid fractures can occur Stability of the TMT articulation may be assessed with
due to compression by the fourth and fifth metatarsal bas- maneuvers such as the “piano key test” (moving the first
es. Patients presenting with such a cuboid fracture of this and second metatarsals into plantarflexion/dorsiflexion
nature should be suspected of having an associated Lisfranc and abduction/adduction). Subluxation or discomfort with
injury. Metatarsal base fractures, particularly of the second, this test suggests TMT joint injury. The first and second
are not uncommon with an abduction mechanism. metatarsals should also be stressed divergently.8 Of note,
Axial loading of the foot with the ankle and metatarso- stress tests in the acute setting may be limited by patient
phalangeal (MTP) joints in plantarflexion is another mecha- discomfort and swelling of the foot.
nism for a Lisfranc injury. Examples include missing a step,
catching one’s heel on a curb while stepping down, or force Imaging
applied when the foot is plantarflexed and the knee is an- An AP view assesses the alignment of the first and second
chored on the ground. The latter usually occurs in American TMT joints, while the oblique view evaluates the other TMT
football players when they are kneeling or lying in a prone joints; the medial border of the second metatarsal should
position and another athlete falls directly onto the heel.6,7 line up with that of the middle cuneiform. On the 30-de-
gree oblique view, the medial border of the fourth metatarsal
Signs and Symptoms should line up with that of the cuboid. Any displacement of
Patients with Lisfranc injuries tend to present with midfoot these lines is diagnostic for Lisfranc injury (Figure 2). Oth-
swelling and inability to bear weight. Classic findings in- er signs of Lisfranc injury include avulsion fractures of the
clude forefoot and midfoot edema, and plantar arch ecchy- second metatarsal base or medial cuneiform (“fleck sign”)
mosis, which are considered pathognomonic for Lisfranc and more than 2.7 mm of diastasis between the first and
injury. Additional findings suggestive of Lisfranc injury in- second metatarsals.9 Lateral radiographs may reveal dorsal
clude diastasis between the hallux and the second toe on an dislocation or subluxation of the TMT joints.6

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If a Lisfranc injury is suspected despite normal imag- as dropping a heavy object onto the forefoot, causing a
ing, “stress views” of the foot should be obtained: an AP transverse or comminuted fracture pattern. In the setting of
weight-bearing radiograph with both feet on a single cassette, crush injuries, second, third and/or fourth metatarsals are
as well as oblique and lateral weight-bearing radiographs of usually involved.
the injured extremity. One should explain the rationale be- Patients with acute metatarsal shaft fractures present
hind these painful radiographs to improve compliance with with pain and swelling of the forefoot, with point tenderness
equal weight distribution on both feet. The alignment of all over the fracture site. With multiple metatarsal fractures, a
columns should be reassessed, and any displacement is diag- neurovascular exam and soft tissue injury assessment are es-
nostic of TMT joint instability. Diastasis between the first sential to monitor for foot compartment syndrome.7 Radio-
and second TMT joints, if greater than 2 mm compared to graphic evaluation includes standard, three-view foot x-rays.
the contralateral side, is indicative of ligamentous Lisfranc Weight-bearing x-rays should be obtained if tolerated, to assess
injury.10 Lateral weight-bearing films should be examined for the extent of displacement, angulation and shortening on each
loss of arch height and subluxation of TMT joints. view. As previously mentioned, fractures at the base of the
second metatarsal should raise suspicion for Lisfranc injury.
Treatment
Unstable Lisfranc injuries should be treated with either Treatment
transarticular fixation or arthrodesis, depending on age, de- Operative indications for metatarsal shaft fractures include
gree of underlying arthritis, ligamentous or bony injury, and greater than 10 degrees of angulation in the sagittal plane,
comminution. Post-operatively, patients are usually placed more than 3 to 4 millimeter translation in any direction,
in a short leg cast for 3 to 4 weeks and then transitioned to rotational toe malalignment, and shortening that alters the
a controlled ankle motion (CAM) boot, which allows ankle distal parabolic relationship of the metatarsal heads.13 These
ROM exercises, for 3 to 5 weeks. Typically, patients do not structural changes can lead to metatarsalgia and painful cal-
bear weight for 8 to 12 weeks, depending on surgeon prefer- luses. Transverse plane displacement can lead to interdig-
ence and patient symptoms. Patients can be transitioned to ital nerve irritation. Additionally, persistent medial or lat-
a shoe with an orthotic insert at 3 months post-operatively. eral displacement of a 1st or 5th MT shaft fracture can widen
Physical therapy should be initiated for balance and gait the foot and create shoe-wear problems, so they should be
training once the patient’s cast is removed.6,7 reduced and fixed.7
Patients with stable injuries can be managed non- Shaft fractures with minimal or no displacement can be
operatively and can bear weight as tolerated in a CAM boot treated either in a short-leg walking cast for several weeks
for 6 to 10 weeks. After 2 weeks in the boot, weight-bearing or in a hard-soled shoe if comfort allows. The advantage of
images are obtained to monitor for any changes in alignment. a hard-soled shoe is that free ROM of the ankle is preserved.
A brief course of physical therapy to regain balance, strength, Other treatment options include a supportive shoe with a
and ROM is recommended. After discontinuing the CAM longitudinal arch support to unload the metatarsal heads.
boot, comfortable, supportive shoes should be worn and some Minimally displaced or non-displaced traumatic metatar-
authors also advocate the use of full-length orthotic inserts.6 sal fractures usually heal within 3 weeks and rarely result
in functional deficit. Prolonged immobilization should be
avoided to prevent joint stiffness.14
M ETATA RS A L FR ACT UR E S Some fractures of the proximal fifth metatarsal deserve
Forefoot Anatomy and Biomechanics special mention, since their high risk of nonunion makes
The forefoot serves two major purposes during gait: (1) the them unique among metatarsal fractures. These so-called
five metatarsals and two sesamoids provide a broad plantar Jones fractures occur at the metaphyseal-diaphyseal junction
surface for load sharing, and (2) the mobile forefoot allows of the fifth metatarsal, involving the fourth-fifth metatarsal
the metatarsal heads to accommodate uneven ground and articulation. Due to the poor blood supply in this region,
maintain even load distribution.11 Displaced metatarsal frac- these fractures have a high incidence of nonunion. These
tures can disrupt the major weight-bearing complex of the fractures are common in athletes involved in contact sports.
foot. It is critical to correct both displacement in the sagittal Management entails strict non-weight-bearing in a short leg
plane and excessive shortening of any individual metatarsal. cast for 6 to 8 weeks. Due to the likelihood of delayed union
These injuries can result in metatarsalgia due to excessive or nonunion, Jones fractures often require surgical interven-
pressure on one or more metatarsal heads.7 tion, particularly in elite athletes. Early surgery minimizes
the risk of non-union and expedites return to sports.15
Metatarsal Shaft Fractures (Acute Traumatic)
In a study of the epidemiology of metatarsal fractures, 68% Metatarsal Stress Fractures (Subacute and Chronic)
were found to involve the fifth metatarsal, most common- Stress fractures of the metatarsal shaft occur as a result
ly resulting from a torsional mechanism.12 Metatarsal shaft of repetitive forefoot stresses, and are commonly seen in
fractures can also occur from a direct blow to the foot, such athletes; they can also occur after metatarsal-shortening

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forefoot procedures that alter the weight-bearing distribu- 4. Trevino SG, Kodros S. Controversies in tarsometatarsal injuries.
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Patients with metatarsal stress fractures usually have Forefoot: Operative and Nonoperative Treatment. J Am Acad
localized pain and tenderness, sometimes without a history Orthop Surg. Mar 1995;3(2):70-78.
8. Arntz CT, Hansen ST, Jr. Dislocations and fracture disloca-
of trauma, but often with a recent change in the patient’s tions of the tarsometatarsal joints. Orthop Clin North Am. Jan
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A thorough medical history may help to detect secondary franc joint. J Bone Joint Surg Am. Dec 1990;72(10):1519-1522.
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should address calcium, vitamin D, and protein intake, as delphia: Lippincott Williams & Wilkins; 2006.
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Standard three-view weight-bearing radiographs yield tarsal fractures. Foot Ankle Int. Mar 2006;27(3):172-174.
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These later findings may appear weeks to months after the body/120058643-2/0/1867/0.html.
onset of symptoms.16,17 15. Shindle MK, Endo Y, Warren RF, et al. Stress fractures about
Since radiographic findings tend to lag behind clinical the tibia, foot, and ankle. J Am Acad Orthop Surg. Mar
symptoms by weeks, x-rays can be negative, particularly ear- 2012;20(3):167-176.
ly in the course of disease. In this setting, technetium bone 16. Daffner RH, Pavlov H. Stress fractures: current concepts. AJR
Am J Roentgenol. Aug 1992;159(2):245-252.
scans and/or MRI can be helpful. Occult stress fractures are 17. Sofka CM. Imaging of stress fractures. Clin Sports Med. Jan
generally visible on bone scans days to weeks earlier than 2006;25(1):53-62, viii.
on radiographs. While a bone scan has high sensitivity for 18. Kiuru MJ, Niva M, Reponen A, Pihlajamaki HK. Bone stress inju-
detecting stress fractures, it is not very specific, and tracer ries in asymptomatic elite recruits: a clinical and magnetic reso-
nance imaging study. Am J Sports Med. Feb 2005;33(2):272-276.
uptake will be seen in the setting of any process that in-
volves bone remodeling, including tumor, infection and Author
stress reaction without fracture.15 MRI is considered equally Heather E. Gotha, MD, is a Senior orthopaedic resident, Dept. of
sensitive and more specific than a bone scan in diagnosing Orthopaedics,The Warren Alpert Medical School of Brown
occult fractures. Diagnostic MRI findings include endosteal University and Rhode Island Hospital.
marrow edema and periosteal edema in the region of injury.18 Craig R. Lareau, MD, is Chief orthopaedic resident, Dept. of
Orthopaedics, The Warren Alpert Medical School of Brown
University and Rhode Island Hospital.
Treatment Todd A. Fellars, MD, is Orthopaedic foot and ankle fellow, Dept.
Treatment of metatarsal stress fractures involves several of Orthopaedics, The Warren Alpert Medical School of Brown
weeks of rest and immobilization in a CAM boot, with the University and Rhode Island Hospital.
duration dependent on tenderness and pain with weight-bear-
ing. A gradual return to previous activity level should begin Disclosures
The authors have no financial disclosures to report.
after the resolution of symptoms. Some institutions also
recommend referral to a metabolic bone disease specialist if Correspondence
secondary causes of stress fracture are suspected.15 Heather E. Gotha, MD
593 Eddy Street
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