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Lisfranc injury

49 citationsUpdated Sep 2026

Overview

Lisfranc injuries represent a broad spectrum of midfoot pathologies that are frequently difficult to diagnose and treat [1]. Because these injuries can cause long-term disability if not detected and appropriately managed, a high index of suspicion is critical to recognize subtle Lisfranc complex injuries [1, 2]. Radiographic diagnostic criteria have been heterogeneous, and there is a high incidence of missed injuries on radiographs even by experienced observers [3, 5]. Column involvement is the most significant factor in determining injury severity and long-term functional outcomes, whereas sagittal displacement is not the most significant factor [6]. Restoration and maintenance of anatomic alignment of the Lisfranc joint is the key to appropriate treatment of midfoot injury [12]. Ligamentous Lisfranc injuries are associated with a smaller ratio of second metatarsal length to foot length, with more than 50% of patients in this group having a ratio of <29% [16]. Potential pitfalls in the treatment of Lisfranc fractures must be anticipated and avoided if possible [17].

Nonoperative treatment has a role in managing Lisfranc injuries, particularly for avulsion and simple intra-articular fractures with < 2 mm of displacement, which can be treated nonoperatively with high functional outcomes [7]. Undisplaced Lisfranc injuries also have excellent outcomes with non-operative treatment [8]. Conversely, displaced Lisfranc injuries have worse outcomes and require anatomical reduction and internal fixation for the best outcome [8]. Stable anatomical reduction of fracture-dislocations leads to the best long-term outcomes, resulting in less arthritis and better AOFAS midfoot scores [18]. The mean outcome from open reduction internal fixation (ORIF) of Lisfranc joint injuries is comparable to internationally quoted figures [9]. Primary arthrodesis for acute Lisfranc injuries is significantly more expensive and has a higher complication rate than ORIF [10]. However, a primary stable arthrodesis of the medial two or three rays appears to have a better short and medium-term outcome than ORIF for ligamentous Lisfranc joint injuries [19]. Flexible fixation, including novel low-cost techniques and InternalBrace use, provides stable anatomic reduction in a joint-sparing fashion, allows some mobility, eliminates the need for implant removal, and provides a biomechanically viable alternative for early postoperative protected weight bearing [11, 21, 22]. K-wire fixation serves as a simple and adequate technique for the acute management of high-energy Lisfranc injuries, maintaining reduction until definitive fixation without increasing complication risk [23].

Patients who undergo surgical repair for chronic, unstable Lisfranc injury without osteoarthritis have improved patient outcomes and few post-surgical complications [4]. MRI provides imaging reference for scanning, diagnosis, and repair of Lisfranc joint injuries [14]. Regarding sports outcomes, 93% to 94% of athletes return to any level of sports after treatment of Lisfranc injuries, while 74% to 88% return to their preinjury level of sport [15].

Anatomy & Pathophysiology

Bony Anatomy

The tarsometatarsal (TMT) joint complex forms the distal limit between the tarsal and metatarsal units [26]. The osseous tarsal complex comprises the navicular, cuboid, and three cuneiform bones [26]. The midfoot acts as a stout connection between the forefoot and hindfoot, serving an important shock-absorbing function [29]. The Chopart and Lisfranc joints are of greater functional importance than the articulations among the midfoot bones [29].

The TMT joint complex is described as a three-column system consisting of the medial column (first TMT joint), the intermediate column (second/third TMT joints), and the lateral column (fourth/fifth TMT joints) [26]. The second metatarsal is recognized as the keystone within the osseous scaffold due to its positioning resulting from a relative short intermedial cuneiform and being sandwiched between the adjacent medial and lateral cuneiforms [26]. The base of the second metatarsal fits into a mortise formed by the proximally recessed middle cuneiform, creating a keystone configuration [40]. In the coronal plane, the second metatarsal base serves as the cornerstone in a Roman arch configuration [40]. The cuboid is the keystone in the lateral column of the foot, articulating with the calcaneus and the bases of the fourth and fifth metatarsals in the axial plane, and the navicular and the lateral cuneiform in the coronal plane [26]. The cuboid is critical to the integrity of the lateral column [29]. The navicular forms the key in the medial column [26].

The cuneiform bones are part of the transverse arch, a tarsal architectural characteristic simulating a Roman arch that acts as a niche for the plantar musculotendinous and neurovascular structures [26]. The longitudinal arch is a dorso-convex bow spanning from the head of the metatarsals to the calcaneus [26]. This arch is stabilized by the plantar aponeurosis, the long plantar ligament, and the peroneus longus tendon [26]. The osseous components of the Lisfranc complex are subjected to compressive stresses during load, resulting in the formation of a characteristic spongy architecture [26].

There is very little mobile articulation at the TMT joints, which form the boundary between the midfoot and forefoot [43]. The lateral column has approximately three times the mobility of the medial column [43]. Within the medial column, the first ray is three times more mobile than the second or third rays [43]. Biomechanical analysis has demonstrated a significant amount of motion in both the first and fifth TMT joints [26]. The dorsoplantar joint diameter of the first TMT joint is about 3 cm [26].

Ligamentous Anatomy

A multiplicity of dorsal and plantar ligamentous connections results in an amphiarthrotic interface of tarsal and metatarsal bones, especially during phases of stance [26]. The TMT line is further stabilized by surrounding muscles in addition to osseous and ligamentous structural support [26]. The Lisfranc articulation is a stable construct because of its bony architecture and strong ligaments [40].

The "Lisfranc ligament bundle" spans from the first cuneiform to the second metatarsal [26]. The Lisfranc ligament connects the medial cuneiform to the base of the second metatarsal [31]. It is 8 to 10 mm wide and 5 to 6 mm thick [40]. The Lisfranc ligament is critical to stabilizing the second metatarsal and maintaining the midfoot arch [40]. The C1-M2 Lisfranc ligament is the most important and the most prone to injury [38].

The ligament complex consists of distinct components: Interosseous component: The interosseous ligament is the stiffest and strongest component of the Lisfranc ligament complex [40]. It originates from the lateral surface of C1 and extends in an inferolaterodistal direction to insert at the medial-lower aspect of M2 [38]. Plantar component: The plantar ligament inserts on the bases of the second and third metatarsals [40]. The pC1-M2M3 ligament connects the plantar aspect of the medial cuneiform to the bases of the second and third metatarsals [26]. The plantar component of the Lisfranc ligament arises from the inferolateral surface of C1 and bifurcates into a deep and superficial band to insert at the bases of M2 and M3, respectively [38]. The plantar Lisfranc ligament links the base of the second metatarsal to the medial cuneiform and is known to be the strongest and most important ligament in this region of the foot [42]. Dorsal component: The dorsal component of the Lisfranc ligament is the weakest [40]. It is the thinnest and is best seen on coronal and sagittal planes as a single hypointense stripe [38].

In biomechanical analysis, load to failure and stiffness were more than two times greater for the Lisfranc ligament than for the dorsal ligament connecting the medial cuneiform and base of the second metatarsal [26]. The more commonly found dorsal displacement is related to the lower load to failure of the dorsal ligament [26]. Intermetatarsal ligaments exist between the second and fifth metatarsal bases [40]. There is no ligament between the base of the first and second metatarsals [31]. There is no direct ligamentous attachment from the first to second metatarsals [40]. Stability in the area between the first and second metatarsals mostly depends on the recessed base of the second metatarsal, the Roman arch wedged shape of the midfoot bones, and the strong Lisfranc ligament [31].

Pathophysiology & Mechanisms

Acute injuries to the TMT or Lisfranc joint are rare, accounting for 0.1% to 0.4% of all fractures and dislocations [26]. The annual incidence of tarsometatarsal (TMT) joint injury is approximately 1 in 60,000 [43]. Motor vehicle crashes account for almost half of TMT injuries [43]. In adults, many Lisfranc injuries are related to motor vehicle accidents, crush injuries, and falls from heights [55]. In children, the most common mechanism of injury is a fall from a height (56%), followed by a fall backward (22%) and heel-to-toe compression (18%) [55].

Injuries to the TMT joint are caused by indirect or direct forces [31]. Indirect forces involve axial loading or twisting on a plantarflexed foot [31]. Direct injury occurs when a load is applied to the midfoot [31]. The typical mechanism of injury involves abduction and direct axial impact to the forefoot while in an equinus position [42]. Three basic mechanisms of Lisfranc injury have been described: indirect injury with impact load in tiptoe position, direct compression injury with heel-to-toe compression, and injury from a fall backward with a fixed forefoot [55]. An indirect load causes hyper-plantar flexion and dorsal-to-plantar ligament disruption, and the bones surrounding the site of injury also may be fractured [43]. Plantar avulsion from the distal row and dorsal compression fracture of the proximal row are consistent with a direct force applied to the forefoot and direct dorsolaterally [63].

Ligamentous Lisfranc injury commonly occurs in athletes as an injury to the ligaments of the TMT joints that may extend to the intertarsal joints [31]. The spectrum of sprains in athletes ranges from a stable sprain without radiographic displacement to a severe sprain with obvious widening between the base of the first and second metatarsals or further into the midfoot [31]. Occurrence of a ligamentous Lisfranc injury is associated with a smaller ratio of second metatarsal length to foot length, with >50% of patients in the injury group having a ratio of <29% [16]. Predisposing factors for Lisfranc injury include a ratio of second metatarsal length to foot length of less than 29% and a greater second metatarsal length relative to the depth of the mortise formed by the cuneiforms [31].

Dislocation without a fracture is rare in Lisfranc injuries [38]. Weight-bearing radiographs usually show lateral displacement of the lesser metatarsals, often with dorsal displacement, in Lisfranc injuries [38]. The first metatarsal may dislocate in the same lateral direction (convergent or ipsilateral dislocation), or in the opposite medial direction (divergent) [38]. The anterior tibial tendon can become displaced and block manipulative reduction of tarsometatarsal dislocations, necessitating open reduction [67].

Patients presenting with a Lisfranc injury have substantial swelling throughout the foot, limited ability to weightbear, and may have plantar ecchymosis, which is pathognomonic for midfoot injury [42]. Ecchymosis on the plantar aspect of the midfoot implies trauma to the tarsometatarsal ligaments and an injury to that joint [28]. Plantar ecchymosis in the midfoot has been described as a sign indicating TMT injury [43]. A gross deformity may be visible with midfoot abduction and loss of the transverse arch in patients with Lisfranc injury [42]. Passive pronation and abduction will elicit increased pain in patients with Lisfranc injury [42]. Injury to the deep peroneal nerve and artery may occur in patients with Lisfranc injury [42]. Compartment syndrome of the foot may occur in high-energy cases of Lisfranc injury [42]. Crush injuries have a particularly strong relationship with foot compartment syndrome [43]. Subtalar dislocations can occur due to low- or high-energy injury mechanisms [20].

Column involvement is the most significant factor in considering the severity of Lisfranc injury and long-term functional outcomes, rather than sagittal displacement [6]. Flattening of the longitudinal arch is associated with a poor prognosis, while the extent of diastasis does not correlate with functional result [52]. Injuries of the midfoot have negative effects on mid- to long-term quality of life after trauma, with considerable potential for long-term impaired functionality [32]. The prognosis of an untreated Lisfranc fracture is generally poor [28]. Insufficient treatment of TMT injuries can lead to painful secondary deformity and impaired function [26]. Nonoperative treatment has been linked to an increased incidence of secondary displacement and inferior functional outcome [26]. Long-term symptomatic osteoarthritis develops in approximately half of patients with TMT injuries [43]. Risk factors for development of osteoarthritis after TMT injury are failure to achieve an anatomic reduction, divergent patterns of TMT incongruence, and a history of smoking [43].

Isolated pure ligamentous TMT instability is misdiagnosed in up to 20% of cases [26]. Nearly 25% of Lisfranc injuries are missed or occult on initial radiographs [38]. Lisfranc injuries are reportedly missed up to 20% of the time, which can result in posttraumatic arthritis, progressive deformity, and pain [42]. Up to a third of Lisfranc injury cases are missed or detected late [45]. Outcomes following Lisfranc injuries are often poor, with the literature revealing that greater than half of this cohort suffer complications [45]. Patient-reported functional scores following Lisfranc injuries are frequently unsatisfactory [45]. In children, deformity of the foot is rare because most injuries are not displaced at the time of injury or reduce spontaneously after injury [28].

Classification

Myerson-Hardcastle (Quenu and Kuss) Classification

The Myerson modification of the Quenu and Kuss classification divides Lisfranc injuries into Type A (total incongruity), Type B (partial incongruity), and Type C (divergent) [25]. Type A injuries, referred to as homolateral, involve displacement of all five metatarsals with or without fracture at the base of the second metatarsal [25]. In these injuries, the metatarsals move as a unit, with usual displacement being lateral or dorsolateral [25]. Type B injuries are characterized by one or more articulations remaining intact [25]. Specifically, Type B1 represents partial incongruity with medial dislocation, while Type B2 represents partial incongruity with lateral dislocation, which may involve the first metatarsal-cuneiform joint [25]. Type C injuries are divergent, with either partial (C1) or total (C2) displacement [25]. These injuries are generally high-energy, associated with significant swelling, and prone to complications, especially compartment syndrome [27]. In adults, the incidence of Type A, B, and C Lisfranc injuries is 17%, 72%, and 10%, respectively [44]. In children, Type A and C patterns are extremely rare, while the Type B pattern usually demonstrates minimal displacement [44].

This classification focuses on metatarsal position and displacement but does not consider the mechanism of injury [45]. It is not prognostic for the result of the injury [27] and does not help guide treatment decisions [33]. Reliability data vary; Talarico et al. found a moderate inter-rater reliability of 54% [33], whereas Mahmoud et al. found an intraobserver and interobserver reliability of 94% and 81%, respectively [33].

Nunley-Vertullo Classification

The Nunley-Vertullo classification grades Lisfranc ligament sprains in athletes based on clinical findings, weight-bearing radiographs, and bone scintigraphy [25]. It introduced the concept of stability, where undisplaced injuries with diastasis less than 2 mm are graded as stage I and treated nonoperatively [33]. Stage I injury is defined by pain only at the Lisfranc complex and increased uptake on bone scan, with negative radiographic findings [25]. Stage II injury is defined by diastasis between the first and second metatarsals of 1 to 5 mm greater than the contralateral side, without loss of midfoot arch height [25]. Alternatively, Stage II is defined by diastasis of 2 mm or greater at the Lisfranc joint (C1 to M2) but with no arch height loss [33]. Stage III injury is defined by diastasis greater than 5 mm and loss of midfoot arch height [25], or by both diastasis and arch height loss [33]. Both stage II and stage III injuries are considered unstable and are recommended for treatment [33].

Other Classification Systems

The Integral Classification of Injuries (ICI) is a logical, descriptive classification system for fractures and dislocations of the foot that precisely codes injuries to bones, joints, and ligaments using a structured alphanumeric system [49]. A 2026 study proposed a new classification system for Lisfranc injuries to address the limitations of existing systems that do not adequately assess soft tissue damage or quantify the extent of osseous disruption [45].

Clinical Presentation

Diagnostic Challenges and Predisposing Factors

Lisfranc injuries are notoriously difficult to diagnose, with approximately 20 to 24% of cases missed at initial evaluation [39]. Despite improvements in diagnostic techniques, missed or overlooked injuries remain common [26]. Injuries to the tarsometatarsal (TMT) joint are frequently misdiagnosed, necessitating a high index of suspicion [31]. Low-energy injuries are particularly challenging to detect due to a less traumatic history and less apparent clinical findings compared to high-energy mechanisms [39]. Insufficient treatment can lead to painful secondary deformity and impaired function [26]. The occurrence of ligamentous Lisfranc injury is associated with a smaller ratio of second metatarsal length to foot length, with >50% of patients in the injury group having a ratio of <29% [16].

Clinical Findings

Patients present with pain in the foot and dorsal swelling, which may be localized over the dorsum of the TMT joint [28]. In cases of significant trauma, the entire dorsum of the foot may be swollen, making localization of pain difficult [28]. Conversely, a mild injury with more focal swelling may allow palpation to identify pain over the TMT joint more clearly [28]. Typical clinical findings include a swollen midfoot, tenderness and pain in the midfoot during passive movements and weight-bearing, and plantar ecchymosis [39]. Pain on attempted weight bearing or persistent inability to bear weight despite a normal physical examination and radiographs should raise suspicion of a TMT injury [28]. Pain with weight bearing, if accompanied by local swelling and tenderness at the midfoot, is the first sign of a Lisfranc injury [31]. Even with a mild injury, the athlete has difficulty pushing off [31]. Pronation-abduction or supination-adduction stress is often painful [31]. Deformity of the foot is rare in children because most injuries are not displaced at the time of injury or reduce spontaneously [28].

Physical Examination and Red Flags

The physical examination should include evaluation of the dorsalis pedis pulse and deep peroneal nerve function [31]. Assessment for a foot compartment syndrome is required in severe Lisfranc fracture-dislocation [31]. Type C injuries are generally high-energy, associated with significant swelling, and prone to complications, especially compartment syndrome [27].

Radiographic Findings

Ten common radiographic findings are indicative of midfoot injury: * Diastasis of first and second metatarsal bones * First and second cuneiform diastasis * Widening between second and third metatarsals * Widening between middle and lateral cuneiforms * Avulsion fracture at the base of the second metatarsal (fleck sign) * Malalignment of tarsometatarsal joints on lateral images * Malalignment of second metatarsal medial border to align with medial border of middle cuneiform * Malalignment of fourth metatarsal medial border to align with medial edge of cuboid * Loss of congruity of metatarsal bases * Compression fracture of the lateral edge of the cuboid [31]

The 'fleck sign' in plain x-ray radiographs, an avulsion of intra-articular bone, is estimated to be detectable in 90% of cases where the dislocation between the first and second metatarsal is greater than 4 mm [39]. An extended space between the first and second toe seen in x-ray radiographs is known as the 'gap' sign [39]. False-negative findings on x-ray radiographs may result from weight-bearing not being tolerated due to pain [39]. Three-dimensional CT radiographic signs function as a valuable diagnostic tool for evaluation and initial screening in the acute injury phase [13]. MRI scanning provides imaging reference for diagnosis and repair of Lisfranc joint injuries [14].

Classification Systems

The Myerson and Hardcastle classification has a moderate inter-rater reliability of 54% according to one study, while another study found intraobserver and interobserver reliability of 94% and 81%, respectively [33]. This classification system is neither prognostic nor does it help guide treatment decisions [33]. The Nunley-Vertullo classification grades Lisfranc ligament sprains in athletes based on weightbearing radiographs and bone scintigrams [33]: * Stage I: Undisplaced injuries with diastasis < 2 mm, treated nonoperatively [33]. * Stage II: Diastasis ≥ 2 mm at the Lisfranc joint but no arch height loss; considered unstable [33]. * Stage III: Both a diastasis and arch height loss; considered unstable [33].

Other classifications describe injury patterns: * Type A: Displacement of all five metatarsals with or without fracture at the base of the second metatarsal, usually lateral or dorsolateral (homolateral) [25]. * Type B: One or more articulations remaining intact; Type B1 represents partial incongruity with medial dislocation, and Type B2 represents partial incongruity with lateral dislocation [25].

Outcomes and Complications

Failure to recognize and treat midtarsal injuries appropriately may lead to late midtarsal subluxation, posterior tibialis dysfunction, and the need for late arthrodesis [34]. Injuries of the midfoot, treated at a level 1 trauma center, have negative effects on mid- to long-term quality of life after trauma, with considerable potential for long-term impaired functionality [32]. Patients who undergo surgical repair for chronic, unstable Lisfranc injury without osteoarthritis have improved patient outcome and few post-surgical complications despite delay in diagnosis [4].

Investigations

Clinical Suspicion and Physical Findings

Lisfranc injuries are frequently difficult to diagnose and treat; if not detected and appropriately managed, they can cause long-term disability [1]. As many as 20% of these injuries are misdiagnosed or overlooked [28]. Plantar ecchymosis on the plantar aspect of the midfoot implies trauma to the tarsometatarsal ligaments and an injury to that joint [28]. This finding is pathognomonic for midfoot injury [42]. Pain on attempted weight bearing or persistent inability to bear weight despite a normal physical examination and radiographs should raise the physician’s suspicion of a tarsometatarsal injury [28]. The "LISFRANC JUT" is a physical finding associated with subtle Lisfranc injuries [24].

Radiographic Evaluation

Plain radiography: Diagnostic imaging of a suspected Lisfranc fracture-dislocation begins with AP weight-bearing radiographs as well as oblique and lateral views [31]. Weight-bearing views should be obtained if possible for TMT joint injuries [43]. A comparison AP view of the contralateral side is useful in subtle cases [42], and comparison with a weight-bearing AP radiograph of the uninjured foot is often helpful [31].

Normal osseous relationships on AP view include the lateral base of M1 aligned with the lateral margin of C1, and the medial margin of M2 base aligned with the medial margin of C2 [38]. On AP view, the medial border of the second metatarsal lines up with the medial aspect of the middle cuneiform and there is <2 mm between first and second metatarsal bases [42]. On oblique views, the medial and lateral margins of M3 base should align with those of C3, and the medial margin of M4 base should align with the medial margin of the cuboid [38]. On oblique view, the medial border of the fourth metatarsal lines up with the medial border of the cuboid [42]. On oblique views, the lateral margin of M5 base should not project more than 3 mm beyond the lateral border of the cuboid [38]. On lateral view, the dorsal cortex of the first metatarsal lines up with the medial cuneiform [42].

Ten common radiographic findings are indicative of midfoot injury, including diastasis of the first and second metatarsal bones, first and second cuneiform diastasis, widening between second and third metatarsals, widening between middle and lateral cuneiforms, avulsion fracture at the base of the second metatarsal (fleck sign), malalignment of tarsometatarsal joints on lateral images, malalignment of the second metatarsal medial border to align with the medial border of the middle cuneiform, malalignment of the fourth metatarsal medial border to align with the medial edge of the cuboid, loss of congruity of metatarsal bases, and compression fracture of the lateral edge of the cuboid [31]. An avulsion fracture at the base of the second metatarsal on CT or other advanced imaging (fleck sign) represents Lisfranc ligament avulsion [31]. Any fleck sign of avulsion fracture should lead to suspicion of TMT injury [43].

If routine radiographs are not diagnostic in a mild injury, stress radiographs taken with the patient under anesthesia may be helpful [31]. If true weight-bearing radiographs are not possible and advanced imaging is equivocal, there is a role for stress examination under anesthesia to evaluate midfoot stability in the setting of suspected Lisfranc injury [42].

Advanced Imaging (CT and MRI)

MRI: If a Lisfranc injury is suspected and plain radiographs are not diagnostic, CT or MRI is useful [31]. MRI is the most sensitive imaging modality for diagnosing Lisfranc injuries, delineating the presence of both osseous and soft-tissue involvement [38]. MRI is beneficial in more subtle cases to evaluate the status of the Lisfranc ligament and presence of occult fractures [42]. Following injury, the Lisfranc ligament may appear edematous and wavy in contour on MRI [38]. Frank disruption of the ligament fibers associated with avulsion fractures and osseous malalignment may be seen on MRI [38]. Smaller avulsion fractures are better demonstrated on CT and radiography than MRI because the fracture fragments may be obscured by marrow and soft-tissue edema [38].

CT: A CT scan is obtained to better assess the degree of displacement and articular involvement if other fractures are thought to be present [42]. Three novel findings on three-dimensional CT showed excellent sensitivity and specificity when compared to intraoperative findings, and they exhibited high inter- and intraobserver reliability [66].

Classification and Diagnostic Criteria

Other Considerations: The Myerson and Hardcastle classification has a moderate inter-rater reliability of 54% among clinicians [33]. The Myerson and Hardcastle classification has an intraobserver and interobserver reliability of 94% and 81%, respectively, according to Mahmoud et al. [33]. The Myerson and Hardcastle classification is neither prognostic nor does it help guide treatment decisions [33].

In the Nunley-Vertullo classification, stage II injuries have diastasis ≥ 2 mm at the Lisfranc joint (C1 to M2) but with no arch height loss [33]. In the Nunley-Vertullo classification, stage III injuries have both a diastasis and arch height loss [33]. Stage I athletic midfoot injury involves pain only at the Lisfranc complex and increased uptake on bone scan, with negative radiographic findings [25]. Stage II athletic midfoot injury exhibits diastasis between the first and second MTs of 1 to 5 mm greater than that of the contralateral side, without loss of midfoot arch height [25]. Stage III athletic midfoot injury is signified by diastasis >5 mm and loss of midfoot arch height [25].

Treatment

General Principles and Outcomes

The various treatment options for Lisfranc injuries yield favorable sport-specific outcomes, with 93% to 94% of athletes returning to any level of sports [15]. However, only 74% to 88% of athletes return to their preinjury level of sport [15]. Open reduction and internal fixation remains the standard treatment for tarsometatarsal joint injuries, although primary arthrodesis has emerged as a viable option for certain types of injuries [51].

Non-Operative

The provided evidence does not detail specific conservative management protocols such as weight loss, physical therapy, NSAIDs, or injections.

Operative

Indications: Primary ORIF is the preferred method of treatment when there is structural ligamentous instability or fracture–dislocation [26]. Primary arthrodesis may be indicated in true TMT dislocations because the long-term stability of these joints depends on ligamentous healing, which is less reliable than bony healing [29].

Surgical Approach / Technique: Surgical reconstruction can reestablish normal gait biomechanics, prevent secondary arthritis, and improve functional outcome [26]. Patients treated with stable anatomical reduction of Lisfranc fracture-dislocations have less arthritis as well as better AOFAS midfoot scores [18]. The use of K-wire fixation as a standalone method for the acute management of high-energy Lisfranc injuries is a simple and adequate technique that maintains reduction until definitive fixation without increasing the risk of complications [23].

Implant Selection: Flexible fixation use in the treatment of ligamentous Lisfranc injury was found to have significant potential as a fixation option, as demonstrated by excellent clinical results [11]. A novel, low-cost, and simple technique for flexible fixation of ligamentous Lisfranc injuries provides stable anatomic reduction in a joint-sparing fashion while allowing some degree of mobility and eliminating the need for implant removal [21].

Other Considerations: Patients who undergo surgical repair for chronic, unstable Lisfranc injury without osteoarthritis have improved patient outcome and few post-surgical complications [4]. Although the treatment results in pediatric foot trauma are generally good, potential pitfalls in the treatment of Lisfranc fractures must be anticipated and avoided if possible [17].

Complications

Missed Diagnosis: Undetected Lisfranc injuries lead to long-term disability [1]. Radiographic identification remains challenging, with a high incidence of missed injuries even among experienced observers [5].

Chronic Pain and Deformity: Untreated injuries or inadequate fixation, including premature hardware removal, result in an abducted, flattened foot with pain over the tarsometatarsal joints [62]. In cases of severe deformity, pain localizes along the plantar midfoot over bony prominences [62].

Persistent Pain and Arthritis: Some patients experience persistent pain despite anatomic reduction [62]. This pain in the setting of midfoot arthritis may stem from fibrosis or arthritic changes secondary to cartilage injury sustained during the initial trauma [62].

Prognostic Factors: Flattening of the longitudinal arch is associated with a poor prognosis [52]. Conversely, the extent of diastasis does not correlate with functional result [52].

Recovery

General Outcomes and Quality of Life: Undetected or inappropriately managed Lisfranc injuries can cause long-term disability [1]. Midfoot injuries treated at a level 1 trauma center have negative effects on mid- to long-term quality of life with considerable potential for long-term impaired functionality [32]. Failure to recognize and treat midtarsal joint injuries appropriately may lead to late midtarsal subluxation, posterior tibialis dysfunction, and the need for late arthrodesis [34].

Return to Sport: 93% to 94% of athletes return to any level of sports after treatment for Lisfranc injuries [15]. 74% to 88% of athletes return to their preinjury level of sport after treatment for Lisfranc injuries [15]. The return-to-play rate for NFL athletes sustaining Lisfranc injuries was 81.8% [50].

Chronic and Delayed Treatment: Patients who undergo surgical repair for chronic, unstable Lisfranc injury without osteoarthritis have improved patient outcome and few post-surgical complications despite delayed diagnosis [4].

Key Evidence

  • [L4] Lisfranc injuries encompass a broad spectrum of injuries that are often difficult to diagnose and treat; if not detected and appropriately managed, they can cause long-term disability. [1] (10.1016/j.injury.2014.11.026)
  • [L5] A high index of suspicion is critical to adequately recognize subtle Lisfranc complex injuries. [2] (10.1016/j.csm.2015.06.006)
  • [L4] The radiographic diagnostic criteria of Lisfranc injuries were heterogeneous. [3] (10.1186/s12891-023-07043-z)
  • [L4] Despite the delay in diagnosis, patients who undergo surgical repair for chronic, unstable Lisfranc injury without osteoarthritis have improved patient outcome and few post-surgical complications. [4] (10.1016/j.injury.2020.04.005)
  • [L4] Our results confirm a high incidence of missed Lisfranc injuries on radiographs even by experienced observers. [5] (10.1016/j.injury.2006.10.002)
  • [L3] Column involvement and not sagittal displacement is the most significant factor in considering the severity of Lisfranc injury and long term functional outcomes. [6] (10.1016/j.injury.2017.03.046)
  • [L4] Nonoperative treatment has a role in the treatment of Lisfranc injuries, and the results of our study support the view that avulsion and simple intra-articular fractures with < 2 mm of displacement can be treated nonoperatively with high functional outcomes. [7] (10.1007/s00402-020-03599-w)
  • [L4] Undisplaced Lisfranc injuries have excellent outcomes with non-operative treatment, whereas displaced injuries have worse outcomes and require anatomical reduction and internal fixation for the best outcome. [8] (10.1007/s00167-013-2491-2)
  • [L4] Our mean outcome from ORIF of Lisfranc joint injuries is comparable to internationally quoted figures. [9] (10.1016/j.injury.2005.12.003)
  • [L3] Primary arthrodesis for the management of acute Lisfranc injuries is both significantly more expensive and has a higher complication rate than open reduction internal fixation. [10] (10.1016/j.injury.2018.10.002)
  • [L4] Flexible fixation use in the treatment of ligamentous Lisfranc injury was found to have significant potential as a fixation option, as demonstrated by excellent clinical results. [11] (10.1177/23259671231186387)
  • [L4] Restoration and maintenance of the anatomic alignment of the Lisfranc joint is the key to appropriate treatment of injury to the midfoot. [12] (10.1177/03635465020300061901)
  • [L3] Three-dimensional CT radiographic signs could function as a valuable diagnostic tool for the evaluation and initial screening for Lisfranc injury in the acute injury phase. [13] (10.1097/corr.0000000000002657)
  • [L4] This study provides imaging reference for MRI scanning, diagnosis, and repair of Lisfranc joint injuries. [14] (10.1186/s13018-018-0968-x)
  • [L1] The different treatment options for Lisfranc injuries allow for good sport-specific outcomes with 93% to 94% of athletes returning to any level of sports, and 74% to 88% of athletes returning to their preinjury level of sport. [15] (10.1136/jisakos-2020-000477)
  • [L3] Occurrence of a ligamentous Lisfranc injury was shown to be associated with a smaller ratio of second metatarsal length to foot length; >50% of patients in the injury group had a ratio of <29%. [16] (10.2106/jbjs.k.01142)
  • [L5] Although the treatment results in pediatric foot trauma are generally good, potential pitfalls in the treatment of Lisfranc fractures, talar neck and body fractures, and lawn mower injuries to the foot must be anticipated and avoided if possible. [17] (10.5435/00124635-200109000-00004)
  • [L3] Stable anatomical reduction of fracture-dislocations of the Lisfranc joint leads to the best long-term outcomes as patients so treated have less arthritis as well as better AOFAS midfoot scores. [18] (10.2106/00004623-200011000-00015)
  • [L1] A primary stable arthrodesis of the medial two or three rays appears to have a better short and medium-term outcome than open reduction and internal fixation of ligamentous Lisfranc joint injuries. [19] (10.2106/jbjs.f.01004)
  • [L4] Subtalar dislocations can occur due to low- or high-energy injury mechanisms. [20] (10.5435/jaaosglobal-d-21-00295)
  • [L5] The authors describe a novel, low-cost, and simple technique for flexible fixation of ligamentous Lisfranc injuries that provides stable anatomic reduction in a joint-sparing fashion while allowing some degree of mobility and eliminating the need for implant removal. [21] (10.1016/j.injury.2019.07.024)
  • [Paper] The use of InternalBrace for ligamentous Lisfranc injuries appears to provide a biomechanically viable alternative for withstanding early postoperative protected weight bearing. [22] (10.1016/j.injury.2021.02.077)
  • [L4] The use of K-wire fixation as a standalone method for the acute management of high-energy Lisfranc injuries is a simple and adequate technique that maintains reduction until definitive fixation without increasing the risk of complications. [23] (10.1016/j.injury.2017.11.012)
  • [L4] [24] (10.1016/j.injury.2020.12.026)
  • [L5] [25] (10.5435/00124635-201012000-00002)
  • [L4] Injuries of the midfoot, treated at a level 1 trauma center, have negative effects on mid- to long-term quality of life after trauma, with considerable potential for long-term impaired functionality. [32] (10.1016/j.injury.2018.09.021)
  • [L4] [33] (10.1302/0301-620x.106b12.bjj-2024-0581.r1)
  • [L5] Failure to recognize and treat these injuries appropriately may lead to late midtarsal subluxation, posterior tibialis dysfunction, and the need for late arthrodesis. [34] (10.5435/00124635-199807000-00006)
  • [L2] [39] (10.1186/s12891-018-2222-4)
  • [L4] [45] (10.1016/j.injury.2026.113422)
  • [L5] The Integral Classification of Injuries (ICI) is a logical, descriptive classification system for fractures and dislocations of the foot that precisely codes injuries to bones, joints, and ligaments using a structured alphanumeric system. [49] (10.1016/j.injury.2004.07.008)
  • [L4] The return-to-play rate for NFL athletes sustaining Lisfranc injuries was 81.8%, which did not support the hypothesis of a low rate. [50] (10.1177/23259671231159935)
  • [L5] Open reduction and internal fixation remains the standard treatment for tarsometatarsal joint injuries, although primary arthrodesis has emerged as a viable option for certain types of injuries. [51] (10.5435/jaaos-d-15-00556)
  • [L4] Flattening of the longitudinal arch is associated with a poor prognosis, while the extent of diastasis does not correlate with functional result. [52] (10.2106/00004623-199173100-00022)
  • [L5] [62] (10.5435/00124635-200409000-00007)
  • [L4] Plantar avulsion from the distal row and dorsal compression fracture of the proximal row are consistent with a direct force applied to the forefoot and direct dorsolaterally. [63] (10.1016/j.injury.2019.01.038)
  • [L5] The article identifies three novel findings on three-dimensional CT that showed excellent sensitivity and specificity when compared to intraoperative findings, and they exhibited high inter- and intraobserver reliability as well. [66] (10.1097/corr.0000000000002727)

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