Courtesy Dr Pradeep Moonot, Dr Ashok Shyam, Ortho TV

Case Example

A 30 year old female sustained a minor fall from stairs.

Initial diagnosis:

• Midfoot sprain
• Fracture of the base of the fifth metatarsal

Treatment:

• Cast immobilization for 6 weeks

Outcome:

• Persistent pain and deformity
• Re-presented after 3 months

Final diagnosis:

• Missed Lisfranc injury

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Why Are Lisfranc Injuries Missed?

Approximately 20 to 40% of Lisfranc injuries are initially missed.

They are commonly mistaken for:

• Midfoot sprain
• Minor foot injury

Reasons for Missed Diagnosis

• Subtle radiographic findings
• Polytrauma patients
• Delayed presentation
• Misinterpretation of imaging
• Failure to obtain weight bearing radiographs

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Importance of the Lisfranc Joint

The Lisfranc joint complex connects:

• Metatarsal bases
• Cuneiforms
• Cuboid

Consequences of Missed Injury

Untreated Lisfranc injuries may result in:

• Chronic midfoot pain
• Progressive deformity
• Loss of foot function
• Post traumatic arthritis
• Difficulty walking and weight bearing

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Factors Influencing Treatment

Management depends on:

• Degree of deformity
• Number of joints involved
• Soft tissue damage
• Cartilage injury
• Ligament disruption
• Presence of arthritis
• Functional demands of the patient

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Treatment Options

1. Conservative Management

Indications

• Minimal displacement
• Low energy injury
• Low demand patients

Limitations

• Painful malunion
• Progressive deformity
• Functional impairment

Conservative treatment is generally reserved for carefully selected cases.

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2. Open Reduction and Internal Fixation (ORIF)

Challenges in Delayed Cases

When presentation occurs more than 6 weeks after injury:

• Reduction becomes difficult
• Extensive soft tissue dissection may be required
• Cartilage damage may already exist
• Osteopenia may compromise fixation

Evidence

Several studies demonstrate that good outcomes can still be achieved even months after injury if an anatomical reduction is obtained.

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3. Arthrodesis (Fusion)

Indications

• Severe cartilage damage
• Post traumatic arthritis
• High energy injuries
• Severe instability
• Failed previous treatment

Advantages

• Eliminates painful arthritic joints
• Provides durable stability

Disadvantages

• Loss of normal joint motion
• Increased stress on adjacent joints
• Potential secondary arthritis

Motion Considerations

Medial Column

• First TMT joint normally has approximately 4 to 6 degrees of motion
• Motion contributes to normal gait

Lateral Column

• Requires greater mobility
• Fusion may lead to stiffness and altered foot mechanics

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4. Biological Reconstruction (Ligament Reconstruction)

Principle

Reconstruction of the Lisfranc ligament using tendon grafts such as:

• Gracilis tendon

Indications

• Predominantly ligamentous instability
• Preserved articular cartilage
• Delayed presentation without advanced arthritis

Reported Outcomes

Studies have shown:

• Reduced pain
• Good functional recovery
• Return to sports
• Good outcomes despite delayed surgery

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Surgical Example

Findings

• Subtle widening between first and second metatarsals
• Subluxation of the second tarsometatarsal joint

Procedure

• Anatomical reduction
• Medial plate fixation
• Dorsal plate stabilization

Outcome

6 Months

• Stable reduction maintained

1.5 Years

• Alignment preserved
• Pain free foot
• High patient satisfaction

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Outcomes of Missed Lisfranc Injuries

Even after treatment:

• Approximately two thirds of patients achieve good results
• One third continue to experience symptoms

This highlights the importance of early diagnosis.

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Management Algorithm for Delayed Lisfranc Injury (> 6 Weeks)

Conservative Treatment

Suitable for:

• Low demand patients
• Minimal displacement
• Stable deformity

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ORIF ± Ligament Reconstruction

Best suited for:

• Low energy injuries
• Medial column involvement
• Preserved cartilage
• No significant arthritis
• Predominantly ligamentous instability

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Arthrodesis

Preferred when:

• High energy trauma
• Severe deformity
• Advanced cartilage damage
• Established arthritis
• Chronic painful instability

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Key Clinical Message

• Lisfranc injuries are missed in 20 to 40% of cases.
• Weight bearing radiographs are essential when Lisfranc injury is suspected.
• Delayed diagnosis significantly increases treatment complexity.
• Anatomical reduction remains the most important determinant of outcome.
• Early diagnosis provides the best chance of restoring normal foot function.

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Exam Pearls

• Lisfranc injury involves the tarsometatarsal joint complex.
• Up to 40% are initially missed.
• Plantar ecchymosis is an important clinical sign.
• Weight bearing radiographs should be obtained whenever possible.
• Untreated injuries lead to chronic pain, deformity, and arthritis.
• Delayed injuries may require ORIF, ligament reconstruction, or arthrodesis.
• Anatomical reduction is the strongest predictor of a successful outcome.