Practice Easily Missed?

Lisfranc injuries

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f4561 (Published 23 July 2013) Cite this as: BMJ 2013;347:f4561
  1. Michael P Wright, resident in orthopaedic surgery,
  2. James D Michelson, attending orthopaedic surgeon
  1. 1Department of Orthopaedics and Rehabilitation, University of Vermont School of Medicine, Stafford 418A, 95 Carrigan Drive, Burlington, VT 05401, USA
  1. Correspondence to: J D Michelson james.michelson{at}uvm.edu
  • Accepted 24 June 2013

A 38 year old office manager presented to the emergency department with pain in her right foot one day after tripping while jogging. She had difficulty bearing full weight, with pain and swelling over the dorsal foot, and tenderness over the dorsal first and second tarsometatarsal joints. Non-weight bearing radiographs of the right foot were read as normal (fig 1, left). A midfoot sprain was diagnosed and the patient was instructed to return for follow-up in two weeks. Her symptoms persisted and weight bearing radiographs were obtained (fig 1, middle). No abnormalities were noted, and she was referred to an orthopaedic surgeon, who did not think the radiographs were true anteroposterior views of the midfoot and so had them repeated. The new radiographs (fig 1, right) showed subtle widening of the medial midtarsal and intermetatarsal space, indicative of a Lisfranc injury. She had surgical reduction and internal fixation of her first and second tarsometatarsal.

Fig 1 Radiographs showing the importance of obtaining the correct positioning to detect a subtle disruption of the Lisfranc joint. The white arrow indicates the medial base of the second metatarsal, the black arrow the proximal medial corner of the intermediate cuneiform, and the small grey arrows where the second tarsometatarsal joint line should be seen. Left: Anteroposterior radiograph of non-weight bearing right foot shows normal anatomical midfoot alignment in a patient with a Lisfranc injury. Note that the second tarsometatarsal joint line is not visible, indicating that the …

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