Endgames Case review

A painful foot: Lisfranc fracture-dislocations

BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i882 (Published 07 March 2016) Cite this as: BMJ 2016;352:i882
  1. Matthew Welck, consultant orthopaedic surgeon1,
  2. Ruslan Zinchenko, foundation year 2 doctor2,
  3. Francois Tudor, consultant orthopaedic surgeon3
  1. 1West Herts NHS Trust, Watford WD18 0HB, UK
  2. 2St George’s Hospital, London, UK
  3. 3Gold Coast University Hospital, Southport, Qld, Australia
  1. Correspondence to: M Welck matthewwelck{at}doctors.org.uk

A fit and well 25 year old man presented to the emergency department with a painful left foot after being tackled while playing football. His left foot had been in plantar flexion when he was tackled just as he was about to kick the ball.

He could not continue playing but could bear weight straight away. His teammates brought him to the emergency department after the match because of increasing pain. A detailed clinical examination showed marked swelling over the dorsum of the left foot, tenderness in the dorsomedial midfoot, and plantar ecchymosis. Weight bearing anteroposterior, internal oblique (figs 1 and 2), and lateral radiographs of the left foot showed a Lisfranc fracture-dislocation of the second tarsometatarsal joint.

Fig 1 Weight bearing anteroposterior radiograph of both feet showing injury to the left foot—subtle diastasis between the metatarsal base and the medial cuneiform (white line) and malalignment of the medial border of the second metatarsal base with the medial border of the middle cuneiform (black lines)

Fig 2 Weight bearing oblique radiograph of the left foot showing a more obvious opening between the second metatarsal base and the medial cuneiform (white lines) and an avulsion fracture from the medial border of the first metatarsal base (arrow)

Questions

  1. What is the anatomy of the Lisfranc joint?

  2. How do acute and chronic Lisfranc injuries usually present?

  3. How do you investigate Lisfranc injuries?

  4. How do you manage Lisfranc injuries?

Answers

1. What is the anatomy of the Lisfranc joint?

Short answer

The Lisfranc (tarsometatarsal) joints are formed by the five metatarsal bones distally and the cuboid bone and three cuneiform bones proximally. The Lisfranc ligament attaches the medial cuneiform bone to the base of the second metatarsal.

Discussion

The Lisfranc joint is considered to be S shaped and is made up of three columns. The medial cuneiform bone and the first metatarsal make up the medial column. …

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