Lisfranc Fracture

A Lisfranc injury affects the midfoot joints where the long metatarsal bones meet the tarsal bones that form the arch. It can involve ligaments, fractures, or both. Prompt diagnosis matters because missed or unstable injuries can lead to midfoot collapse and arthritis. Stable, undisplaced injuries may be treated in a cast; displaced or unstable injuries usually need surgery.

Lisfranc injuries range from ligament sprain to displaced fracture-dislocation, classically from an axial load through a plantarflexed foot. They can follow high-energy trauma such as a road traffic collision or a fall from height, and also lower-energy sports or twisting injuries.

What are the symptoms?

• Pain and swelling across the midfoot
• Difficulty or inability to put weight on the foot
• Bruising on the sole of the foot (plantar ecchymosis), which is almost pathognomonic
• Tenderness over the tarsometatarsal joints
• In severe cases, visible deformity

How is it diagnosed?

Diagnosis starts with clinical suspicion after a midfoot injury. Weight-bearing X-rays (AP, oblique and lateral) look for disruption of the alignment between the second metatarsal and the middle cuneiform, widening between the first and second metatarsals, a bony fleck, or dorsal displacement. Comparative weight-bearing X-rays of both feet at 10–14 days may help identify subtle instability. CT is useful for subtle injuries and surgical planning; MRI can help when the injury is purely ligamentous.

Non-surgical treatment

Non-operative care is appropriate for stable, undisplaced injuries (and some low-demand or high-risk patients): a non-weight-bearing cast for 6 weeks, with weight-bearing radiographs repeated at 2 to 3 weeks to exclude subtle instability, then a walker boot for another 4–6 weeks, weight-bearing as tolerated. Mr Hester's live page describes non-surgical care for stable, non-displaced injuries as non-weight-bearing in a cast for six weeks, then a walking boot with gradual return to activity, plus arch support or orthotics.

When is surgery needed?

Most displaced or unstable Lisfranc injuries need surgery. Unstable injuries are mostly treated surgically, and outcomes are strongly associated with the accuracy of reduction. Options include:

• Open reduction and internal fixation (ORIF) with screws and/or plates
• Primary fusion (arthrodesis) when joint surfaces are badly damaged, or in some delayed presentations

Screws may later be removed or left in place, depending on the case. Mr Hester's live page notes that a lifelong medial arch support is often required to protect the midfoot long-term.

Risks of surgery

Risks discussed on the live page include pain, bleeding, infection, scarring, nerve or blood vessel injury, deep vein thrombosis, pulmonary embolism, stiffness, non-union, malunion, and the need for further surgery such as metalwork removal. Post-traumatic osteoarthritis developed in 80% (8/10) of patients with non-anatomic reduction after Lisfranc ORIF in one series, versus 35% after anatomic reduction (Madadi & Adib, Research in Medicine 2007;31(1):13–17). In a long-term series, symptomatic osteoarthritis was reported in 54.1% of patients at a mean of about 11 years after surgical treatment of Lisfranc (tarsometatarsal) injuries (ORIF or primary arthrodesis) (Dubois-Ferrière et al., JBJS Am 2016, PMID 27147683). Deep infection is an uncommon but recognised risk after Lisfranc surgery.

What is recovery like after surgery?

This is the typical pathway on Mr Hester's live Lisfranc page; the exact plan depends on the injury and fixation and is confirmed at each review.

• Weeks 0–2: temporary cast; strictly non-weight-bearing; elevate with toes above the level of the nose, ideally for 55 minutes out of every hour
• At 2 weeks: cast changed to a boot if possible for soft-tissue care; otherwise a further cast to week 6
• At 6 weeks: cast removed; short surgical boot or Vacoped boot depending on the surgery
• Physiotherapy: starts once the limb is accessible (2 or 6 weeks)
• Exercise: core and upper-body work from as early as week 2 (nothing through the injured limb); cross-trainer, static bike and swimming from 6 weeks; running and jumping normally from about 12 weeks, depending on the fracture
• Longer term: improvement can take up to 18 months; swelling often lasts 9 to 12 months, and some swelling often persists lifelong

How Mr Hester can help

Mr Hester is a dual fellowship-trained foot and ankle surgeon (FRCS Tr&Orth) and Consultant at King's College Hospital Major Trauma Centre. He sees patients privately at The London Clinic, Cromwell Hospital, King Edward VII's Hospital and HCA The Shard. His NHS practice is at King's College Hospital.

Insured patients need a GP referral and an authorisation code from their insurer. Self-pay patients are welcome. To book, call 020 7046 8004.

Frequently Asked Questions

Sources

1. Lis Franc injury. Royal Free London NHS Foundation Trust. https://www.royalfree.nhs.uk/patients-and-visitors/patient-information-leaflets/lis-franc-injury
2. Lis Franc Injury (Virtual Fracture Clinic leaflet). Whittington Health NHS Trust. https://www.whittington.nhs.uk/document.ashx?id=14983
3. Carter TH, Heinz N, Duckworth AD, White TO, Amin AK. Management of Lisfranc Injuries: A Critical Analysis Review. JBJS Reviews. 2023. PMID: 37014938. https://pubmed.ncbi.nlm.nih.gov/37014938/
4. Madadi F, Adib F. Osteoarthritis after open reduction and internal fixation of lisfranc fracture. Research in Medicine. 2007;31(1):13–17. https://pejouhesh.sbmu.ac.ir/article-1-348-en.html (not indexed on PubMed).
5. Dubois-Ferrière V, Lübbeke A, Chowdhary A, Stern R, Dominguez D, Assal M. Clinical Outcomes and Development of Symptomatic Osteoarthritis 2 to 24 Years After Surgical Treatment of Tarsometatarsal Joint Complex Injuries. J Bone Joint Surg Am. 2016;98(9):713–20. PMID: 27147683. https://pubmed.ncbi.nlm.nih.gov/27147683/