Tarsometatarsal (Lisfranc) joint complex injuries
- Anthony Beutler, MD
Anthony Beutler, MD
- Associate Professor of Family Medicine
- Uniformed Services University
- Cole Taylor, MD
Cole Taylor, MD
- Assistant Professor of Family Medicine
- Uniformed Services University of the Health Sciences
Injuries to the tarsometatarsal (TMT) joint complex, commonly referred to as the "Lisfranc joint," are not common, but they are frequently missed and often lead to osteoarthritis and long-term disability. The risk of such adverse outcomes increases substantially when TMT joint complex injuries are diagnosed late and managed improperly. The Lisfranc joint is named for Jacques L Lisfranc, a French gynecologist and Napoleonic surgeon. Lisfranc described an amputation through the TMT joint line in a soldier who had suffered a midfoot injury during a fall from his horse .
The presentation, diagnosis, and management of TMT joint complex injuries is reviewed here. Other common foot injuries and fractures are discussed separately. (See "Evaluation and diagnosis of common causes of foot pain in adults" and "Metatarsal shaft fractures" and "Proximal fifth metatarsal fractures" and "Navicular stress fractures of the foot" and "Cuboid and cuneiform fractures".)
Acute injuries to the tarsometatarsal (TMT) joint complex comprise approximately 0.1 to 0.4 percent of all fractures and dislocations . Unfortunately, nearly 20 percent of these injuries are missed or misdiagnosed on initial assessment . TMT joint complex injuries can occur from direct or indirect trauma that may occur in the setting of a motor vehicle collision, fall from a height, or field sports, such as American football.
An understanding of midfoot anatomy is required for the assessment of tarsometatarsal (TMT) joint complex injuries and for determining which injuries require surgical referral. Osseous components of the TMT joint complex include the five metatarsals, the three cuneiforms, and the cuboid (figure 1 and figure 2). The bases of the first (associated with great toe) through third (associated with middle toe) metatarsals and their articulations with the cuneiform bones form the transverse (or "Roman") arch (figure 3) [4,5]. Within this arch, the second metatarsal acts as a keystone, forming articulations with the other five bones. If there is displacement between the second metatarsal and the middle cuneiform, associated displacement of the third through fifth metatarsals is often present as well.
The Lisfranc ligament, also referred to as the oblique interosseus ligament, is the strongest supporting structure of the TMT joint complex . It connects the medial border of the base of the second metatarsal with the lateral aspect of the medial cuneiform (figure 4). Further strengthening this connection are plantar and dorsal ligaments that also run from the medial cuneiform to the second metatarsal (figure 5 and figure 6 and figure 7). Of these three oblique ligaments, the Lisfranc ligament is the strongest, capable of withstanding approximately twice the loads of the dorsal ligament .
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- CLINICAL ANATOMY
- MECHANISM OF INJURY
- HISTORY AND EXAMINATION FINDINGS
- DIAGNOSTIC IMAGING
- CLASSIFICATION OF INJURY
- INDICATIONS FOR SURGICAL REFERRAL
- DIFFERENTIAL DIAGNOSIS
- Acute treatment
- Soft tissue injuries without dislocation
- Bony injury
- Return to sport
- SUMMARY AND RECOMMENDATIONS