Tarsometatarsal (Lisfranc) joint complex injuries
- Anthony Beutler, MD
Anthony Beutler, MD
- 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
- Section Editors
- Patrice Eiff, MD
Patrice Eiff, MD
- Section Editor — Adult Orthopedics; Sports-Related Injuries
- Professor of Family Medicine
- Oregon Health & Science University
- Chad A Asplund, MD, FACSM, MPH
Chad A Asplund, MD, FACSM, MPH
- Associate Professor of Health and Kinesiology
- Director of Athletic Medicine
- Head Team Physician
- Georgia Southern University
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
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 "Stress fractures of the tarsal (foot) navicular" 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 .To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Lisfranc J. Nouvelle méthode opératoire pour l'amputation partielle du pied dans son articulation tarso-métatarsienne. Paris: L’imprimerie de Feuguery; 1815:1.
- Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury 2006; 37:691.
- Trevino SG, Kodros S. Controversies in tarsometatarsal injuries. Orthop Clin North Am 1995; 26:229.
- Komenda GA, Myerson MS, Biddinger KR. Results of arthrodesis of the tarsometatarsal joints after traumatic injury. J Bone Joint Surg Am 1996; 78:1665.
- Goossens M, De Stoop N. Lisfranc's fracture-dislocations: etiology, radiology, and results of treatment. A review of 20 cases. Clin Orthop Relat Res 1983; :154.
- Solan MC, Moorman CT 3rd, Miyamoto RG, et al. Ligamentous restraints of the second tarsometatarsal joint: a biomechanical evaluation. Foot Ankle Int 2001; 22:637.
- Kura H, Luo ZP, Kitaoka HB, et al. Mechanical behavior of the Lisfranc and dorsal cuneometatarsal ligaments: in vitro biomechanical study. J Orthop Trauma 2001; 15:107.
- Nunley JA, Vertullo CJ. Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med 2002; 30:871.
- Lattermann C, Goldstein JL, Wukich DK, et al. Practical management of Lisfranc injuries in athletes. Clin J Sport Med 2007; 17:311.
- Shapiro MS, Wascher DC, Finerman GA. Rupture of Lisfranc's ligament in athletes. Am J Sports Med 1994; 22:687.
- Ross G, Cronin R, Hauzenblas J, Juliano P. Plantar ecchymosis sign: a clinical aid to diagnosis of occult Lisfranc tarsometatarsal injuries. J Orthop Trauma 1996; 10:119.
- Curtis MJ, Myerson M, Szura B. Tarsometatarsal joint injuries in the athlete. Am J Sports Med 1993; 21:497.
- Arntz CT, Hansen ST Jr. Dislocations and fracture dislocations of the tarsometatarsal joints. Orthop Clin North Am 1987; 18:105.
- Kuo RS, Tejwani NC, Digiovanni CW, et al. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am 2000; 82-A:1609.
- Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle 1986; 6:225.
- Raikin SM, Elias I, Dheer S, et al. Prediction of midfoot instability in the subtle Lisfranc injury. Comparison of magnetic resonance imaging with intraoperative findings. J Bone Joint Surg Am 2009; 91:892.
- Kalia V, Fishman EK, Carrino JA, Fayad LM. Epidemiology, imaging, and treatment of Lisfranc fracture-dislocations revisited. Skeletal Radiol 2012; 41:129.
- Haapamaki VV, Kiuru MJ, Koskinen SK. Ankle and foot injuries: analysis of MDCT findings. AJR Am J Roentgenol 2004; 183:615.
- Preidler KW, Peicha G, Lajtai G, et al. Conventional radiography, CT, and MR imaging in patients with hyperflexion injuries of the foot: diagnostic accuracy in the detection of bony and ligamentous changes. AJR Am J Roentgenol 1999; 173:1673.
- Hatem SF. Imaging of lisfranc injury and midfoot sprain. Radiol Clin North Am 2008; 46:1045.
- Libby B, Ersoy H, Pomeranz SJ. Imaging of the Lisfranc injury. J Surg Orthop Adv 2015; 24:79.
- Coss HS, Manos RE, Buoncristiani A, Mills WJ. Abduction stress and AP weightbearing radiography of purely ligamentous injury in the tarsometatarsal joint. Foot Ankle Int 1998; 19:537.
- Myerson MS. The diagnosis and treatment of injury to the tarsometatarsal joint complex. J Bone Joint Surg Br 1999; 81:756.
- 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