Lisfranc injuries

Anatomy

Your foot’s bones are divided into three parts: the hindfoot, midfoot, and forefoot. The midfoot is critical in stabilizing your arch and in walking (your gait). During walking, the midfoot transfers the calf muscles’ forces to the front of the foot. The midfoot joint complex is also called the Lisfranc joint. The joint complex has a specialized bony and ligamentous structure, providing stability to this joint.

This type of injury typically describes some type of adverse event occurring in the foot’s middle region. This part of the foot contains many bones and soft tissues like ligaments, which connect bones.

Specifically, the mid-foot region is made up of several small bones forming a cluster that comprises an arch. This cluster of bones then extends downward to form the toe bones, also known as the metatarsals. The metatarsals are held in place by ligaments stretching both down and across the foot’s mid-region.

Besides the before mentioned components is a structure known as the Lisfranc joint complex. This is a collection of soft tissues connecting the foot’s middle and fore regions.

About

Lisfranc (midfoot) injuries result if bones in the midfoot are broken, or if the ligaments that support the midfoot are torn. The severity of the damage can vary from simple to complex and may involve many joints and bones in the mid-foot.

The mid-foot is affected if the bones are broken (fractured) or the ligaments are torn (ruptured). Injuries can vary, from a simple injury that affects only a single joint to a complex injury that disrupts many different joints and includes multiple fractures.

This injury can happen from a low-energy injury such as a simple twist and fall. They can also be caused by a more severe injury such as a fall from a height. In some cases, turning or twisting your foot in the wrong direction can result in simple strains or fractures. Trauma, such as that occurs in events like automobile accidents, falls, or large or heavy objects that are dropped on your foot, usually results in more complicated cases.

A Lisfranc injury is usually mistaken for a sprain, especially if the injury is a result of a straightforward twist and fall. Injury to the joint is a severe injury that may take many months to heal and need surgery to treat.

Symptoms

The most common symptoms of a Lisfranc injury are:

• Noticeable swelling, especially atop the foot
• Pain when the mid-foot region is touched
• Bruising on both the top and bottom of the foot – bruising on the bottom of the foot is highly suggestive
• Pain that worsens when you stand, walk, place any pressure, or attempt to push off on the affected foot
• Pain that can be so severe that crutches may be required
• Continual pain that does not let up with rest

In the most severe cases, standing or walking may be impossible without supportive aids like crutches or walking (support) boots.

Potential complications

Failing to diagnose and treat a Lisfranc injury can result in several complications. The most common issue is added stress on other foot components. Such pressure could ultimately lead to these structures becoming injured, leading to further pain and disability.

Diagnosis

Lisfranc injuries are often difficult to diagnose because they mimic several other common physical injuries. A firm diagnosis will be made only after a careful and thorough examination.

Your Florida Orthopaedic Institute physician will look at your symptoms, medical history, and overall medical health, followed by a physical examination. Although some of the physical tests the doctor will perform may be painful, none will make the injury worse.

First, your orthopedic specialist will ask if you recently participated in any sports or were involved in any type of accident. If your physician believes there is damage to the joint complex or foot’s midsection is the issue in question, they might perform one of several of the following tests:

• Heel grasping – Your doctor grasps your heel and gently twists your foot’s frontal region. If this action causes pain in the foot’s middle section, Lisfranc problems might be the cause.
• The piano key test – During this exam, your physician moves your toes up and down. This procedure usually produces discomfort in the mid-foot when this type of injury is present.
• Tiptoes examination – Your doctor will have you stand on one leg, on your tiptoes. An uncomplicated injury may produce pain under such conditions.

Your physician may also choose to order imaging tests to confirm your diagnosis and rule out other possible causes. These tests include:

• X-rays – Broken bones (fractures) and the bones’ position can be seen in an x-ray and show the alignment of the Lisfranc joint. Any change in the joint from normal may suggest injury to the ligaments.
• Computerized tomography (CT) scans – These scans are more detailed than x-rays and can create cross-section images of the foot. This test is not required to diagnose a Lisfranc injury, but CT scans help evaluate the exact extent of the damage and the number of joints that have been injured. CT scans also help plan surgery.
• Magnetic resonance imaging (MRI) scans – MRIs create better images of soft tissues like tendons. While this test is not required to diagnose, your physician may order it in cases where the diagnosis may be in doubt.

Treatment

There are both surgical and nonsurgical treatment options available to help you recover from a Lisfranc injury. Nonsurgical treatments are typically chosen if bones were not broken or dislocate. Both treatment options are successful and get you back to your regular routine.

The specific treatment your doctor chooses to use will depend on several factors, including:

• The injury’s location
• The specific component that is damaged, such as a bone or soft tissue structure
• The injury’s severity
• The injury’s impact on your ability to perform basic yet important actions like standing or walking

Simpler injuries typically need less aggressive therapy than complicated ones.

Nonsurgical treatments

If there are no fractures or dislocations in the joint and the ligaments are not completely torn, a nonsurgical treatment plan may be chosen.

In uncomplicated cases where there are no bone fractures or serious soft tissue tears, your doctor might recommend beginning treatment using the RICE method, short for Rest, Ice, Compress, and Elevate.

You will need to rest the affected foot as much as possible and, if need be, get around using a walking boot, cast, or crutches until significant healing has occurred. Ice can help reduce swelling.

You must be very careful about not putting any weight on your injured foot for six weeks. After the cast or boot is removed, you will be allowed to put weight on your foot again with the assistance of a removable cast boot or an orthotic.

Compressing the injured area using thick bandages or other compressing materials can keep the damaged components in place, limiting their chances of sustaining a greater injury. Keeping the foot elevated above your heart as much as possible can increase blood flow to the area, speeding up the healing process.

Your physician may also prescribe pain medications to ease any associated discomfort.

Uncomplicated cases usually heal within six weeks.

Your physician will regularly follow up with you and take additional x-rays to make sure your foot is healing correctly. If there is any evidence that the bones in the injured joint have moved, then surgery will be needed to put the bones back in place.

Surgical treatments

The goal of surgical treatment is to realign the joints and return the broken (fractured) bone to normal positions. Two different surgical procedures may be used to repair a Lisfranc injury: internal fixation and fusion.

During an internal fixation, the bones are repositioned correctly (known as reduction) and held in place with plates or screws. Since the plates or screws will be placed across joints that normally have some motion, some or all this hardware may be removed later. This can vary from 3 to 5 months after surgery and is up to your surgeon to decide. This operation is also called bone realignment.

If the injury is severe and has damage that cannot be repaired, a fusion may be recommended. This procedure involved fusing the damaged bones together so that they can heal into a single, solid piece. The midfoot joints have very little motion and mainly transfer stress to the front of the foot. Patients who do need fusion surgery will still be able to move relatively normally.

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