Fractures of the Mid Foot Tarsometatarsal (Lisfranc) Injury

Injuries to the tarsometatarsal joints are quite common. These occur in athletics, from minor twisting injuries when stepping unevenly, to more violent injuries that may occur in motor vehicle accidents or falls. Historically it is of some interest that the injury used to occur commonly in the cavalry in the Napoleonic era. In those days, the foot was violently wrenched in the stirrup and the only way that this could be treated at that time was by partial amputation of the foot by the renowned surgeon of Napoleon, Lisfranc. The term Lisfranc injury has stuck, although fortunately, treatment by amputation is almost never required.

The anatomy of the tarsometatarsal joint is quite complex. It consists of the articulations of multiple bones (the five metatarsals, the three cuneiforms and the cuboid bone). Injuries of the tarsometatarsal joint can be quite subtle and are not always easy to diagnose on x-ray.

On the right is an x-ray of a normal tarsometatarsal area. The picture on the left shows damage. Note the fuzzy changes of all of the joints between the metatarsals and the cuneiforms.

In the x-ray on the left we see normal joints between the metatarsals and the smaller bones in the middle of the foot, called the cuneiforms. On the right see how the metatarsals have shifted over towards the outside of the foot. This is called a tarsometatarsal or "Lisfranc" injury.

Surgery is required for the majority of these injuries. The treatment of tarsometatarsal injuries is usually done by reduction of the fraction or dislocation by means of screws that are inserted internally into the bones across the joints. These can be inserted through multiple punctures made on the skin without resorting to incisions on the foot.

Left: A typical fracture dislocation of the tarsometatarsal joints. Note the widening and the shift of the bones. The picture on the right shows how the injury has been fixed with screws.

The screws are typically left in for approximately four to five months following the surgery. Often after this time they are removed. There is no cast after the surgery. No walking on the foot is permitted for about six weeks and then walking is initiated with a removable boot. Swimming and biking are permitted early on. Walking in the boot is gradually discontinued at about ten weeks.

If untreated, a fracture or dislocation of the tarsometatarsal joint will often lead to painful arthritis that requires treatment. Arthritis is common if the joints are not carefully lined up and held with screws. If arthritis does occur, then these joints need to be fused.

This patient had painful arthritis after injury of the mid foot tarsometatarsal joints which was treated with arthrodesis (fusion ) of the mid foot joints with screws.