Lisfranc Fracture: Diagnosing a Foot Injury

When Napoleon led his army to disaster in the Russian winter, many of his soldiers suffered from frostbite and developed gangrene of the toes and feet. Dr. Jacques Lisfranc de St. Martin figured out the anatomy of the foot, and found that cutting through joint spaces made amputation easier. His legacy is that fractures, dislocations, and sprains that affect the junction between the upper and lower foot bones bear his name. Lisfranc injuries refer to damage to the joints where the long thin metatarsal bones of the foot meet the tarsal bones (the cuboid and cuneiforms) that make up the midfoot.

Lisfranc fractures often occur when a person steps in a hole and the toes become caught, and then the person falls forward. This torque causes the ligaments that hold the joints together to tear, the joint to become unstable, and the alignment of the bones to be lost. In car accidents or other major trauma injuries, not only can the ligaments be damaged, but when the bones break, the midfoot can dislocate. In football, the Lisfranc joint is damaged when the toe is pointed downward and another player falls on the exposed heel. Such was the fate that befell Matt Schaub of the Houston Texans in 2011, and Dwight Freeney of the Indianapolis Colts in 2007.

When a person walks or runs, all of the body's weight bearing is directed through the midfoot, and since  the Lisfranc joint doesn't tolerate much injury or damage, even minor sprains can cause significant pain and difficulty with walking. Often, health care practitioners can be fooled. The foot clinically seems broken, with pain and swelling on the top of the foot, but X-rays appear normal. A high index of suspicion is needed to consider CT scans of the foot to look for hidden fractures. If the diagnosis is missed or treatment delayed, the long-term consequences can include arthritis and loss of function of the foot. But even with appropriate care, many individuals with a Lisfranc joint fracture end up with those complications.

Lisfranc fractures need to be appropriately aligned to heal well for good results. Depending upon the alignment and the orthopedic or podiatric surgeon's opinion as to whether stability can be maintained over the long-term, surgery may be needed to allow proper healing. Sometimessurgery is not needed, and a non-weight bearing cast may be recommended for a minimum of six weeks. Regardless of what treatment is provided, this injury carries significant consequences and should not be considered just another sprain.

Orthopedic care has come a long way since the Napoleonic wars. The rush to amputate injures has given way to thoughtful planning and not rushing to operate if other treatment options are available. The right treatment decision is sometimes difficult. Lisfranc fractures can heal wonderfully, but if one measures success with a good looking X-ray, it does not guarantee that the patient will not experience future problems with pain, arthritis, and instability; a measure of failure. Just as in making the correct diagnosis, relying on X-rays to evaluate results may not provide the entire picture of how an injury is healing, or has healed.