Figure 1. Anteroposterior radiograph of the left foot.
Figure 2. Anteroposterior weight-bearing radiograph of both feet.
A 50–year-old woman presents with severe pain and swelling in her left foot after a large table landed on her foot 2 days prior. She is having difficulty bearing weight on the foot following the injury. Anteroposterior radiograph of the left foot is obtained (Figure 1), as is a bilateral weight-bearing radiograph of the feet (Figure 2).
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A Lisfranc injury is a forefoot injury characterized by a disruption of the articulation between the medial cuneiform bone and the base of the second metatarsal.1 The Lisfranc articulation provides critical stability to the forefoot during gait. Disruption of the Lisfranc joint can lead to arch collapse and, over time, degenerative arthritis of the forefoot.1
These injuries can often be subtle on radiography and are frequently missed at initial presentation.1 A Lisfranc disruption can be confirmed by a >2 mm disruption between the second metatarsal base and the medial cuneiform on anteroposterior radiograph or an avulsion fracture at the base of the second metatarsal.1 For subtle injuries, weight bearing radiographs help stress the joint and increase displacement. Magnetic resonance imaging can help identify Lisfranc disruptions if patients are unable to stand on the injured foot during a stress radiograph.2,3
This patient has a subtle avulsion fracture at the base of the second metatarsal consistent with a Lisfranc injury. The patient underwent surgical fixation that included closed reduction of the Lisfranc joint with a percutaneous screw through the medial cuneiform to the base of the second metatarsal. A percutaneous screw was also placed though the second tarsometatarsal joint.2,3
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopedics for Physician Assistants.
1. Bloomberg J. Lisfranc injury. OrthoBullets website. https://www.orthobullets.com/foot-and-ankle/7030/lisfranc-injury. Updated August 13, 2020. Accessed August 18, 2020.
2. Raikin SM, Elias I, Dheer S, Besser MP, Morrison WB, Zoga AC. Prediction of midfoot instability in the subtle Lisfranc injury. Comparison of magnetic resonance imaging with intraoperative findings. J Bone Joint Surg Am. 2009;91(4):892-899.
3. Benirshke SK, Meinberg E, Anderson SA, Jones CB, Cole PA. Fractures and dislocations of the midfoot: Lisfranc and Chopart injuries. J Bone Joint Surg Am. 2012;94(14):1325-1337.