Lisfranc injuries are commonly associated with sporting injuries and are easily diagnosed with severe midfoot pain, swelling, deformity and inability to bear weight centred on the second tarsometatarsal joint. Amit Chauhan, P. Raju and Rajiv Limaye discuss the controversy surrounding the joint.
Lisfranc injury commonly describes injury to the midfoot centred on the second tarsometatarsal (TMT) joint [1,2]. Historically, the Lisfranc joint is named after a French army surgeon and gynaecologist, Jacques Lisfranc de St Martin (1790–1847), who originally described amputation through the joint [3]. There has been a controversy in the use of ‘Lisfranc joint’ and ‘Lisfranc joint complex’ in the literature, and it has been suggested that Lisfranc joint complex should refer to TMT articulations, whereas Lisfranc joint should mean medial articulation between the first and second metatarsals with medial and middle cuneiforms [4].
Epidemiology
Injuries to the foot are common in athletic population, accounting for approximately 16 per cent of all sporting injuries. TMT joint injury is the second most common trauma pattern, second only to metatarsophalangeal (MTP) joint injuries [5,6]. The incidence of Lisfranc injuries have been reported to be one in 55,000 annually, accounting for approximately 0.2 per cent of all fractures [3]. These injuries have shown to be co-existent with tarsal and metatarsal fractures [7].
The incidence of Lisfranc injuries is rising and has been reported in various sports, including horse riding, football, gymnastics and running [8,9]. Though these are common in athletes, it has been reported that one-third of injuries occur in low-energy sport trauma. More commonly (87.5 per cent), these are closed injuries [10].
Anatomy
Anatomically, the Lisfranc complex consists of an intricate balance of various bony and ligamentous structures. The midfoot is classically divided into three columns: medial, middle and lateral. The medial column consists of the first metatarsal, medial cuneiform, and its navicular facet; the middle column consists of the second and third metatarsals, their corresponding cuneiforms, and the central and lateral facets of the navicular; the lateral column consists of the fourth and fifth metatarsals and their articulations with the cuboid [11].
Much of the bony stabilisation is as a result of recession of the base of the second metatarsal into a mortise formed by the three cuneiforms, and the trapezoidal shape of the middle three metatarsal bases, often referred to as Roman arch [12]. The base of the second metatarsal is recessed approximately 8mm relative to the distal articular surface of the medial cuneiform and 4mm relative to the lateral cuneiform, and is recognised as a keystone that helps lock in stability to the midfoot and Lisfranc complex [13]. The plane of the TMT joints is relatively perpendicular to the ground, leaving little inherent bony stability during stance. Hence ligamentous anatomy is essential to maintain appropriate alignment and stability of articular structures.
The ligamentous anatomy of TMT articulations is very complex with three types of ligaments: dorsal, plantar and interosseous. All TMT articulations are crossed by dorsal and plantar TMT ligaments. The second through to the fifth metatarsal bases are also linked by intermetatarsal ligaments; however, there is no intermetatarsal ligament between the first and second metatarsals. Plantar ligament from the lateral side of the medial cuneiform to the medial side of the second metatarsal is referred to as the ‘Lisfranc ligament’. The first and second TMT ligaments, with the Lisfranc ligament, are often collectively referred to as the ‘Lisfranc ligament complex