Review Question - QID 3896

The radiograph demonstrates a purely ligamentous Lisfranc injury. The ligament injured is Lisfranc's ligament which connects the base of the second metatarsal to the medial cuneiform (point D to point A).

A Lisfranc injury includes injuries to the base of the metatarsals, their articulations with the four distal tarsal bones, and the Lisfranc ligament, a strong interosseous attachment located between the medial cuneiform and the second metatarsal. The ligament is 8-10 mm wide and 5-6 mm thick. It tightens with pronation and abduction of the forefoot. This is the strongest ligament which stabilizes the midfoot.

Watson et al. performed a review of the treatment of Lisfranc injuries. They report that several osseous relationships contribute to the intrinsic stability of the midfoot. The trapezoidal shape of the middle three MT bases and their associated cuneiforms produce a stable arch referred to as the “transverse” or “Roman” arch. The keystone to the transverse arch is the second TMT joint, a product of the recessed middle cuneiform, which occupies a position 8 mm proximal to the medial cuneiform and 4 mm proximal to the lateral cuneiform.

Ly et al. performed a prospective, randomized clinical trial comparing primary arthrodesis compared with open reduction and internal fixation of Lisfranc injuries. Patients with arthrodesis estimated that their postoperative level of activities was 92% of their preinjury level, compared to 65% in the open reduction and internal fixation group. They conclude that a primary stable arthrodesis of the medial two or three rays appears to have a better short and medium-term outcome than ORIF of purely ligamentous Lisfranc joint injuries. However, this treatment strategy remains controversial with conflicting papers that show similar outcomes between the two groups.

Figure A demonstrates a Lisfranc injury. Illustration A by Watson et al. is a labeled illustration of the Lisfranc ligament and its relationship to surrounding structures. Of the three ligaments, the Lisfranc ligament is the strongest, followed by the plantar ligaments and the dorsal ligaments. Illustration B shows plantar ecchymosis on the medial aspect of the foot which can be associated with Lisfranc injuries.

Incorrect Answers:
Answers 1, 2, 3, 5: The Lisfranc ligament attaches the base of the second metatarsal to the base of the medial cuneiform. There are no ligamentous attachments between the first and second metatarsals.