Lisfranc Injury: Refined diagnostic methodology using weightbearing and non-weightbearing radiographs
Level of Evidence: III
Scientific Literature Review
Reviewed by: Kelly Bier, DPM
Residency Program: Hennepin Country Medical Center – Minneapolis, MN
Podiatric Relevance:
This study’s goal was to determine a standardized diagnostic protocol for subtle Lisfranc injuries when comparing weight bearing and non-weight bearing radiographs. This information could lead to better reliability of diagnosis of Lisfranc injuries on radiographs and therefore lead to sooner diagnosis and better outcomes.
Methods:
This article was a retrospective study of patients with purely ligamentous Lisfranc injuries from 1991 to 2018 who had undergone surgical treatment with weight bearing and non-weight bearing radiographs preoperatively. These patients were compared to a control group consisting of patients who presented in a similar time frame with a 5th metatarsal avulsion fracture that had weight bearing and non-weight bearing radiographs taken. The radiographs of both groups were then compared measuring the medial cuneiform to second metatarsal distance (C1M2), 1st metatarsal to 2nd metatarsal (M1M2), step off at the 2nd TMT (C2M2), intercuneiform distance (C1C2), and alignment of the 3rd and 4th TMT joints (C3M3 and C4M4). Additionally arch height, dorsal step-off of the 1st and 2nd TMT joint, and plantar gapping of the 1st TMT joint were assessed on the lateral radiographs. Radiographs were then independently reviewed by two of the authors.
Results:
Twenty-six patients were identified for the inclusion criteria and 26 patients were matched from the control group for comparative analysis. In the non-weight bearing radiographs, C1M2 was significantly larger in the Lisfranc group as well as M1M2. Additionally, dorsal step off at the 2nd TMT joint was also significantly larger in the Lisfranc group. There was no significant difference in C2M2. When comparing the weight bearing radiographs there was a significantly larger difference in C1M2 and C2M2 in the Lisfranc group compared to the control group. When comparing the weight bearing and non-weight bearing radiographs of the control group, M1M2 was significantly higher on weight bearing radiographs. However, in the Lisfranc group C1M2 and C2M2 values were significantly larger on weight bearing radiographs. Finally, the Lisfranc group had a significantly larger increase in C1M2, C1C2, and C2M2 when comparing weight bearing radiographs of injury to the control group.
Conclusions:
The authors concluded that although there are differences seen on non-weight bearing radiographs, there is a significantly larger difference in these measurements with weight bearing radiographs. The authors recommend that if a Lisfranc injury is clinically suspected, to obtain weight bearing radiographs. With weight bearing radiographs C2M2 and C1M2 can help differentiate between Lisfranc injuries and not. It is also worth noting that M1M2 was not a reliable indicator for Lisfranc injury. This study did demonstrate that there is a difference between non-weight bearing and weight bearing radiographs as well as a difference between Lisfranc injured patients and control patients on weight bearing radiographs. However, this is still primarily a clinical diagnosis and does not greatly affect clinical decision making for surgical intervention of Lisfranc injuries.