Lisfranc dislocation fracture/instability

What is the Lisfranc Complex?

The Lisfranc complex refers to the tarsometatarsal joints (TMT I-V) and the stabilizing ligaments between the sphenoid bones (Ossa cuneiformia), the cuboid bone (Os cuboideum) and the bases of the metatarsals (Metatarsalia). Particularly important is the strong Lisfranc ligament between the medial cuneiform bone and the base of the second metatarsal bone.

The special interlocking of the bones - the second metatarsal bone sits like a wedge between the sphenoid bones - ensures stability in everyday life when rolling, jumping and changing direction. If this system is injured, even a slight displacement can lead to significant loss of function and pain.

• Tasks: Power transmission from the rear foot to the forefoot rays
• Stability: Connective tissue guidance through the Lisfranc ligament and adjacent ligaments
• Special feature: The 2nd ray is a key segment; Instability here is prognostically relevant

Causes and accident mechanisms

Lisfranc injuries occur due to direct or indirect force. Sports and traffic accidents are common, but even seemingly banal twisting events with a twisted foot can overload the ligaments in the metatarsal.

• Indirect: Torsion of the plantar flexed foot (e.g. when abruptly changing direction or falling down the stairs)
• Direct: Axial force on the sole of the foot (e.g. pedal trauma in a car, fall with load on the foot)
• Sports: soccer, American football, equestrian sports, sprint and jumping disciplines
• Facilitating factors: forefoot instability, previous metatarsal injuries, inadequate footwear

The ligament injury can occur in isolation or be combined with bony avulsions/fractures. Depending on the extent, this can lead to painful instability and even dislocation of individual rays (dislocation fracture).

Typical symptoms

The symptoms range from stress-related pain in the metatarsal to significant misalignment in the event of dislocation. It is not uncommon for the injury to initially be underestimated as a “sprain”.

• Acute metatarsal pain, increased when stepping and rolling
• Swelling and tenderness over the tarsometatarsal area
• Plantar hematoma (bruise on the sole of the foot) – an important warning sign
• Uncertainty, buckling or feeling of “giving way” in the midfoot
• Inability to bear weight, sometimes cracking noise in the event of an accident

Diagnostics: clinical and imaging

The diagnosis combines a structured clinical examination with targeted imaging. The aim is to reliably detect instability and record the injury pattern (ligament, bone, combination).

• Clinical: Inspection for swelling/misalignment, tenderness over TMT joints, plantar hematomas, careful stress testing
• X-ray in 3 planes, ideally under stress; If necessary, side comparison
• CT for accurate assessment of bony avulsions/fracture patterns
• MRI to detect ligament injuries, bone marrow edema and accompanying lesions

Even minor misalignments can be clinically significant. An early diagnosis is important because overlooked instabilities increase the risk of metatarsal arthrosis.

Severity levels and classification

When deciding on therapy, a distinction is made between stable, non-displaced ligament injuries and unstable, displaced injuries. In addition, isolated ligament injuries are differentiated from combined dislocation fractures.

• Stable: no relevant diastasis or shift on imaging, no sign of instability
• Borderline: slight diastasis, discrete subluxation under stress
• Unstable/shifted: visible misalignment or joint level/diastasis between the 1st and 2nd rays
• Combined patterns: ligament tear with bony avulsion or multi-ray involvement

The exact classification is based on the clinic and imaging and influences the choice between conservative and surgical therapy.

Conservative treatment: when it makes sense

Conservative treatment is the priority for stable, non-displaced Lisfranc injuries without evidence of instability under weight-bearing. The aim is to reduce pain, protect healing and gradually build up function.

• Immobilization: Lower leg cast or sturdy walker boots
• Relief: initially 6 weeks of partial to zero weight bearing with forearm crutches (individually adjusted)
• Then gradually increase the load with physiotherapeutic support
• Insoles/orthoses for metatarsal support and relief of the TMT joints
• Medication: needs-based pain management, if necessary local cooling
• Control examinations: clinical and radiological to ensure stability

If the follow-up shows an increase in diastasis or persistent symptoms of instability, the treatment strategy is reassessed and, if necessary, surgical stabilization is recommended.

Surgical options: if instability is proven

Surgery is considered when there is instability or relevant displacement - particularly in the case of dislocation fractures, significant diastasis between the 1st and 2nd rays, or subluxation of the TMT joints. The aim is to anatomically restore the joint position and stabilize it in order to reduce subsequent damage.

• Open or minimally invasive reduction and internal fixation (e.g. screws, plates, staples)
• Primary arthrodesis (joint stiffening) for severe ligamentous injuries, comminuted fractures or a high risk of osteoarthritis
• Surgical timing: as soon as possible after the soft tissue swelling has subsided; Emergency care for open injuries
• Education: benefits, limitations, possible complications and realistic expectations

Which method makes sense in each individual case depends on the injury pattern, bone quality, comorbidities and activity goals. We will discuss the options in detail and coordinate the procedure with you. If an operation is recommended, we work with experienced foot surgeons.

Follow-up treatment and rehabilitation

Follow-up treatment is crucial for the result – regardless of whether the treatment is conservative or surgical. It is determined individually and checked regularly.

• Regular clinical and imaging checks
• Thrombosis prophylaxis according to risk profile
• Pain and scar management, if necessary physiotherapy and manual lymphatic drainage
• In the case of surgical treatment: later, if necessary, material removal after individual consideration

Course, risks and possible long-term consequences

With early and adequate treatment, there is a good chance of walking again with little pain and taking up everyday activities. Nevertheless, the Lisfranc injury is not a trivial matter: Even with optimal therapy, residual symptoms or limits of stress can occur.

• Possible long-term consequences: metatarsal arthrosis, chronic pain, residual instability
• Complications: Wound healing disorders, infections (rare), complex regional pain syndrome (CRPS)
• Resilience: Return to running often only after several months; Contact/stop-and-go sports may take longer
• Prognostic factors: initial malalignment, multi-ray involvement, soft tissue damage, start of therapy and consequences

A realistically coordinated rehabilitation plan and close monitoring support a good recovery of function and help to limit consequential damage.

Prevention and everyday tips

• Sport: well-fitting footwear with metatarsal stabilization, appropriate warm-up, technique training
• Everyday life: non-slip soles, be careful on stairs and uneven surfaces
• Regeneration: plan a moderate increase in load, take breaks from overload
• Insoles: Useful as a prophylactic measure in cases of pronation-prone gait or metatarsal instability
• Find out early: if you have metatarsal pain after twisting your ankle, do not continue training, but have it examined by a doctor

When should you come to us?

Please seek medical advice promptly, especially if the following symptoms occur:

• Severe metatarsal pain with inability to bear weight
• Plantar hematomas (bruise on the sole of the foot) after an ankle twist
• Misalignment, increasing swelling or numbness
• Open wounds or suspected fracture/dislocation

In our practice at Dorotheenstrasse 48, 22301 Hamburg, we offer a structured assessment and individual therapy planning - conservatively wherever possible. If there is an operational need, we coordinate further care with experienced partner clinics.

Your treatment in Hamburg-Winterhude

As an orthopedic specialist practice in Hamburg-Winterhude, we value thorough diagnostics, clear information and a conservative treatment approach. We take the time to understand your goals – whether pain-free everyday life, a quick return to work or a planned start to sports.

• Individual treatment planning based on severity and activity goal
• Conservative measures with close control as a first step
• In case of instability: structured indication for surgery and transfer to specialized foot surgery
• Rehabilitation with physiotherapy, insoles and functional construction

We would be happy to arrange an appointment with you for clarification. Use Doctolib or write to us - we will advise you transparently and without promises of healing.

Frequently asked questions (FAQ)

Below we answer common questions about Lisfranc dislocation fracture and instability.