Lis Franc

HistoryLis Franc

Jacques LisFranc De St-Martin (1790 - 1847)

General Surgeon in Napoleonic army




High energy


1.  Twisting / Abduction injury of forefoot

- original description is fall from horse with foot caught in stirrups



2.  Axial Loading


A Extrinsic axial compression applied to heel

B Extreme ankle equinus with axial loading of body weight


3.  Direct Crushing

- to dorsum of mid-foot

- greatest risk of compartment syndromes and open fractures




A: Quenu & Kuss; Modified by Hardcastle (JBJS 1982)


1. Homolateral 

- all 5 metatarsals displaced in same direction

- most common


Homolateral Lis FrancLis Franc Homolateral


2.  Isolated 

- only 1st MT injured / displaced


Lis Franc


3.  Divergent 

- 1st MT displaces medially

- other 4 MT displace laterally

- least common


B: Myerson

A: Total incongruity (medial or lateral)

B: Partial incongruity

  B1: Medial

  B2: Lateral (most common)

C: Divergent displacement

  C1: Partial

  C2: Total




Bony Stability


1-3 MT articulate with cuneiforms

4 & 5 articulate with cuboid


Bases of MT wider dorsally than plantar

- form 1/2 of Roman arch 


Metatarsal Base Roman ArchFoot CT


2nd MT is keystone of transverse MT arch

- medial cuneiform is recessed proximally

- mortise provided for base of second


Ligamentous stability


Lis Franc ligament

- plantar structure

- 1 cm long x 0.5 cm diameter

- base 2nd MT to medial cuneiform

- avulsion as 'fleck fracture'


Note: no intermetatarsal ligament from 1st MT to 2nd


Mobility (Sagittal)


Medial Column (1st MT) - 3.5 mm

Middle Column (2/ 3) - .6mm

Lateral Column (4/5) - 13mm




Swelling and pain

- out of proportion

- must suspect Lis Franc


Brusing plantar aspect foot

- indicative of Lis Franc Ligament rupture


Signs compartment syndrome




Fleck sign

- avulsion of LF from base of 2nd MT

- can be only sign of isolated Lis Franc Injury


Lis Franc Fleck SignLis Franc Fleck Sign


Diastasis between 1st & 2nd MT

- may need to perform bilateral weight bearing stress view


Lis Franc Diastasis


AP / Assess medial column

- medial border 1st MT should line up medial border medial cuneiform

- medial border of 2nd MT should line up with medial border middle cuneiform


 Lis Franc Medial Column ViewFoot Medial Column Normal


Internal Oblique 30o / Assess lateral column

- medial border 3rd MT line up with medial border lateral cuneiform

- medial border of 4th MT line up with medial border cuboid


Lis Franc Lateral ColumnLis Franc Lateral Column Disruption


CT scan


Confirm displacement of MT from respective joints


Lis Franc Displaced TMT Joints CT0001Lis Franc Displaced TMT Joints CT0002


Identify fleck sign


Lis Franc CT Fleck SignLis Franc CT Fleck Sign and Diastasis


Identify dorsal displacement of metatarsals


Lis Franc CT Dorsal Displacement MTLis Franc Dorsal Displacement


Compression fractures / nutcracker of cuboid


Cuboid Fracture Lis Franc




Confirm oedema or tear of Lis Franc ligament

Bone brusining tarsometatarsal ligaments

Subluxation of ligaments



Curtis stress views

Hindfoot stabilised & forefoot pronated/ abducted




Residual pain & stiffness with non-anatomical reduction

- 2° OA

- progressive planovalgus




Non Operative


Sprains with no displacement

- 6/52 in NWB SLPOP

- close serial follow up

- strapping/ medial arch support 6/12






Any displacement


Closed Technique



- isolated Lis Franc with diastasis

- early diagnosis and treatment



- longitudinal traction

- reduction first intermetatarsal joint

- percutaneous fixation screws

- from medial cuneiform to 2nd metatarsal


Lis Franc Isolated Injury FixationLis Franc Medial Column ORIF


Open Technique



- wait for swelling to reduce

- may take 2 - 3 weeks



- reduced and stabilise all MTJ that are injured


First incision

- dorsal

- between 1st and 2nd MT

- lateral to EHL

- protect branches of SPN

- dorsalis pedis and DPN are in this intermetatarsal space

- very difficult to identify



- clean out joint

- reduce first and second metatarsal to cuneiforms

- check AP reduction


Provisional fixation

- K wire 1st MT to medial cuneiform

- K wire 2nd MT to intermediate cuneiform

- K wire medial cuneiform to base 2nd MT

- +/- K wire medial to intermediate cuneiform if unstable

- insert 4.0 mm cannulated screws


Lis Franc Post ORIF


2nd incision between 3rd and 4th MT if required

- reduce 3rd and 4th MTPJ

- K wire / screw 3rd MT to lateral cuneiform

- Fix 4th and 5th to cuboid with K wires

- 5th K wire usually inserted percutaneously

- check with oblique view

- may use screw / k wire to 3rd MTPJ


Post op


Strict NWB for 8/52

- Lis Franc ligament takes time to heal


Removal of K wires at six weeks


Screw removal

- no sooner than 4/12

- broken screws rarely bothersome




Compartment Syndrome


Open fracture

- closed reduction and hold with external fixator


Midfoot Arthritis

- can develop later

- require midfoot fusion

- some surgeons advocate primary fusion if joint surfaces very damaged / comminuted