Effective detection and management of low-velocity Lisfranc injuries in the emergency setting

Oblique view of the injured foot: Note the subtle shift of the second metatarsal base away from the medial cuboid bone, and the bony comminution that sits in the resultant space. The second metatarsal shaft fracture is a not-uncommon concomitant injury with this mechanism.

Lateral view of the injured foot: Note the subtle shift of the second metatarsal base away from the medial cuboid bone, and the bony comminution that sits in the resultant space. The second metatarsal shaft fracture is a not-uncommon concomitant injury with this mechanism.

Relationship of the metatarsal (MT) bones: A) The anteroposterior view of the foot displays the relationship of the first and second MTs to their corresponding medial and intermediate cuneiform bones. Specifically, the medial border of the second MT should align with the medial border of the intermediate cuneiform. B) The interruption of the second MT–intermediate cuneiform line is noted, signifying an unstable Lisfranc injury.

Contours of the tarsometatarsal joints: A) The oblique radiograph of the foot displays the normal contours (demarcated with white lines) of the third to fifth tarsometatarsal joints. These should be smooth and uninterrupted. B) There is an interruption of the normally smooth line between the third metatarsal and the lateral cuneiform bone. This signifies an unstable Lisfranc injury.

The fleck sign: Avulsion fracture of the base of the second metatarsal bone.

The 3-sided splint is applied in the following manner: All of the bony prominences (including the heel) are generously padded with cotton undercast padding. Then the plaster slabs are applied so that they never touch anteriorly along the distal tibia, and so that the foot, except for the plantar portion of the slab, is left relatively uncovered by plaster (black arrows). These features allow for the substantial swelling that can accompany foot trauma and Lisfranc injuries.