Metatarsal and Lisfranc injuries

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Mechanism sets the level of concern. Direct crush can fracture multiple rays and devitalise dorsal and plantar tissue. Indirect Lisfranc injury occurs when a plantarflexed forefoot is twisted or axially loaded during sport, a fall or a missed step; deformity may reduce spontaneously. Establish immediate and current ability to bear weight, footwear, occupation and sport, diabetes or neuropathy, smoking, bone health and previous cavus alignment. Examine knee, fibula, ankle and hindfoot as linked injuries can coexist.

Look at the foot unloaded and, only when safe, during gentle loading. Note swelling, arch shape, widening, abduction, wounds, blisters and plantar ecchymosis. Palpate tarsometatarsal joints and each metatarsal from base to head. Gentle forefoot abduction and pronation, piano-key movement of an individual ray or passive movement may reproduce midfoot pain, but aggressive stress is unnecessary when the history and swelling already imply instability. Document dorsalis pedis and posterior tibial pulses and named sensory and motor function.

The Ottawa foot rule guides initial imaging for traumatic midfoot pain. Navicular tenderness, base-of-fifth tenderness or inability to take four steps both after injury and at assessment makes it positive. It does not exclude Lisfranc injury outside its landmarks, classify displacement or substitute for plantar examination. Altered sensation, unreliable communication, gross deformity and persistent clinical concern warrant judgement beyond a decision rule. Negative radiographs do not justify discharge when plantar bruising and inability to load remain unexplained.

Radiographs require correct views and loading context. Obtain AP, thirty-degree oblique and lateral foot films. On AP, the medial border of the second-metatarsal base should align with the medial border of the middle cuneiform; on oblique, the fourth metatarsal aligns with the cuboid; on lateral, dorsal displacement and arch collapse are sought. A fleck avulsion may mark Lisfranc ligament failure. Bilateral weight-bearing comparison views reveal subtle widening when the patient can safely stand. CT maps fractures and joint incongruity; MRI detects primarily ligamentous disruption.

Metatarsal decisions depend on ray, displacement and multiplicity. First-ray length and sagittal position are particularly important to load transfer. Stable central shaft fractures often receive a stiff-soled shoe or boot with weight bearing as comfort and pattern allow. Important angulation, translation, rotation, shortening, articular displacement or several unstable rays needs reduction and fixation assessment. Open fractures follow immediate antibiotic and orthoplastic principles. Toe alignment and plantar head prominence should be assessed after reduction, not just the AP image.

The proximal fifth metatarsal is divided clinically. Zone-one tuberosity avulsions commonly unite with symptomatic protection and early loading. A zone-two fracture at the fourth-fifth intermetatarsal articulation is a Jones injury, while zone-three proximal diaphyseal fracture often reflects stress; both have higher delayed-union risk. Athletes, displaced injuries, cavus loading and established nonunion may favour fixation. Calling every proximal fracture a Jones fracture obscures prognosis and leads to incorrect advice.

Lisfranc care restores a stable plantigrade arch. Gross dislocation or threatened skin is reduced urgently, then protected non-weight bearing. A stable purely ligamentous sprain without displacement on adequate weight-bearing assessment may use immobilisation and close repeat imaging. Any instability, displacement or loss of column alignment needs specialist operative assessment, using fixation or primary arthrodesis according to joints, tissue and patient demand. Rehabilitation progresses from tissue protection to ankle and toe motion, then loading, calf strength and push-off, with long-term surveillance for arthritis.

Key points

Expose and inspect the sole as well as the dorsum. Plantar midfoot bruising is a powerful warning for Lisfranc injury and should not be relabelled as a simple sprain after inadequate films.
Palpate every metatarsal, navicular, cuboid, cuneiform region and tarsometatarsal joint; test pain with gentle forefoot abduction-pronation and compare alignment without forceful stress in an unstable foot.
Use the Ottawa foot rule in eligible people older than 5 years: midfoot pain plus navicular tenderness, fifth-metatarsal-base tenderness or inability to take four steps indicates foot radiographs.
Obtain AP, oblique and lateral foot radiographs; weight-bearing bilateral comparison views are preferred for subtle Lisfranc instability when safe and tolerable, but are inappropriate in gross displacement or severe pain.
Use CT to map fractures and subtle joint displacement and MRI when radiographs and CT remain non-diagnostic but ligamentous Lisfranc injury is still suspected.
A small fleck between the first and second metatarsal bases, widening or loss of the second-metatarsal to middle-cuneiform alignment supports Lisfranc complex disruption.
Differentiate fifth-metatarsal tuberosity avulsion from metaphyseal-diaphyseal Jones and proximal diaphyseal stress patterns because protection, union risk and operative thresholds differ.
Stable aligned injuries can use protected loading and surveillance; unstable Lisfranc displacement, open injury, threatened skin, multiple unstable metatarsals or compartment syndrome needs urgent specialist care.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Direct crush

A heavy object or vehicle wheel can fracture several metatarsals, disrupt tarsometatarsal joints and cause major dorsal and plantar soft-tissue injury.

Twisting on plantarflexion

Rotation through a fixed forefoot can disrupt the Lisfranc ligament and joint complex with little obvious fracture or initial deformity.

Inversion avulsion

Peroneus brevis and lateral-band plantar fascia traction can avulse the fifth-metatarsal tuberosity during a common ankle-twisting mechanism.

Repetitive load

Running, marching and dance produce metatarsal stress fractures, while cavus alignment and limited vascularity increase proximal fifth-metatarsal risk.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Lisfranc keystone failure
The recessed second-metatarsal base and Lisfranc ligament stabilise the transverse arch; disruption permits column separation and progressive midfoot collapse.
2
Articular incongruity
Tarsometatarsal displacement concentrates load across small cartilage surfaces, leading to persistent pain and post-traumatic arthritis even after modest malalignment.
3
Metatarsal cascade disruption
Shortening, elevation or plantar displacement alters pressure transfer between rays and produces metatarsalgia, callosity and transfer lesions.
4
Fifth-metatarsal vascular watershed
The metaphyseal-diaphyseal junction has relatively vulnerable perfusion, contributing to delayed union and nonunion in Jones-type and proximal diaphyseal injuries.
5
Compartment pressure
Crush bleeding and oedema within foot compartments compromise intrinsic muscles and nerves, causing contracture, clawing, neuropathic pain and deformity.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Subtle Lisfranc injury

Plantar bruising, midfoot swelling and pain with forefoot stress after twisting on a plantarflexed foot may occur despite normal non-weight-bearing films.

Displaced Lisfranc injury

Arch flattening, forefoot abduction, palpable step or dorsal skin tenting signals column displacement that requires immediate alignment and orthopaedic care.

Fleck and diastasis

A small avulsed fragment between first and second rays or widening between metatarsal bases supports disruption of the Lisfranc ligament complex.

Tuberosity avulsion

A zone-one fifth-metatarsal base fragment after inversion lies proximal to the intermetatarsal articulation and generally has good healing potential.

Jones or proximal stress pattern

A transverse zone-two or zone-three proximal fifth-metatarsal fracture has higher delayed-union risk and warrants stricter protection and specialist planning.

Multiple metatarsal instability

Parallel displacement may preserve apparent spacing while the entire metatarsal cascade shifts, so lateral and oblique alignment and plantar contour are essential.

Red flags requiring action

Plantar midfoot ecchymosis, marked tarsometatarsal swelling, pain with forefoot stress or inability to load after axial or twisting trauma should trigger an urgent Lisfranc pathway even if non-weight-bearing films look normal.
Gross midfoot displacement, skin tenting, open wound, absent pulse or sensory or motor deficit needs immediate reduction or operative escalation before elective cross-sectional planning.
Escalating pain, tense swelling, passive-toe-stretch pain or progressive paraesthesia after crush injury suggests foot compartment syndrome and must not wait for pulse loss.
A proximal fifth-metatarsal fracture at the metaphyseal-diaphyseal junction or proximal diaphysis has greater delayed-union risk than a tuberosity avulsion and needs precise localisation and follow-up.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Ottawa foot ruleFirst step
Why
Identify eligible acute-trauma patients who need initial foot radiographs.
Interpretation and limitations
Midfoot pain plus navicular or fifth-base tenderness or inability to take four steps is positive; it does not rule out injuries outside those criteria.
02
First-line foot radiographsFirst line
Why
Define metatarsal fracture and tarsometatarsal alignment.
Interpretation and limitations
Use AP, oblique and lateral views; scrutinise ray-cuneiform and ray-cuboid lines, fleck sign, sagittal displacement, arch height and every metatarsal.
03
Weight-bearing bilateral radiographs
Why
Reveal dynamic diastasis or loss of arch alignment in a subtle suspected Lisfranc injury.
Interpretation and limitations
Obtain when safe and tolerable, ideally with comparison; inability to bear weight does not clear the injury and instead supports CT, immobilisation and review.
04
CT foot
Why
Map tarsometatarsal fractures, small avulsions and articular displacement.
Interpretation and limitations
CT is particularly useful after high-energy injury or suspicious inconclusive films and supports fixation planning, but non-weight-bearing CT may not demonstrate purely dynamic instability.
05
MRI foot
Why
Confirm ligamentous Lisfranc injury or occult metatarsal stress injury.
Interpretation and limitations
Use when clinically important suspicion persists despite radiography and CT and the result changes immobilisation or operative referral.
06
Post-reduction imaging
Why
Verify restored column length, ray alignment and joint congruity.
Interpretation and limitations
Obtain radiographs after urgent reduction and CT as required, while continuing skin and neurovascular checks because imaging cannot prove tissue safety.
07
Serial clinical loading review
Why
Determine whether a presumed stable injury remains aligned as pain settles.
Interpretation and limitations
At specialist follow-up reassess plantar pain, ability to load and repeat appropriate weight-bearing films before reducing protection.
08
Bone-health investigations
Why
Identify contributors to insufficiency or recurrent stress fracture.
Interpretation and limitations
Use targeted vitamin D, calcium, renal, thyroid, coeliac, endocrine and DXA assessment according to age, menstrual and energy history, recurrence and fragility mechanism.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Midfoot sprain

Stable ligament injury can cause dorsal pain and swelling, but only adequate loading assessment and imaging can distinguish it from subtle Lisfranc instability.

Navicular or cuboid fracture

Focal medial or lateral midfoot tenderness and column shortening may represent tarsal injury accompanying or mimicking tarsometatarsal trauma.

Ankle sprain

Lateral ankle pain can coexist with a fifth-metatarsal avulsion, so the base and midfoot must be palpated explicitly.

Metatarsal stress fracture

Insidious load-related pain, focal shaft tenderness and normal early radiographs suggest fatigue injury rather than acute displaced fracture.

Charcot neuroarthropathy

A hot swollen relatively painless foot in neuropathy may show fragmentation and subluxation and needs immediate off-loading and specialist assessment.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01EmergencyProtect a threatened footFirst stepThere is open injury, gross dislocation, skin pressure, neurovascular change or possible compartment syndrome.

1Complete trauma assessment, expose the sole and dorsum and document wounds, compartments, pulses and named nerve function.
2Cover an open wound, give immediate network intravenous prophylaxis, address tetanus and avoid repeated emergency-department probing.
3Urgently reduce gross displacement or skin tenting, apply a padded non-weight-bearing splint and repeat tissue and neurovascular examination.
4EscalationEscalate compartment concern, irreducibility, recurrent displacement and vascular change directly to orthopaedic and relevant reconstructive teams.

02MetatarsalPreserve the pressure-sharing cascadeImaging confirms one or more metatarsal fractures without emergency tissue compromise.

1Define ray, zone, articular involvement, rotation, angulation, shortening and whether adjacent fractures move together.
2Use a stiff-soled shoe, boot or cast for a stable acceptable pattern and write precise loading, movement and review instructions.
3Refer displaced first-ray, articular, rotated, shortened or multiple unstable fractures and high-risk fifth-metatarsal patterns for fixation assessment.
4Repeat films when displacement or delayed union is plausible and assess plantar pressure, toe alignment and gait before discharge from follow-up.

03LisfrancRestore a stable plantigrade midfootClinical and imaging findings show or strongly suggest tarsometatarsal ligament or fracture instability.

1Keep non-weight bearing and obtain adequate weight-bearing comparison films when safe, using CT or MRI for remaining structural questions.
2Treat a demonstrably stable injury in immobilisation with early specialist review and repeat loading assessment before progression.
3Use fixation or selected primary arthrodesis for unstable displaced joints according to column, cartilage, soft tissue and functional demand.
4Advance loading only after clinical and imaging review and monitor arch, push-off, footwear and post-traumatic arthritis over time.

Key medicines and prescribing safety2 treatments · regimens, roles and cautions

Offers non-sedating baseline analgesia for protected mobilisation and repeated examination of swelling, compartments and neurovascular status.

Paracetamol

Give 1 g orally up to four times daily as required, with at least 4 hours between doses and a maximum of 4 g in 24 hours; reduce the maximum for weight below 50 kg, frailty, malnutrition or hepatic risk.

Check all combination analgesics and liver or alcohol history; symptom relief does not make weight-bearing testing safe in a grossly unstable or skin-threatening injury.

Reduces deep infection risk in open metatarsal and tarsometatarsal injury before operative wound excision.

Intravenous prophylaxis for an open foot fracture

Give the current major-trauma network's specified intravenous antibiotic and weight-based adult dose immediately and ideally within 1 hour, recording dose and time and following contamination-specific continuation through the formal debridement plan.

Confirm severe allergy and renal adjustment without delaying the first suitable dose; farm, water and heavily contaminated wounds need protocol and microbiology input rather than a single universal regimen.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Post-traumatic midfoot arthritis

Missed or incompletely reduced Lisfranc injury causes painful stiffness, arch collapse and difficulty with push-off, sometimes requiring later fusion.

Delayed union or nonunion

Jones-type and proximal diaphyseal fifth-metatarsal fractures, smoking and premature loading can prolong pain and require fixation or bone stimulation.

Transfer metatarsalgia

Residual shortening, angulation or malunion redistributes plantar pressure and causes callosity, interdigital nerve irritation and adjacent-ray overload.

Skin and deep infection

Open crush injury and tense swelling can progress to necrosis, infection and osteomyelitis, especially with diabetes or vascular disease.

Compartment contracture

Unrecognised foot compartment syndrome produces intrinsic muscle necrosis, claw toes, sensory disturbance and chronic neuropathic pain.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Repeat dorsal and plantar skin, compartment, pulse, capillary refill and named nerve findings after reduction, splintage and every swelling or pain change.
Check boot, cast and off-loading adherence and give direct return advice for pressure injury, numbness, toe colour change, escalating pain or wet dressings.
Repeat weight-bearing or standard radiographs at specialist intervals to detect Lisfranc widening, metatarsal displacement and delayed union before progressing load.
Assess wound and pin or implant sites for drainage, erythema and infection, with lower thresholds in diabetes, neuropathy, smoking and vascular disease.
Track arch shape, plantar callosity, toe alignment, ankle and toe movement, calf strength, push-off, footwear tolerance and return to work or sport.
Reconsider bone health, energy availability and metabolic investigation after recurrent, low-energy or delayed-healing metatarsal injury.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Inspect the sole

Plantar ecchymosis can be the clearest sign of deep tarsometatarsal disruption while dorsal swelling appears non-specific.

Loading changes the picture

A subtle ligament injury may align when unloaded and separate only under physiological weight, explaining a normal initial film.

Parallel displacement can deceive

Several rays may shift together without obvious intermetatarsal widening, so cuneiform, cuboid and sagittal relationships must also be checked.

Not every fifth fracture is Jones

Zone-one avulsion, zone-two Jones and zone-three stress patterns have different biology, protection and operative discussions.

First-ray position controls transfer

Shortening or elevation unloads the first ray and shifts pressure laterally, producing painful callosity despite union.

Stable must be demonstrated

A ligamentous Lisfranc injury is not safely labelled stable until adequate specialist clinical and loading assessment shows maintained alignment.

11Common pitfallsFrequent interpretation and management errors.

01
Examining only the swollen dorsum and missing plantar ecchymosis, a wound or a pressure point.
02
Using a negative Ottawa rule or non-weight-bearing radiograph to dismiss strong clinical evidence of Lisfranc injury.
03
Calling every proximal fifth-metatarsal fracture a Jones fracture without locating it relative to the intermetatarsal articulation.
04
Assessing each central metatarsal in isolation and missing parallel displacement of the whole cascade.
05
Forcing weight-bearing views in a grossly displaced, severely painful or skin-threatening foot.
06
Ending follow-up at union without assessing arch stability, plantar pressure, footwear, push-off and post-traumatic arthritis.