Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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A displaced midfoot can threaten both skin and function
Lisfranc fracture-dislocation, open metatarsal injury and foot compartment syndrome may look less dramatic than major long-bone trauma yet cause skin necrosis, muscle ischaemia and permanent painful collapse.
Action: Perform trauma and whole-limb assessment, inspect the plantar and dorsal foot, document pulses and named nerve function, cover open wounds and give immediate antibiotics, urgently reduce gross dislocation or threatened skin, splint and keep non-weight bearing, and obtain same-day orthopaedic review for instability, compartment concern or neurovascular change.
Synopsis
Distinguish simple metatarsal injury from unstable tarsometatarsal disruption, apply foot imaging rules without missing plantar signs, use weight-bearing radiographs and CT appropriately, and protect alignment, skin and long-term midfoot function.
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.
Key red flags
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.
Investigation priorities
01
Ottawa foot ruleFirst step
Identify eligible acute-trauma patients who need initial foot radiographs.
02
First-line foot radiographsFirst line
Define metatarsal fracture and tarsometatarsal alignment.
Management branches
EmergencyProtect a threatened foot
There is open injury, gross dislocation, skin pressure, neurovascular change or possible compartment syndrome.
Complete trauma assessment, expose the sole and dorsum and document wounds, compartments, pulses and named nerve function.
Cover an open wound, give immediate network intravenous prophylaxis, address tetanus and avoid repeated emergency-department probing.
LisfrancRestore a stable plantigrade midfoot
Clinical and imaging findings show or strongly suggest tarsometatarsal ligament or fracture instability.
Key medicines
ParacetamolGive 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.
Intravenous prophylaxis for an open foot fractureGive 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.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.