For Patients > Foot & Ankle Procedures > Trauma > Fractures to the Mid Foot
Director Tuvi Mendel, M.D.
Fractures to the Mid Foot Tarsometatarsal (Lisfranc) Injury
Injuries to the tarsometatarsal joints are quite common. These occur in athletics, from minor twisting injuries when stepping unevenly, to more violent injuries that may occur in motor vehicle accidents or falls. Historically it is of some interest that the injury used to occur commonly in the cavalry in the Napoleonic era. In those days, the foot was violently wrenched in the stirrup and the only way that this could be treated at that time was by partial amputation of the foot by the renowned surgeon of Napoleon, Lisfranc. The term Lisfranc injury has stuck, although fortunately, treatment by amputation is almost never required.
The anatomy of the tarsometatarsal joint is quite complex. It consists of the articulations of multiple bones (the five metatarsals, the three cuneiforms and the cuboid bone). Injuries of the tarsometatarsal joint can be quite subtle and are not always easy to diagnose on x-ray.
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On the right is an x-ray of a normal tarsometatarsal area. The picture on the left shows damage. Note the fuzzy changes of all of the joints between the metatarsals and the cuneiforms.
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Fractures of the Metatarsals
There are five metatarsals in the foot. The first metatarsal is the most important and fractures of the first metatarsal usually require surgery. Fractures of the middle metatarsals (the second, third and fourth) do not require surgery unless there are significant displacements of the bone.
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The metatarsals of the foot. These are the bones that connect the toes to the middle bones of the foot. The first metatarsal (1) connects to the big toe, and the 5th metatarsal to the baby toe.
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Each metatarsal is divided anatomically into different segments (the head and neck, the shaft, and the base). The treatment of these fractures depends on where the metatarsal bone is fractured.
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On the left are fractures of the neck of the metatarsals.
On the right are fractures of the middle or the shaft of the metatarsals.
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Injuries to the metatarsals are sustained in many different ways ranging from minor twisting to falls and injuries sustained when heavy objects fall on the foot and literally crush the metatarsals.
Fractures of the fifth metatarsal are quite varied, and the treatment is determined according to the specific location of the fracture in this bone. The treatment of the metatarsals varies depending on the injury. Some patients simply wear a very stiff-soled shoe or a special type of rigid heeling shoe or a short leg walking cast. Surgery is reserved for the more serious of these fractures. These are usually certain types of fractures of the first and fifth metatarsal.
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This fracture of the 5th metatarsal shaft is a relatively easy one to treat, and usually heals quite well in a special shoe or boot, without any surgical treatment.
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Fractures of the fifth metatarsal are unique in that they commonly occur associated with sporting activities. There is one type of fracture in particular, called the Jones fracture, which is a difficult fracture to get to heal. Because of problems with blood supply to the bone where the fracture occurs, these fractures are difficult to heal and often surgery is required.
If surgery is not performed, then a boot or cast is used. It can take eight to ten weeks for this fracture to heal and it is not always predictable whether or not full healing will occur. If a cast or boot is used, no walking on the foot is permitted for about 6 weeks. The results of bone healing are unpredictable. Studies have shown about 70% heal with cast treatment.
On the other hand, surgery for the Jones fracture has about a 95% success rate. Therefore, surgery is preferable for most Jones fractures. In this treatment, a tiny puncture is made in the skin on the outside of the foot and a screw is inserted. An x-ray monitor is used to help position the screw. The screw helps speed up the healing process. Healing occurs quite rapidly and walking on the foot (with a removable boot) is permitted within a few days after surgery. Typically, bike exercise can be commenced at about four weeks. Patients may return to running approximately six weeks after this type of surgery.
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