Diagnostic Criteria for Lisfranc Fracture of the Foot

Radiographic Evaluation

Radiographic evaluation with weight-bearing views is the cornerstone of diagnosing Lisfranc injuries, with specific attention to diastasis between the first and second metatarsal bases and the presence of the "fleck" sign, as recommended by the American College of Radiology 1, 2, 3
A three-view radiographic study (anteroposterior, oblique, and lateral) should be the initial imaging modality for suspected Lisfranc injuries, according to the American College of Radiology 1, 2, 3
An additional anteroposterior view with 20° craniocaudal angulation improves visualization of the Lisfranc joint, as suggested by the American College of Radiology 1, 2, 3
Weight-bearing radiographs are essential as non-weight-bearing images are unreliable for detecting subtle injuries, as stated by the American College of Radiology 1, 2, 3
Bilateral imaging with both feet on anteroposterior radiographs helps detect subtle malalignment when compared to the uninjured side, as recommended by the American College of Radiology 1, 2, 3

When radiographs are normal but clinical suspicion remains high, further imaging is warranted, according to the American College of Radiology 1, 2, 3, 4
CT is recommended for evaluating the true extent of osseous injury and detecting nondisplaced fractures, as suggested by the American College of Radiology 1, 2, 3, 4
MRI shows high correlation with intraoperative findings for unstable Lisfranc injuries, as stated by the American College of Radiology 4, 5

In polytrauma patients, approximately 25% of midfoot fractures identified on CT are overlooked on radiographs, as reported by the American College of Radiology 6
Patients with neuropathy require special attention as they may be able to bear weight despite fractures, as noted by the American College of Radiology 6
Purely ligamentous injuries without diastasis are particularly challenging to diagnose and may require MRI, according to the American College of Radiology 1, 2, 3
Ultrasound may have a limited role in Lisfranc injury evaluation but is not considered a primary diagnostic tool, as stated by the American College of Radiology 4, 5

Relying solely on non-weight-bearing radiographs can lead to missed diagnoses, as warned by the American College of Radiology 1, 2, 3

Conventional radiographs, including weight-bearing images, are not sufficient for routine diagnostic workup of acute hyperflexion injuries, according to the American College of Radiology 7
CT is recommended as the primary imaging technique for acute hyperflexion injuries, high-energy polytrauma, patients unable to bear weight, and demonstrating multiple metatarsal and cuneiform fractures associated with ligamentous Lisfranc injury, as suggested by the American College of Radiology 7, 8
MRI is indicated for evaluation of the Lisfranc ligamentous complex when radiographs are normal but clinical suspicion remains high, and for direct visualization of ligamentous injuries, with 3-D volumetric acquisitions proven superior to orthogonal proton density fat-suppressed imaging, according to the American College of Radiology 7
MRI has a high correlation with intraoperative findings for unstable Lisfranc injuries, as reported by the American College of Radiology 7