Lisfranc Injury Classification: Myerson Types, Diagnosis, and Surgical Treatment

Lisfranc injuries — disruptions of the tarsometatarsal (TMT) joint complex — represent a spectrum from subtle ligamentous sprains to high-energy fracture-dislocations, unified by involvement of the second TMT joint and its stabilizing ligament complex. They are among the most commonly missed injuries in the foot: up to 20% of Lisfranc injuries are initially misdiagnosed as ankle sprains or foot contusions because non-weight-bearing X-rays may appear normal despite significant ligamentous disruption. The injury is named for Jacques Lisfranc de St. Martin, who described the amputation level through the TMT joints — the same anatomic zone that, when disrupted by trauma, can permanently alter midfoot mechanics and lead to post-traumatic arthritis, chronic instability, and loss of push-off if not recognized and treated appropriately. The classification system most widely used clinically is Myerson’s modification of the Quenu-Kuss classification, which guides surgical decision-making based on direction and completeness of displacement.

Lisfranc Injury Classification: Myerson Types and Clinical Correlation

Classification	Description	Displaced Structures	Mechanism	Treatment
Quenu-Kuss Type A — Total incongruity	All 5 metatarsals displaced in the same direction (homolateral); entire TMT joint complex disrupted; most severe pattern	All 5 TMT joints; intercuneiform and cuneo-navicular ligaments; Lisfranc ligament always disrupted	High-energy axial load (MVA, fall from height, industrial crush); direct dorsal or plantar force	ORIF with plate and screw fixation of all disrupted joints; 2nd/3rd TMT screws are primary fixation points; consider primary arthrodesis for purely ligamentous high-energy injuries
Quenu-Kuss Type B1 — Partial medial incongruity	Medial divergence: 1st metatarsal displaced medially while 2nd-5th remain in place or shift laterally; less common variant	Medial TMT joint; naviculocuneiform ligament; Lisfranc ligament lateral band	Twisting/rotation mechanism; indirect axial load with foot plantar flexed	ORIF of 1st TMT joint ± 2nd; if stable lateral column, medial fixation alone may suffice
Quenu-Kuss Type B2 — Partial lateral incongruity	One or more of the 2nd-5th metatarsals displaced laterally while 1st metatarsal remains reduced; most common subtype; includes isolated 2nd TMT dislocation	2nd TMT joint (most important); Lisfranc ligament (connects 1st cuneiform to 2nd metatarsal base); 3rd-5th variable	Low to moderate energy; sports injury; indirect axial load; equestrian injury (foot caught in stirrup with axial load)	ORIF 2nd TMT as primary; additional fixation of displaced joints; anatomic reduction critical — even 1-2mm step-off leads to arthritis
Quenu-Kuss Type C1 — Divergent partial	Divergent pattern: 1st metatarsal displaces medially and 2nd-5th displace laterally simultaneously; creates widening of 1st-2nd interspace	Complete Lisfranc ligament disruption; all medial column ligaments; 1st-3rd TMT joints minimum	High-energy axial load with rotational component; MVA foot-on-brake injuries	ORIF or primary arthrodesis; divergent patterns often have complete ligamentous disruption making ORIF less stable — primary medial column arthrodesis increasingly preferred
Quenu-Kuss Type C2 — Divergent total	Complete divergent dislocation of all 5 metatarsals; all TMT joints disrupted; most severe; often associated with compartment syndrome	All TMT joints; intercuneiform ligaments; plantar fascia; intrinsic musculature; may include navicular fracture	Highest energy mechanism; industrial crush; MVA; polytrauma patient	Emergency reduction of dislocation; fasciotomy if compartment syndrome; staged ORIF after soft tissue stabilization; primary arthrodesis of medial 3 rays; 4th-5th often treated non-operatively if reduced
Purely ligamentous (no fracture)	Lisfranc disruption with ligamentous injury only — no bony fracture; fleck sign (avulsion at base of 2nd metatarsal) may be only radiographic finding; often missed on non-weight-bearing films	Lisfranc ligament complex; intermetatarsal ligaments; plantar ligaments (stronger than dorsal); variable	Low-energy sports; indirect axial load on plantar-flexed foot; American football, gymnastics, equestrian	If non-displaced on stress weight-bearing films: non-operative (NWB cast 6-8 weeks) for truly stable injuries; if any instability: ORIF or primary arthrodesis — purely ligamentous injuries treated non-operatively have higher rates of instability and late arthritis than equivalent bony injuries

Lisfranc Injury: Diagnosis Pearls, Imaging Protocol, and Surgical Outcomes

Category	Details
Clinical presentation and examination	Midfoot pain, swelling, and inability to bear weight after axial load or twisting mechanism. Key findings: plantar ecchymosis (pathognomonic — bruising on plantar arch from torn plantar ligaments; present in 40-50% of Lisfranc injuries); painful TMT stress testing (forefoot abduction/pronation reproduces pain); tenderness over 2nd TMT joint base specifically; inability to perform single-leg heel rise. Absent findings that fool examiners: intact ankle range of motion (not an ankle sprain), and normal non-weight-bearing X-ray (50% of partial ligamentous injuries appear normal without stress)
Imaging protocol	Standard: bilateral weight-bearing AP, lateral, and oblique foot X-rays. Diagnostic thresholds: 2nd metatarsal base–medial cuneiform alignment disrupted on AP view; 1st-2nd metatarsal interspace >2mm wider than contralateral side; any step-off at the medial border of the 2nd metatarsal base aligning with medial cuneiform. Fleck sign: small bony avulsion fragment between 1st cuneiform and 2nd metatarsal base = pathognomonic for Lisfranc ligament disruption. CT scan: gold standard for defining fracture pattern, planning fixation, and identifying subtle incongruity. MRI: best for isolated ligamentous injuries — shows Lisfranc ligament signal disruption without fracture
ORIF vs. primary arthrodesis debate	ORIF (open reduction internal fixation): preferred for bony fracture-dislocations and partial injuries where ligament quality allows anatomic reduction; hardware removed at 6-12 months; 70-80% good outcomes. Primary arthrodesis: preferred for purely ligamentous injuries (no bone to heal), severe comminution, and high-energy divergent patterns; eliminates need for hardware removal; multiple RCTs (including Ly and Coetzee 2006) show superior outcomes for primary arthrodesis vs ORIF in purely ligamentous injuries. Lateral column (4th-5th TMT): almost never fused — preserves flexible forefoot motion critical for push-off; typically treated with temporary Kirschner wire fixation only
Compartment syndrome risk	Foot compartment syndrome complicates 5-10% of Lisfranc fracture-dislocations and up to 40% of total divergent injuries. Presents with severe foot pain out of proportion, pain with passive toe extension (intrinsic compartment stretch), tense foot swelling. Nine foot compartments: medial, central superficial, central deep, lateral, interosseous (4), adductor. Compartment pressures >30 mmHg or within 30 mmHg of diastolic BP = fasciotomy indicated. Missed foot compartment syndrome causes clawing of all toes (intrinsic minus deformity) and permanent dysesthesias
Post-traumatic arthritis	Most significant long-term complication — develops in majority of Lisfranc injuries regardless of treatment when anatomic reduction is not achieved. 2nd TMT joint arthritis is most functionally limiting. Key principle: 1mm step-off at the 2nd TMT joint produces a 10-fold increase in contact pressure and near-certain post-traumatic arthritis at that joint. Arthritis salvage: TMT arthrodesis (medial column fusion); outcomes acceptable at 70-80% patient satisfaction. Prevention through anatomic reduction is superior to salvage

At Balance Foot & Ankle in Howell and Bloomfield Hills, suspected Lisfranc injuries are evaluated with bilateral weight-bearing foot X-rays in all patients able to bear weight, because a 2mm interspace asymmetry or plantar ecchymosis in a patient with midfoot pain and a twisting or axial mechanism warrants CT scan and orthopedic evaluation — missing a Lisfranc injury condemns the patient to post-traumatic arthritis and midfoot collapse. Call (810) 206-1402.