What is the anatomy of the Lisfranc joint relevant to Lisfranc fracture dislocation?

Updated: Apr 20, 2020
  • Author: Nirmal Tejwani, MD, MPA; Chief Editor: Thomas M DeBerardino, MD  more...
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The Lisfranc joint is composed of five TMT joints in which the first through third MTs articulate with their corresponding medial, middle, and lateral cuneiforms, whereas the fourth and fifth MTs articulate with the cuboid. Functionally, the Lisfranc joint can be divided longitudinally into three columns, as follows:

  • Medial column, or first ray
  • Middle column, consisting of the second and third TMT joints
  • Lateral column, consisting of the fourth and fifth TMT joints

A transverse line through these joints is not straight but highlights a recess, termed the keystone (much as in a Roman arch), that is formed by the second TMT joint. This joint lies approximately 1 cm proximal to the first TMT joint line and 0.5 cm proximal to the third TMT joint line.

The joints are bound by thick plantar ligaments that form an interlocking pattern between the tarsal and lesser MT bones 2-5. These are reinforced by attachments of the posterior tibialis tendon. The first TMT joint also has strong plantar ligaments across the joint; these are reinforced by the attachment of the peroneus longus and anterior tibialis tendons.

Also present between the lesser MTs is a series of intermetatarsal ligaments, which force the group to function more as a unit. No intermetatarsal ligaments exist between the first and second MTs, which is why they often exhibit divergent behavior. The weaker dorsal ligaments explain the majority of dorsal dislocations. [2]

The Lisfranc ligament originates from the plantar lateral aspect of the medial cuneiform and attaches to the plantar medial aspect of the second MT base. It is the thickest of the ligaments in this region, measuring up to 1 cm wide. This ligament provides the only soft-tissue link between the medial ray and the lesser MT and is responsible for this area's stability.

Motion at the TMT joints is variable. The second and third joints are the stiffest, with minimal motion in the dorsal or plantar plane and none in the medial or lateral plane. The third and first TMT joints exhibit progressively more motion in both planes but still are relatively stiff and mainly function as areas of adjustment to allow the MT heads to share weight equally.

The lateral two TMT joints demonstrate roughly three times more motion in the dorsal or plantar plane than the first TMT joint does. That motion is significant in the function of the foot and must be preserved to maintain normal function, especially if stiffness occurs in the medial and middle columns.

In the column theory, the middle column is more important for rigidity, and the medial and lateral columns are more important for shock absorption during gait. The lateral joints are more important for their mobile contributions to the balancing of forefoot weightbearing. This principle is important in treating these injuries.

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