Evaluating Unstable Lisfranc Injuries on Plain Radiographs and Computed Tomography: An Imaging Review of Underdiagnosed Injuries

Purpose or Learning Objective: Lisfranc fracture dislocations are complex midfoot injuries that frequently require surgical intervention and can have significant consequences if missed. Imaging findings can be subtle with varying evidence on the diagnostic capabilities of plain radiographs (XR) and computed tomography (CT) to identify unstable Lisfranc and associated injuries.

In this imaging series, we highlight review areas where injuries may be underdiagnosed on XR when compared with subsequent CT. We also compare the usefulness of XR versus CT in a trauma center setting.

Methods or Background: A retrospective analysis was performed of patients who sustained a Lisfranc injury and underwent surgery in two UK trauma centers between 2013 and 2022. Patients with unstable Lisfranc fracture dislocation who had surgical fixation and had both preoperative XR and CT imaging were included. The studies were reviewed independently to identify associated fractures.

Results or Findings: A total of 175 patients were reviewed. Our assessment shoed that XR significantly underdiagnoses midfoot and metatarsal fractures. The largest discrepancies between detection rates of XR and CT included fractures of the cuboid (5.7% versus 28%), medial cuneiform (20% versus 51%), and lateral cuneiform (4% versus 36%).

XR also demonstrated reduced sensitivity when compared with CT, primarily of lateral column injuries, specifically fractures of the lateral cuneiform, cuboid, and fourth and fifth metatarsals.

Our imaging case series highlights review areas on XR where injuries may be underdiagnosed.

Conclusion: Our analysis in two trauma centers demonstrates that plain radiography can significantly miss associated fractures in patients with an unstable Lisfranc fracture dislocation, especially in lateral column injuries. CT is recommended for appropriate surgical planning.

Publication History

Article published online:
26 May 2023