A 25 yo male presents after an MVC with severe right foot pain.  The plain film is shown.  What's the diagnosis?  Scroll down for answer.

Answer: Lisfranc injury (tarsometatarsal fracture dislcoation)

• Lisfranc injury can range from purely soft tissue injury to fracutre dislocation as above
• occurs at articulation of medial cuneiform to base of second metatarsal
• MVAs and athletic injuries are common mechanisms
• hyperflexion with abduction of forefoot (history of this mechanism in athletic injuries should raises suspicion for Lisfranc in subtle cases)
• diagnosis usually by plain radiograph - oblique, lateral or stress views may be needed
• the main radiographic signs of Lisfranc injury

1. disruption of straight line from base of medial second metatarsal to medial aspect of middle cuneiform (AP view)   
2. widening between first and second metatarsal bases

• CT is useful for subtle injuries, MRI may be used in diagnosis of purely ligamentous injuries
• orthopedics consultation recommended
• many require operative repair

Reference: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8eEds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016, pg 1568-69