Management of Lisfranc Injury With Anterolateral Calcaneal Compression Fracture

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Management of Lisfranc Injury With Anterolateral Calcaneal Compression Fracture: A Study on Misdiagnosis, Treatment, and Outcomes

Foot injuries are deceptively complex. A twist, a fall, or a car accident can damage bones and joints that are easy to overlook—especially when one injury overshadows another. A 2022 study from orthopedic surgeons at Shanghai Jiao Tong University Affiliated Sixth People’s Hospital and Ludian County People’s Hospital highlights a rare but risky combination: Lisfranc injury (a midfoot joint sprain or fracture) paired with an anterolateral calcaneal compression fracture (a crushed fragment on the front outer part of the heel bone). The findings offer critical lessons on avoiding misdiagnosis and improving treatment for this often-missed condition.

What Is This Injury—and Why Is It Hard to Diagnose?

The Lisfranc joint connects the long bones of the foot (metatarsals) to the smaller tarsal bones in the midfoot. An anterolateral calcaneal compression fracture affects the calcaneus (heel bone), specifically the front outer edge where it meets the cuboid bone (part of the midfoot). These injuries usually stem from an abduction force—like rolling the foot outward forcefully (e.g., in a car crash or sports injury).

The problem? The heel bone fragment is often too tiny to show up on regular X-rays, and surgeons tend to focus on the more obvious Lisfranc damage. In the study, 38% of patients had the calcaneal fracture missed initially. “If a patient has tenderness on the outer side of the foot, doctors should suspect this fracture immediately,” says lead author Wenqi Gu, MD, of Shanghai Sixth People’s Hospital. The team urges using 3D CT scans for all midfoot injuries—they reveal small fragments that X-rays miss.

Study Details: 13 Patients, 2 Years of Follow-Up

The researchers studied 13 adults with this combined injury. All underwent open reduction and internal fixation (ORIF): surgery to realign displaced bones and fix them with implants. The key innovation? Using a mini-fragment plate to “raft” the tiny calcaneal fragment in place. Unlike wires (which can loosen) or screws (which may fail in small/broken fragments), the plate provides stable, even pressure to hold the bone together.

After an average of 28 months (range: 1–5 years) of follow-up, results were promising:

  • Pain relief: Average pain scores (Visual Analogue Scale, VAS) dropped from 5.9 (moderate pain) to 1.8 (mild/no pain).
  • Function recovery: The American Orthopaedic Foot & Ankle Society (AOFAS) midfoot score—measuring walking, standing, and pain—averaged 82.1 (out of 100), with most patients scoring “good” to “excellent.”
  • Return to work: Everyone went back to their jobs within 5–12 months (average: 7.5 months). Patients with fewer symptoms or higher AOFAS scores returned faster.

Treatment Insights: Why ORIF and Mini-Fragment Plates Work

The team chose ORIF over primary arthrodesis (fusing bones together) for two reasons:

  1. Preserve joint health: Fusion can speed up degeneration of nearby joints.
  2. Patient preference: Many Chinese patients are hesitant to have permanent joint fusion.

The mini-fragment plate was a game-changer for the calcaneal fracture. “It stabilizes the fragment without needing screws to go into the tiny piece,” explains Dr. Gu. “This prevents the fragment from shifting again and makes implant removal easier later.” No patients in the study had the fragment re-displace or the plate fail.

Complications: What to Watch For

Even with successful surgery, midfoot injuries carry risks:

  • Posttraumatic arthritis: 15% of patients developed mild arthritis in the Lisfranc joint, managed with painkillers and supportive braces.
  • Midfoot stiffness: 23% reported stiffness, linked to keeping implants in too long.
  • Implant breakage: 3 patients had broken plates during removal (no pain or harm).

The team’s advice: Remove Lisfranc screws before full weight-bearing and plates by 10 months to avoid stiffness or breakage.

Key Takeaways for Patients and Doctors

For doctors:

  • Don’t stop at the Lisfranc joint—check the entire midfoot, including the Chopart joint (heel-to-midfoot connection).
  • Use 3D CT scans for all midfoot injuries to catch hidden fragments.

For patients:

  • If foot pain lingers after an injury, ask about a 3D CT scan—you might have a hidden fracture.
  • ORIF with mini-fragment plates is a reliable treatment, and most people return to normal activity.

The Bottom Line

This combined injury is rare, but it’s dangerous if missed. With careful diagnosis (3D CT scans) and targeted treatment (ORIF with mini-fragment plates), patients can recover well. The study also highlights a bigger issue: foot injuries require a whole-foot evaluation—not just focusing on the most obvious problem.

As Dr. Gu notes: “The midfoot is a complex system. You can’t fix one part without checking the rest.”

This study was published in the Chinese Medical Journal (2022) by Wenqi Gu, Rui Zhang, Wanjun Liu, Zhongmin Shi, Guohua Mei, Jianfeng Xue, Jian Zou, Xiaokang Wang, and Jiantao Jiang.
doi.org/10/d84h5x (10.1097/CM9.0000000000001924)

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