Hardcastle Classification System
Jacques Lisfranc (1790-1847) was a French surgeon in Napoleon's
army. He is best known today for describing the joint that bears his name.
What is Lisfranc's joint?
Lisfranc's joint is the joint where the
midfoot attaches to the metatarsal bones (the long bones in the ball of
the foot through which the toes attach to the foot). This is
also known as the tarso-metatarsal joint. See the X-ray to the right
to see Lisfranc's joint
What is a Lisfranc's dislocation?
A Lisfranc's dislocation is where one or several of the metatarsal bones
become misaligned with the bones of the midfoot (the cuneiforms and the cuboid
bones). Small chip fractures of the metatarsals are often associated with this
condition, but the biggest problem is the dislocation itself, which can be very
debilitating when left untreated.
Lisfranc's dislocations are
sometimes obvious, but they can be very difficult to diagnose at times,
with radiographic (X-ray) changes often very subtle and difficult to
discern. For this reason, it is very important that these
conditions be assessed by an individual who specializes in the foot.
In the example to the left, the films look reasonably normal, until you
notice the gap between the first and second metatarsal bones.
(This would be classified as a Hardcastle B2 injury, a classification
system described below.)
Who gets Lisfranc dislocations?
There are two main groups:
Those exposed to sudden trauma. The trauma
causing this injury may be severe, but modest "freak" injuries may
result in this condition more frequently than you might expect. The
mechanism is usually plantarflexion (the foot is pointed downwards) with a
sudden twisting of the foot.
Those with poor sensation in their feet.
The largest members in this category are diabetic
and alcoholic neuropathy.
Lack of sensation from these conditions may lead to a
Lisfranc dislocations and severe arthritis and deformity.
How are Lisfranc injuries classified?
Most podiatric physicians use a modified version of
Hardcastle Classification System:
Total incongruity (all the metatarsals are dislocated,
and together move as a unit in one direction).
Partial incongruity involving the medial metatarsals
(the metatarsals nearest the big toe are dislocated).
Partial incongruity involving the lateral metatarsals
(the metatarsals nearest the little toe are dislocated). The example
above is a B2 because the 1st metatarsal has not moved; the 2nd, 3rd, 4th, and
5th metatarsals (the lateral metatarsals) have moved together away from the
Divergent incongruity involving some metatarsals (2 or
more metatarsals are dislocated in different directions.
Divergent incongruity involving all the metatarsals (all
the metatarsals are dislocated, moving in different directions.
How are Lisfranc injuries treated?
A non-weight-bearing cast may be attempted in some
cases, but in the majority of cases surgery is performed. Surgery usually
involves realigning the metatarsals and holding them in place with pins
(K-wires), Screws or External Fixation, then casting the patient in a
non-walking cast. (For more information about how to hold bones together,
please visit our web page on fixation
How do Lisfranc
Often quite well, but Lisfranc injuries often lead
to long-term, chronic arthritis in the affected foot. Additional surgery
to fuse the bones is sometimes necessary. Early diagnosis and treatment
increases the odds greatly of successful long-term treatment.