A 26-year-old footballer lands awkwardly and develops midfoot pain. Weight-bearing radiographs show more than 2 mm of diastasis between the bases of the first and second metatarsals, with a small avulsed bony fragment lying between them. The small fragment represents avulsion of which structure?

• A The bifurcate ligament
• B The plantar fascia attachment to the second metatarsal base
• C The peroneus longus tendon insertion
• D The Lisfranc ligament from the lateral aspect of the medial cuneiform ✓

Explanation

This is the fleck sign of a Lisfranc injury. The Lisfranc ligament runs from the lateral border of the medial cuneiform to the medial base of the second metatarsal, the keystone of the tarsometatarsal joint. Avulsion produces a small osseous fragment in that interval with diastasis of the first and second rays. The bifurcate ligament connects the calcaneus to the cuboid and navicular, and the other structures do not produce this fragment.

Reference: Campbell's Operative Orthopaedics, 14th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.