A 26-year-old man sustains a twisting injury during a football match. Weight-bearing radiographs of the foot show diastasis between the bases of the first and second metatarsals and a small bony fragment at the medial base of the second metatarsal. What does the small fragment represent?

• A Avulsion of the Lisfranc ligament attachment ✓
• B Avulsion of the plantar plate by the peroneus longus tendon
• C Sesamoid bone of the second ray
• D Fracture of the medial cuneiform by direct compression

Explanation

The fleck sign is a small avulsion fragment at the base of the second metatarsal or the medial cuneiform representing rupture of the Lisfranc ligament, which runs from the lateral surface of the medial cuneiform to the medial base of the second metatarsal. Its presence confirms a Lisfranc fracture-dislocation requiring surgical fixation. The second metatarsal has no sesamoids, and peroneus longus inserts on the first metatarsal base, not the second.

Reference: Bailey and Love's Short Practice of Surgery, 28th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.