Asymmetric lambda sign of the second tarsometatarsal joint on axial weight-bearing cone-beam CT scans of the foot: preliminary investigation for diagnosis of subtle ligamentous Lisfranc injuries in a cadaveric model



Subtle Lisfranc joint injuries remain challenging to diagnose. Although of questionable accuracy, the current gold standard to assess these injuries is through bilateral weight-bearing radiography. However, weight-bearing cone beam–computed tomography (CBCT), providing clearer visualization of bony landmarks, can also be utilized for evaluation. This study aims to establish the hypothesis that a specific weight-bearing CBCT finding (asymmetric lambda sign) can serve as an independent indicator of a subtle Lisfranc injury.


Weight-bearing CBCT images of 24 match-paired cadaveric legs were acquired, initially intact, and then following sequential dissection of each aspect (dorsal, interosseous, and plantar ligaments, respectively) of the Lisfranc ligamentous complex (LLC). All scans were taken in non- (NWB, 0 kg), partial- (PWB, 40 kg), and full-weight-bearing (FWB, 80 kg) manners. The lambda sign was then inspected axially for asymmetry (positive sign) by identifying three symmetrical joint spaces created between the medial cuneiform and the second metatarsal base (C1-M2), the medial and middle cuneiform (C1-C2), and the second metatarsal base and middle cuneiform (M2-C2).


A positive sign was observed in 25.6% (221/864) of all studies. Most notably, the fully dissected specimens demonstrated an asymmetric lambda sign in 33.3%, 72.2%, and 83.3% in NWB, PWB, and FWB conditions, respectively. The inter- and intra-observer reliability kappa value was calculated to be 0.843 and 0.912.


An asymmetric lambda sign is a simple and useful indicator for a complete LLC injury in PWB and FWB conditions using a cadaver model.

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The authors wish to thank Sebastian Drago Perez for his assistance in measuring applicable study parameters and Arne Burssens for creating the 3D model used in our study analysis.

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Correspondence to Alexej Barg.

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Level of Evidence: Level 4; Diagnostic study, Case series

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Sripanich, Y., Steadman, J., Krähenbühl, N. et al. Asymmetric lambda sign of the second tarsometatarsal joint on axial weight-bearing cone-beam CT scans of the foot: preliminary investigation for diagnosis of subtle ligamentous Lisfranc injuries in a cadaveric model. Skeletal Radiol 49, 1615–1621 (2020).

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  • Tarsometatarsal
  • Ligament
  • Subtle
  • Cone-beam CT
  • Diagnostic sign