Subtle Lisfranc instability. A, Intraoperative fluoroscopic radiograph showing fleck sign at medial cuneiform–second metatarsal articulation. Patient was taken to operating room because standing radiographs in office showed subtle subluxation, swelling, and tenderness and pointed to more serious instability. B, Intraoperative stress radiographs showing subluxation of first through third tarsometatarsal articulations. C, Provisional stabilization with guidewires inserted under fluoroscopic control. D, Final fixation with cannulated screws.