High impact Lisfranc injuries are becoming more common, often resulting in dislocations that should be reduced emergently to preserve soft tissue integrity. Open reduction and internal fixation of Lisfranc disruptions should be used to stabilize the midfoot, even if the injury is primarily ligamentous. Arthrodesis is not necessary and should not be routinely used as the definitive treatment. Reduction and fixation proceeds proximally to distally and medially to laterally, wherein the goal is to provide stability to the medial foot while preserving lateral column motion.