Adolescents with Lisfranc Injury Frequently Have Different Pathology with Higher Incidence of Proximal Extension of the Ligamentous Disruption

Abstract

Category:Midfoot/Forefoot; TraumaIntroduction/Purpose:Lisfranc injuries are rare injuries in the adolescent age group and can be easily missed. Ligamentous Lisfranc injuries have been classically descried as disruption of the Lisfranc ligament (between medial cuneiform and second metatarsus) and ligamentous disruption of the first metatarso-phalangeal joint. The study aimed to report pathological pattern of Lisfranc injury in adolescent patient and if it was different from the common adult forms.Methods:This is a retrospective study of patients with Lisfranc injury treated at a Level 1 trauma center between 2012 and 2019. This study has been IRB approved. The inclusion criteria were of adolescents with isolated Lisfranc injuries and treated via surgical intervention. The surgical intervention helped to identify the exact pathology. The study excluded patients over the age of 18, patient with high energy injuries and patients treated non-operatively. Patients' demographics including age and gender, were recorded. Other variables included the mechanism of injury, side of injury, fracture type, the intraoperative findings of the ligamentous injury and follow-up data. Follow up radiographs were reviewed for time to bony union and any post-traumatic complications. Outcomes include wound healing status, the union status of the fracture, and complications that may arise along with treatment and follow-up.Results:A total of 9 patients met the study inclusion criteria. Mean age was 15.4 years old, male to female ratio of 5:4, mean follow-up time was 9.5 months. All patients achieved full union at the final follow-up. The postoperative course went without complications except one for patient. The patient had prominent screw under the skin. The screw removed in the office under local anesthesia. Intraoperative findings in 6/9 (66.6 %) cases demonstrated a Lisfranc injury pattern with proximal extension through the inter-cuneiform ligament. Operative treatment in cases of proximal extension included added fixation between the middle cuneiform and middle cuneiform (screws or plates). Also noted in 2 cases, that the 1st tarso-metatrsal joint was not affected (in contrast to classic Lisfranc injury in adults). In these cases, no fixation was need for the 1st TMT joint.Conclusion:Lisfranc injury in adolescent has frequently different pathology compared to adults' counterparts. It commonly involves proximal extension with the ligament disruption. It also sometimes spares the ligaments of the 1st TMT joint. Orthopedic surgeons should be aware of these changes as it implies changes in the treatment strategy and fixation construct.