What is the treatment for a Lisfranc injury in a 16-year-old?

Treatment of Lisfranc Injury in a 16-Year-Old

For a Lisfranc injury in a 16-year-old, surgical treatment with open reduction and internal fixation (ORIF) is recommended after proper radiographic diagnosis, as this approach provides the best outcomes for morbidity, mortality, and quality of life by preventing long-term complications such as chronic pain and arthritis.

Diagnostic Approach

Initial evaluation should include:

1. Radiographic assessment:

   • Standard foot radiographs (anteroposterior, lateral, and oblique views) 1
   • Weight-bearing radiographs when possible, as these increase detection of subtle malalignment 1
   • Comparison views of both feet on AP radiographs to identify subtle malalignment 1

2. Advanced imaging if radiographs are normal or equivocal:

   • CT scan - useful for evaluating osseous injury and preoperative planning 1
   • MRI - high correlation with intraoperative findings for unstable Lisfranc injuries 1

Treatment Algorithm

1. Initial Management

• Non-weight bearing status
• Elevation and ice to reduce swelling
• Pain management as appropriate for age

2. Definitive Treatment

• Surgical intervention is indicated for any displacement or instability of the Lisfranc joint complex 1, 2
• Surgery should be performed by a surgeon with expertise in foot injuries 1
• Timing: Early surgical intervention (within 24 hours when possible) does not lead to worse outcomes compared to delayed fixation 3

3. Surgical Approach

• Open reduction and internal fixation (ORIF) with plates, screws, or Kirschner wires 2
• Anatomic reduction is critical to prevent long-term complications
• Hardware removal typically performed 4-5 months after surgery 2

4. Post-Surgical Management

• Non-weight bearing for 6-8 weeks
• Regular follow-up with radiographic assessment
• Progressive weight-bearing as healing progresses
• Physical therapy to restore range of motion, strength, and function

Special Considerations for Adolescents

1. Growth potential: At 16 years, most adolescents are approaching skeletal maturity, but this should be confirmed

2. Rehabilitation focus: Emphasize weight-bearing exercise, maintenance of joint range, and maximizing strength and endurance during recovery 1

3. Follow-up: Regular clinical and functional assessments should be made, including radiography at 12 months post-surgery, or earlier if concerns arise 1

Potential Complications and Prevention

• Missed diagnosis: Lisfranc injuries are frequently undetected with estimates ranging from 20% to 80% 4
• Chronic pain and arthritis: Can result from inadequate treatment or missed diagnosis 2
• Foot deformity: May occur with improper treatment 2

Pitfalls to Avoid

1. Misdiagnosis as a simple sprain: Maintain high index of suspicion for Lisfranc injury with midfoot pain and swelling 5

2. Inadequate imaging: Standard radiographs may appear normal in grade I or II sprains; weight-bearing views are essential 1, 5

3. Premature weight-bearing: Do not allow weight-bearing until advised by the treating surgeon 1

4. Delayed treatment: Delays in proper diagnosis and treatment can lead to poorer outcomes and long-term disability 4, 2

Early recognition and appropriate surgical management of Lisfranc injuries in adolescents is crucial for preventing long-term complications and ensuring optimal functional outcomes.