Tarsometatarsal injury in a child

The Posttraumatic Tarsometatarsal Joints

Tarsometatarsal joint injuries can be painful and debilitating and are most commonly due to direct or indirect trauma. Posttraumatic arthritis is a well-known long-term complication, with incidence as high as 58%. Conservative treatment options include shoe modifications, orthotic inserts, topical or oral anti-inflammatories, and intra-articular corticosteroid injections. There are various joint prep and fixation techniques reported in the literature, many with positive clinical and radiographic outcomes. This article discusses nonoperative and operative management of posttraumatic tarsometatarsal joint arthritis, reviews available literature, and includes the authors' tips and techniques.

Arthrodesis in Acute and Chronic Lisfranc's Patients: A Retrospective Cohort Study

Injury to Lisfranc's joint complex affects the longitudinal and transverse arches of the foot and can significantly alter its biomechanics. Some of the previous studies have suggested primary arthrodesis to be superior to open reduction and internal fixation for treating primarily ligamentous Lisfranc injuries. Additionally, arthrodesis is often used for treating chronic Lisfranc injuries, including those which previously underwent open reduction and internal fixation and subsequently developed arthrosis. The purpose of this study was to retrospectively evaluate the outcomes of arthrodesis at the level of Lisfranc's articulation for both acute and chronic injuries. Patients who underwent midfoot arthrodesis surgical procedures between years 2001 and 2017 were retrospectively reviewed. About 187 patients with an average age of 55.9 ± 13.2 years old and a minimum follow-up of 1 year were included in the study. Median time to return to preoperative activities was 11 weeks. Overall successful joint fusion rate was 81.4%. However, concomitantly fused joints of the midfoot and hindfoot, in addition to the tarsometatarsal joints (TMTJ), were included in the overall fusion rate. Fusion rate at the first TMTJ was 90.2% (101 out of 112), second TMTJ was 94.4% (67 out of 71), and third TMTJ was 97.8% (45 out of 46). The present study demonstrates that patients who undergo arthrodesis for both acute and chronic Lisfranc injuries typically can return to activity in under approximately 3 months postoperatively (acute patients significantly faster) with a high union rate at the TMTJs. However, the overall union rate is significantly lower when concomitant proximal midfoot and rearfoot arthrodesis procedures are performed.

Radiographic Anatomy of the Pediatric Lisfranc Joint

BACKGROUND

Injuries to the Lisfranc joint in children and adolescents are rare. The incomplete ossification of the bones of the foot makes it difficult to detect injuries.The aim of this study was to determine age-specific radiographic measurements of the Lisfranc joint to provide guidance to the radiologist, emergency physicians, and surgeons to decrease misdiagnosis of Lisfranc injuries and improve detection.

METHODS

We retrospectively reviewed all foot radiographs without traumatic injury made between August 2014 and February 2015 in all patients younger than 18. The attendance list of the Emergency Department and Outpatient Clinic of a level-1 trauma center were used. Using a non-weight-bearing anteroposterior-view of the foot the distance between the base of metatarsal 1 and metatarsal 2 (MT1-MT2) and the distance between the medial cuneiform (MC) and the base of metatarsal 2 (MC-MT2) were measured. Median normal values were calculated per age.

RESULTS

A total of 352 patients between the age of 0 and 18 years were screened for eligibility. Excluded were 109 patients because of anatomic abnormality, a fracture, inadequate radiograph, pain at the base of the first metatarsal, second metatarsal or MC, persisting pain at the Outpatient Clinic checkup or no follow-up. Included in the analysis were 243 patients.

CONCLUSIONS

The distance between the base of MT1-MT2 was constant below 3 mm. Measurements for both MT1-MT2 and MC-MT2 distance approached adult values at the age of 6.

LEVEL OF EVIDENCE

Level III.

Midfoot Degenerative Arthritis and Partial Fusion After Pediatric Lisfranc Fracture-Dislocation

We present a case of a 10-year-old girl who sustained a Lisfranc fracture-dislocation after an all-terrain vehicle accident. She underwent open reduction and internal fixation with smooth Kirschner wires. At 5-year follow-up, she had developed functional pain and radiographic evidence of degenerative arthritis and partial fusion of her midfoot. There are several possible explanations for this outcome, including loss of reduction, traumatic or iatrogenic physeal injury, and severity of initial injury. Long-term outcomes in children with Lisfranc injuries are not well described. Our case may begin to shed light on the natural history of these injuries in the pediatric population, with the consideration of potential treatment implications and pitfalls.

Age, sex, causal and injury patterns in tarsometatarsal dislocations: a literature review of over 2000 cases

BACKGROUND

The causes and mechanisms of tarsometatarsal (TMT) dislocations are poorly characterized. Unfortunately, the rarity of these injuries makes it difficult and costly to gather the epidemiological data needed to better understand the populations at risk and the circumstances under which injury is most likely to occur.

METHODOLOGY

To address this issue, literature reports of TMT dislocations were identified and analyzed to generate statistical descriptions of the common causes of injury, the age and sex of those injured, and the pattern of injury. Over 2000 injuries were identified from 187 articles.

RESULTS

The analysis reveals that over 40% of injuries were related to traffic accidents. Based on the Hardcastle classification system, more than 60% of TMT dislocation were partial (type B) injuries. Over 55% of the injured were between 15 and 35 years of age, and males were injured more than twice as frequently. Conversely, the victims of falls tended to be older and represented a larger proportion of females. The age and sex of those injured by TMT dislocations vary by cause.

CONCLUSION

An improved understanding of the epidemiologic patterns will benefit research into the mitigation and prevention of these injuries.