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Percutaneous K-wire Fixation in A 17-Year Old Male Following A High-Energy Midfoot Injury: A Case Report by Dominick Mastracco DPM1, Dustin Huntsman DPM2, and Gary Most DPM3

The Northern Ohio Foot and Ankle Journal 4(27): 1-5

Abstract: The midfoot is a made up of five bones with numerous articulations. Midfoot fractures are often associated with high-energy trauma and may have a significant impact on function and quality of life. This case of a 17-year old exemplifies the complexity of midfoot fractures and the importance of restoring proper anatomic alignment to decrease morbidity and improve long-term functionality in patients.

Key words: Midfoot injury, Lisfranc injury, Chopart’s joint, pediatric injury, percutaneous fixation

Accepted: April, 2018 Published: May, 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution License. It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Northern Ohio Foot and Ankle Foundation Journal. (www.nofafoundation.org) 2014. All rights reserved.

Midfoot fractures are well studied in the adult

population but are relatively uncommon in

adolescents [1]. Midfoot fractures and dislocations are

most commonly the result of high-energy trauma but

may occur secondary to low energy injuries. In a

review of the literature, midfoot injuries occur in

roughly 10% of polytrauma [4]. A thorough clinical

exam is of critical importance in any patient where

midfoot injuries are suspected. These types of injuries

may present with a wide variability, ranging from

localized pain, that is exaggerated with weight bearing,

to severe edema and hematoma formation over the

midfoot. In subtle injuries, pain to palpation may be

the only positive finding. In more severe injuries,

plantar ecchymosis may be a pathognomonic sign of

midfoot injuries, suggesting rupture of the strong

plantar ligaments [3]. Midfoot injuries are often

Address correspondence to: dvmastracco@mercy.com. 1Podiatric Medicine and Surgical Resident, Mercy Regional Medical Center, Lorain, Ohio. 2Staff, Chief of Podiatry Hillcrest Hospital, Mayfield Heights, Ohio

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Volume 4, No. 27, May 2018 Mastracco, Huntsman, Most

missed and underdiagnosed thus, resulting in

significant morbidity and functional decline. High

energy type injuries, such as a high fall, can cause

gross deformities and severe crush injuries.

Neurovascular exam is a key component in ruling out

compartment syndrome. If significant dislocations or

fractures are present, urgent reduction and splinting

should be performed to minimize the risk of soft

tissue necrosis and neurovascular compromise.

Depending on the stability of the injury or fracture

pattern, the use of temporary external fixation may

be necessary. Radiographic assessment is essential and

should include both foot and ankle views.

Conventional radiography can be misleading,

especially in subtle injuries. Computed tomography

(CT) is an important tool in understanding the extent

of an injury and may be critical for pre-operative

planning. Fixation may vary depending on many

factors such as the patient’s age, fracture or

dislocation pattern, severity of injury, and quality of

the soft tissue envelope. Goals of fixation should be

aimed at achieving proper reduction of all fracture/

dislocations and restoring the integrity of the

longitudinal and transverse arches of the foot. We

present a case of a 17 year old male who sustained a

high-energy complex midfoot injury involving

dislocation and fractures of the midfoot after a 15-

foot fall from a rooftop.

Methods

A search of the literature was conducted regarding pediatric midfoot crush injures, and treatment options until April 2018. References from the appropriate articles were also reviewed to find all reports and outcomes of pediatric injuries in the literature.

Case Report

A 17-year-old male presented to clinic complaining of a painful right foot. The patient worked as a local roofer and stated that he fell from a height of 15 feet while working and landed on his right foot. On initial presentation, the patient described four out of ten aching pain across the right foot. He denied pain to the contralateral foot or leg, neck, lower back, hips or knees. The patient had no significant past medical history, was not on any medications and had no known drug allergies. A year earlier, the patient underwent open reduction internal fixation (ORIF) of his left fourth metatarsal following a fracture due to a similar type of injury, that ended up healing uneventfully.   On physical exam, pedal pulses were palpable with brisk capillary refill to all digits. A neurological exam was negative for any paresthesia’s. Dermatologic exam was significant for diffuse non-pitting edema and ecchymosis to the plantar, medial, and lateral right foot. There were no fracture blisters noted. On musculoskeletal exam there was a significant amount of midfoot instabi l i ty noted with manual manipulation. Pain was elicited with palpation across the right midfoot. Range of motion and muscle strength was deferred secondary to pain.

Right foot plain film radiographs were taken in clinic and revealed multiple midfoot fractures including comminution of the cuboid and plantar subluxation of the navicular. A CT scan revealed multiple

The Northern Ohio Foot & Ankle Foundation Journal, 2018

Volume 4, No. 27, May 2018 Mastracco, Huntsman, Mostadditional fractures to the intermediate and lateral cuneiforms and to metatarsal bases one, three and four.

"

" Figure 1a & 1b. Lateral and oblique views of the right foot demonstrated partial dislocation of the cuneiform-navicular joint along with comminution of the cuboid.

" "

Figure 2. CT coronal views displaying fractures of

the cuboid, intermediate and lateral cuneiforms and

metatarsal bases 1, 3, and 4.

Due to the patient’s persistent swelling and concerns of further soft tissue injury, the decision was made pre-operatively to percutaneously reduce and stabilize the midfoot using k-wire fixation. This allowed for stabilization and reduction of the fractures and dislocations while minimizing trauma to the soft tissue envelope.

The patient underwent spinal anesthesia with a

popliteal block to the right lower extremity. Closed

reduction under fluoroscopy was attempted to

relocate the navicular-cuneiform joint.   After the

dorsal cortices of the talus, navicular, and medial

cuneiform were re-aligned, the medial column

was  then stabilized with two 0.62 k-wires. Next, the

second tarsometatarsal joint and calcaneo-cuboid

joint were reduced and stabilized with a 0.62 k-wires

as well. For extra stabilization and reduction, k-wires

were then placed across the fourth tarsometatarsal

joint and intercuneiform joints. One last k-wire was

placed through the base of the first metatarsal and

into the base of the second metatarsal. A total of

eight 0.62 k-wires were used to reduce and stabilize

the patient’s midfoot. Exiting K-wires were covered

with antibiotic ointment and non-adherent dressings.

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Volume 4, No. 27, May 2018 Mastracco, Huntsman, Most

Finally, a dry sterile compressing dressing was applied

with a posterior splint. Follow up radiographs were

taken on post-op days (POD) 15, 43, and 71.

Radiographic assessment of alignment and boney

consolidation were adequate at each visit. All K-wires

were removed on POD 43. Afterwards, the patient

was instructed to begin partial weight bearing in a

Figure 3a & 3b. Intraoperative fluoroscopy

displaying the use of percutaneous k-wires to obtain

anatomical reduction of all fractures/dislocations.

CAM boot. Following the fourth and final office

follow up, on POD 71, the patient was full weight

bearing and pain free.

" "

Figure 4a & 4b. Weight bearing radiographs 10

weeks post op with boney consolidation and

appropriate anatomic alignment.

Discussion

There has been little published data regarding Lisfranc and midfoot injuries in children and adolescents. It has been reported that foot and ankle fractures only represent 12% of all pediatric fractures, with malleolar fractures being the most dominant injury [13]. Current estimates within the adult population suggest that the incidence of Lisfranc injuries is approximately 1 in 55,000 emergency room visits. Estimates suggest 1 in every 5 Lisfranc injuries are missed on initial exam. Koster et al. reported that 41% of all midfoot fractures are missed completely [4,10].  Midfoot injuries that go undiagnosed may result in significant morbidity.  Current literature suggests that Chopart’s joint injuries are even less common compared to tarsometatarsal joint injuries, although both are just as likely following high-energy trauma [5].  Whether a Lisfranc, Chopart’s, or both, it is important to evaluate and treat for possible soft tissue or neurovascular injury, compartment syndrome, and fractures else where in the foot and body.  Regardless of fixation techniques, most authors are in agreement that proper anatomical reduction needs to be the focus of treatment. Anatomical alignment is defined as the medial border of the middle cuneiform being in line with the second metatarsal base on anterior-posterior radiographs, the lateral border of the lateral cuneiform being in line with the third metatarsal base on oblique radiographs, and the medial border of the cuboid being in line with the base of the fourth metatarsal base on oblique radiographs as well [14].

Veijola et al. retrospectively examined seven teenagers who had experienced a Lisfranc injury. Injuries ranged from purely ligamentous, to osseous fracture or dislocations.  All seven patients underwent ORIF with the use of screws and K-wires.   In this study all but one patient returned to pre-injury activity level and had good anatomic reduction of their injuries [6]. It is worth noting that not all pediatric midfoot injuries involve a fracture of bone. Hill et al. also examined

The Northern Ohio Foot & Ankle Foundation Journal, 2018

Volume 4, No. 27, May 2018 Mastracco, Huntsman, Mostresults from fifty-six children following Lisfranc injuries through their own retrospective analysis. Their results showed that 39 injures were reported as fractures, while the remaining 17 were just ligamentous sprains and about 61% of these injures were sustained while playing some sport [9]. The authors went on to report that 100% of Lisfranc sprains received no form of intervention and went on to heal uneventfully [9]. The author also mentioned that out of the 39 reported Lisfranc fractures, about 19 patients, or 34% of patients underwent operative treatment, and noted that patients with closed physes were more likely to undergo surgical correction [9].

There is limited published literature regarding pediatric midfoot injuries, and even fewer reports d o c u m e n t i n g t h e u s e o f p e r c u t a n e o u s fixation.   Wagner et al. examined twenty-two patients who underwent percutaneous screw fixation following a Lisfranc injury. In this study they evaluated time until full weight bearing.    Results showed 100% anatomical reduction of injuries, and full-unrestricted weight bearing at 12.4 weeks [7].  Doshi et al. published a similar case report, where surgical intervention was performed using percutaneous k-wire fixation. Authors reported a 24-year-old male who sustained a fall from a significant height resulting in a dorsal dislocation of the intermediate cuneiform. The patient underwent closed reduction in the operating room, followed by percutaneous k-wire fixation to further maintain and support proper anatomic alignment [8].   The patient was kept non-weight bearing for 6 weeks and k-wires were subsequently removed at that time.

Looking at the data published for Lisfranc and midfoot injuries within the adult population provides better comparison of fixation techniques against one another. Schepers et al. examined the anatomical reduction of Lisfranc injuries for patients who underwent closed reduction versus open reduction with internal fixation. Reported results favored ORIF, with 86% (19/22) of ORIF patients achieving acceptable reduction, compared to only 33% (2/6) of patients undergoing closed reduction classified as acceptable reduction [11]. When comparing different forms of ORIF, Hu et al. prospectively examined

sixty patients undergoing two forms of ORIF to repair Lisfranc fractures, with thirty-two patients undergoing solely screw fixation verses those who underwent screw and plate fixation. Overall, patients receiving a dorsal plate crossing the TMTJ complex reported better AOFAS scores, and reported less post operative pain. Authors suggested the plate enhanced the “rigid stability” across the Lisfranc complex [14]. This notion of increased “rigid stability” for these midfoot injuries can be seen as reproduction of Coetzee’s 2007 historical article comparing ORIF and primary arthrodesis. Coetzee’s results indicated that patients who underwent arthrodesis of the Lisfranc joint following a Lisfranc injury not only reported better AOFAS scores, but had a higher percentage (92% vs 65%) to return to pre-injury activity [12].  

In conclusion, more research and investigation may be warranted regarding incidence and treatment for high-energy midfoot injuries sustained within the pediatric and adolescent populations. Although there is much literature within treatment options for the adult population, there is little consensus on proper fixation for children who experience some form of a midfoot injury.    Further research may help provide additional information in order to effectively manage these patients, thus affording more positive surgical outcomes within this specific patient demographic.

References 1. Benirschke, Stephen K., et al. "Fractures and dislocations of the midfoot: Lisfranc and Chopart injuries." JBJS 94.14 (2012): 1325-1337.

2. Swords, Michael P., et al. "Chopart fractures and dislocations."  Foot and ankle clinics  13.4 (2008): 679-693.

3. F.P. Dewar, D.C. Evans. Occult fracture-subluxation of the midtarsal joint. J Bone Joint Surg Br, 50 (1968), pp. 386-388.

4. Vosbikian, Michael, et al. "Outcomes After Percutaneous Reduction and Fixation of Low-Energy Lisfranc Injuries."  Foot & ankle international  38.7 (2017): 710-715.

5. Dutt, Laksha, et al. "Transcuneiform Crush Injury: A Case Report." Clin Res Foot Ankle 3.162 (2015).

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Volume 4, No. 27, May 2018 Mastracco, Huntsman, Most6. Veijola, Kia, Heikki-Jussi Laine, and Olli Pajulo. "Lisfranc injury in adolescents."  European journal of pediatric surgery 23.04 (2013): 297-303.

7. Wagner, Emilio, et al. "Early weight-bearing after percutaneous reduction and screw fixation for low-energy lisfranc injury." Foot & ankle international 34.7 (2013): 978-983.

8. Doshi, Deepak, Prashanth Prabhu, and Atanu Bhattacharjee. "Dorsal dislocation of the intermediate cuneiform with fracture of the Lisfranc joint: a case report."  The Journal of Foot and Ankle Surgery  47.1 (2008): 60-62.

9. Hill, J. F., Heyworth, B. E., Lierhaus, A., Kocher, M. S., & Mahan, S. T. (2017). Lisfranc injuries in children and adolescents.  Journal of Pediatric Orthopaedics B, 26(2), 159-163.

10. Kösters, C., Bockholt, S., Müller, C., Winter, C., Rosenbaum, D., Raschke, M. J., & Ochman, S. (2014). Comparing the outcomes between Chopart, Lisfranc and multiple metatarsal shaft fractures.  Archives of orthopaedic and trauma surgery, 134(10), 1397-1404.

11. Schepers, T., Oprel, P. P., & Van Lieshout, E. M. (2013). Influence of approach and implant on reduction accuracy and stability in Lisfranc fracture-dislocation at the tarsometatarsal joint. Foot & ankle international, 34(5), 705-710.

12. Coetzee, J. C., & Ly, T. V. (2007). Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and i n t e r n a l f i x a t i o n : s u r g i c a l technique. JBJS, 89(2_suppl_1), 122-127.

13. Rammelt, S., Godoy-Santos, A. L., Schneiders, W., Fitze, G., & Zwipp, H. (2016). Foot and ankle fractures during childhood: review of the literature a n d s c i e n t i f i c e v i d e n c e f o r a p p r o p r i a t e treatment. Revista brasileira de ortopedia, 51(6), 630-639.

14. Cheow, X., & Lam, K. Y. (2018). Midterm functional outcomes in operatively treatedadolescent Lisfranc injuries. Journal of pediatric orthopedics. Part B.

15. Hu, S. J., Chang, S. M., Li, X. H., & Yu, G. R. (2014). Outcome comparison of Lisfranc injuries treated through dorsal plate fixation versus screw fixation. Acta ortopedica brasileira, 22(6), 315-320. The Northern Ohio Foot & Ankle Foundation Journal, 2018