Objective <p>To analyze the causes of poor prognosis in pediatric patients with Lisfranc injuries treated by open decompression and screw fixation.</p> Methods <p>A total of 186 children with Lisfranc injuries who underwent open decompression combined with cannulated screw fixation were included as the study group. Additionally, 150 pediatric patients with Lisfranc injuries treated with Kirschner wire fixation following open reduction during the same period were enrolled as the control group. Surgical outcomes and risk factors for poor prognosis were compared between the two groups.</p> Results <p>Postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores significantly improved in both groups compared to preoperative scores, with the study group showing higher scores than the control group (P &lt; 0.05). The study group also had shorter operative time, less intraoperative blood loss, and higher rates of excellent and good outcomes compared to the control group (P &lt; 0.05). Significant differences were observed between the good prognosis and poor prognosis subgroups in terms of time from injury to hospital admission, injury type, operative duration, and presence of postoperative complications (P &lt; 0.05). Logistic regression analysis identified time from injury to admission ≥ 24&#xa0;h, injury classified as type B or C (Hardcastle classification), delayed (elective) surgery, and postoperative complications as independent risk factors for poor prognosis in pediatric Lisfranc injuries (P &lt; 0.05).</p> Conclusion <p>Open decompression combined with screw fixation is an effective treatment for Lisfranc injuries in children. However, delayed admission, injury type, prolonged surgery, and postoperative complications are significant factors associated with poor prognosis.</p>