Pediatric and Adolescent Foot Injuries Rang’s Children’s Fractures Wenger and Pring 2005

Introduction Injuries to children’s feet are usually simple and easily managed Missed midfoot fracture-dislocation may lead to disability Magnitude of the soft tissue injury may be more significant than the fracture

Phalangeal Fractures Pain may be out of proportion to the x-ray findings Simple fractures may require a combination of: Buddy taping Hard-sole shoe Casting

Phalangeal Fractures Displaced fracture Usually Salter II May require digital block for reduction Use a pencil in the web space as a fulcrum to assist in the reduction Confirm reduction with x-rays

Phalangeal Fractures Displaced fracture May require open reduction if perisoteum or soft tissue is interposed in fracture site blocking reduction K-wire or screw fixation may be required to maintain reduction ORIF may be associated with long term stiffness

Phalangeal Fractures Great Toe Stubbed toe may suffer a Salter V physeal injury with late growth arrest Open Salter I or II fracture with damage to nail bed and matrix Debride fracture site Oral antibiotic coverage May require pinning if unstable

Phalangeal Fractures Great Toe Displaced Salter III or IV fracture of the base of the proximal phalanx common in sports Fracture requires accurate reduction Non-surgical management for fracture displacement <2mm Cast Non-weight bearing for 3 weeks

Phalangeal Fractures Great Toe Displaced Salter III or IV fracture of the base of the proximal phalanx Symptomatic non-union >2-3mm displacement consider operative reduction with K-wire or screw fixation Cast ORIF

Common with: High energy trauma Skateboarding Dirt-bike racing Metatarsal Fractures Common with: High energy trauma Skateboarding Dirt-bike racing Fall from height

Neck and shaft fracture Metatarsal Fractures Neck and shaft fracture Moderate to severe swelling Dependent edema Compartment syndrome

Neck and shaft fracture Metatarsal Fractures Neck and shaft fracture Obtain 3 x-ray views to evaluate fracture Most may be treated with short leg walking cast for 3-6 weeks Split cast Compression dressing and splint for severe swelling

Metatarsal Fractures Multiple fractures Displaced fracture may require reduction and fixation Consider age of patient

Metatarsal Fractures Multiple fractures 2nd ,3rd & 4th metatarsal displacement is better tolerated than 1st and 5th metatarsal displacement May accept up to 45o of angulation at the metatarsal neck fracture site due to remodeling in younger children

Metatarsal Fractures Less angulation may be accepted as child reaches skeletal maturity May require operative reduction and fixation of displaced and angulated fractures as child reaches skeletal maturity Prevent: Splayfoot deformity Asymmetric loading of metatarsal heads

Metatarsal Fractures Operative reduction and fixation of displaced and angulated fractures Traction Manipulation Percutaneous pinning if reduction unstable Possible ORIF Maintain length and alignment

Metatarsal Fractures Operative reduction and internal fixation of displaced and angulated fractures Irreducible fractures Dorsal longitudinal incision Intramedullary or bicortical placement of K-wire Monitor for compartment syndrome

Metatarsal Fractures Proximal first metatarsal fracture Physeal damage may result in shortening of the medial side of the foot Lisfranc type injury with fracture of the physis at the base of the first metatarsal and injury to the medial cuneiform bone

Proximal first metatarsal fracture Metatarsal Fractures Proximal first metatarsal fracture Crush injury may result in shortening of the first metatarsal Pin the 1st metatarsal to the 2nd metatarsal to maintain length of the 1st metatarsal

Metatarsal Fractures Fifth metatarsal base fracture Inversion injury to ankle and foot during sports activities Avulsion as a result of pull of Lateral head of plantar fascia Peroneus brevis tendon Abductor digiti minimi tendon

Metatarsal Fractures Fifth metatarsal base fracture Direction of fracture line different that apophyseal growth center (os vesalianum) Fracture line transverse Apophysis parallel to the shaft of the metatarsal Apophysis appears around the age of 8 Apophysis unites to the shaft at 12 years-old in girls Apophysis unites to the shaft at 15 years-old in boys

Metatarsal Fractures Fifth metatarsal base fracture Direction of fracture line different that apophyseal growth center (os vesalianum) Apophysis may be traumatically avulsed with little or no displacement Treat true fractures and apophyseal avulsions with short-leg-weight-bearing cast for 3-6 weeks

Metatarsal Fractures Fifth metatarsal base fracture Jones Fracture Not involving the tuberosity Higher incidence of non-union More long term problems Result from vertical or mediolateral ground forces on the weight-bearing foot

Metatarsal Fractures Fifth metatarsal base fracture Jones Fracture Limited blood supply to fracture site Looks like greenstick fracture Treat non-weight bearing in cast Bone grafting, bone stimulator or intramedullary screw fixation for delayed on non-union

Metatarsal Fractures Fifth metatarsal base fracture Jones Fracture In athletes this may represent a stress fracture or an acute fracture superimposed on a chronic stress reaction For acute fractures in athletes consider Intramedullary screw fixation

Fifth metatarsal base fracture Metatarsal Fractures Fifth metatarsal base fracture Jones Fracture Other treatment options External fixation with distraction of medical cortex to complete fracture followed by compression of fracture site Casting with low dose pulsed ultrasound bone stimulator incorporated into cast

Metatarsal Fractures Stress Fractures March fractures-military recruits Athletes Following surgery to correct clubfoot, hallux valgus and hallux rigidus with redistribution of the weight-bearing to the lesser metatarsal heads Repetitive microstress to bone at a level greater than the bone’s ability to heal

Metatarsal Fractures Stress Fractures May present with foot pain with normal x-rays Follow-up x-rays show periosteal new bone or fracture Second and third metatarsals most commonly involved Consider a bone scan or MRI Consider evaluation for reduced bone density Treat with short-leg cast 3-6 weeks Correct training errors and biomechanics

Tarsometatarsal Injuries Indirect trauma more common than direct trauma Force applied to forefoot Violent abduction Forced plantarflexion Midfoot swelling May have spontaneous reduction of deformity Look for fracture of second metatarsal base and cuboid CT scan to evaluate foot

Tarsometatarsal Injuries Non-displaced tarsometatarsal dislocation Initial treatment with compression dressing and elevation Short leg cast for 4-6 weeks

Tarsometatarsal Injuries Displaced tarsometatarsal dislocation patterns All metatarsal as a unit undergo medial or lateral displacement Medially displaced first metatarsal or all lesser metatarsals laterally displaced (homolateral) Divergent between first metatarsal medially and lesser metatarsals laterally displaced

Tarsometatarsal Injuries Displaced tarsometatarsal dislocation Manipulation, closed reduction, percutaneous K-wire fixation with stabilization of the second metatarsal base Splint first week post-op to allow for swelling Non-weight bearing cast for 4-6 weeks Remove K-wires at 4-6 weeks post-op Weight bearing in a cast of hard-sole shoe for additional 2-4 weeks after pin removal

Midfoot Fractures Lesser tarsal bones Navicular Cuneiforms Cuboid May be consequence of crush injury such as a heavy object falling onto the foot from a height Associated with severe injury to foot

Midfoot Fractures Compression of cuboid bone from a jumping injury is a common injury and diagnosed as sprain Monitor x-rays for radiodense healing line Treat isolated nondisplaced fractures with weight-bearing cast for 3-6 weeks

Calcaneal Fractures Children seldom fracture the os calcis Usual mechanism is a fall from a height Open fractures from lawn mower injuries Bohler’s angle reduced form normal 20o-40o in the lateral x-ray view Evaluate Harris axial view of os calcis Obtain CT scan of os calcis

Calcaneal Fractures Most fractures in children involve the tuberosity and heal uneventfully Non-displaced fracture Short-leg cast 4-6 weeks Initially split cast for swelling Begin weight bearing on second week after cast repaired or replaced

Calcaneal Fractures Displaced fractures Avulsions of tuberosity Significant displacement Consider ORIF by experience surgeon Non-weight bearing casting for 6 weeks will provide favorable results in most cases due to remodeling potential in the growing child

Calcaneal Fractures Extra-articular fractures Usually do well with non-surgical treatment ORIF for displaced anterior process fractures at the calcaneocuboid joint Open fractures require debridement, irrigation and fixation in the operating room

Subtalar Dislocation Rare injury in children May be associated with Talar neck fractures Other fractures around the foot and ankle Reduction usually can be accomplished by closed methods

Unusual in children Talus anatomy Saddle shaped Neck, body and head Talar Fractures Unusual in children Talus anatomy Saddle shaped Neck, body and head

Talus anatomy Talar Fractures Almost entirely articular Limited blood supply Sinus Tarsi Dorsum aspect of talar neck Deep to deltoid ligament medially

Obtain x-rays in 3 views centered on the hindfoot CT Scan Talar Fractures Mechanism of injury Forced dorsiflexion of foot Obtain x-rays in 3 views centered on the hindfoot CT Scan

Talar Fractures Talar neck Majority of fractures are undisplaced Long leg non-weight bearing cast with the knee flexed for 6-8 weeks Followed by 2-4 weeks in a weight bearing short leg cast

Talar Fractures Talar neck Majority of fractures are undisplaced Rarely associated with osteonecrosis Severe injuries may disrupt blood supply and result in AVN of talar dome

Talar Fractures Talar neck Displaced fractures Urgent reduction within 5mm of displacement and 5o of angulation Reduce closed in plantarflexion Cast in dorsiflexion if reduction is stable

Talar Fractures Talar neck Displaced fractures Cast in plantarflexion with inversion or eversion position based on instability K-wire percutaneous fixation if unstable ORIF if ankle mortise is displaced

Talar Fractures Talar neck Displaced fractures ORIF if ankle mortise is displaced Posterior-lateral approach adjacent to Achilles tendon Add anterior approach dorsomedial ( medial to EHL) if indicated

Talar neck Talar Fractures Displaced fractures K-wires, 2-4mm screws or single larger screw for fixation Monitor vascular status of talus for 6 months Follow patient for 1-2 years

Talar body Rare Requires ORIF Talar Fractures Talar body Rare Requires ORIF Same surgical approach as talar neck fracture

Talar Fractures Lateral wall and process Snowboarder’s talus Osteochondral avulsion by anterior talofibular ligament Dorsiflexion of inverted foot Evaluate oblique x-ray and CT scan May require ORIF or excision

Talar Fractures Os Trigonum Normal variant May be confused with a fracture of the posterior process of the talus Unlike a fracture it appears rounded and smooth

Os Trigonum Talar Fractures Accessory center of ossification that appears around the age of 8 to 10 in girls 11-13 in boys

Talar Fractures Os Trigonum Ossification center may be injured and chronic movement through the fibrous union my cause symptoms Ballet dancers Surgical excision resolves problems

Puncture Wounds of the Foot Pseudomonas found in socks and inside shoes A nail penetrating the shoe my inoculate Pseudomonas and produce osteomyelitis 0.06% of puncture wounds result in a Pseudomonas abscess Infection becomes apparent 1-2 weeks following puncture

Puncture Wounds of the Foot Pseudomonas infection Pain Swelling Erythema

Puncture Wounds of the Foot Pseudomonas infection Septic arthritis if joint punctured Common at metatarsophalangeal joint Radiographic changes may take 3-4 weeks Obtain triple phase bone scan or MRI

Puncture Wounds of the Foot Pseudomonas infection Debridement in OR in general anesthesia Antibiotic coverage for Pseudomonas -gentamycin Antibiotic coverage for Staphylococcus Aureus (MRSA) Joint and physis may be permanently damaged Chronic infection rare

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