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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

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

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

12. 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

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

14. 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

15. 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

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

18. 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

20. 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

21. 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

23. 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

24. 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

25. 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

27. 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

28. 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

29. 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

30. 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

32. 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

33. 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

35. 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

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

37. 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

39. 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

40. 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

41. 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

43. 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

46. 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

47. 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

48. 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

50. 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

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

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

54. 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

55. 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

56. 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

57. 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

58. 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

59. 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

60. 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

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

62. 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

63. 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

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

65. 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

67. 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

68. Puncture Wounds of the Foot
Pseudomonas infection
Pain
Swelling
Erythema

69. 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

71. 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

72. Questions?