pediatric foot fractures

Journal of the American Academy of Orthopaedic Surgeons308

Foot fractures account for 5% to 8%of pediatric fractures and approxi-mately 7% of all physeal injuries.1-4

These fractures are very rare ininfants and toddlers due to thelarge cartilage component of theirfeet (hence the relative resistance tofracture), but the incidence increaseswith age. The more elastic and com-pressible nature of cartilage in com-parison to bone partly explains whyfoot fractures are less common inchildren than in adults. As with mosttraumatic injuries, pediatric footfractures occur more commonly inboys than in girls.

The child’s foot is generally a for-giving location for fractures. Thevast majority of pediatric foot frac-tures do well with nonoperativemanagement. There are, however, agroup of these fractures that mayhave poor results even with ana-tomic reduction and internal fixa-tion. A comprehensive understand-ing of the anatomy of the foot, espe-cially the location and nature of

injury to the physes, is requisite foroptimal evaluation and treatment ofchildren with these injuries.

Anatomy

As with other musculoskeletal inju-ries, a thorough understanding ofthe relevant anatomy is crucial inthe diagnosis and treatment of pe-diatric foot fractures. The foot canbe thought of as consisting of threemain subdivisions: the forefoot,the midfoot, and the hindfoot. Theforefoot consists of the metatarsalsand phalanges. The phalangealphyses are located proximally, butthe metatarsal physes are locateddistally in all but the first meta-tarsal. The forefoot is separatedfrom the midfoot by the tarsometa-tarsal (Lisfranc) joint.

The tarsometatarsal joints havetremendous intrinsic stability as aresult of both the osseous architec-ture and the associated ligamentous

structures. The recessed base of thesecond metatarsal locks betweenthe medial and lateral cuneiforms,limiting medial-lateral translationof the metatarsals. Another ana-tomic consideration is the trape-zoidal shape of the middle threemetatarsal bases, which form a“Roman arch” configuration whenthey are positioned side by side,affording stability in the sagittalplane. The metatarsals are heldtogether by the transverse metatar-sal ligaments distally. In addition,the bases of the lateral four metatar-sals are secured by the intermeta-tarsal ligaments. There is no inter-metatarsal ligament between thefirst and second metatarsals, whichcan predispose to a medial Lisfrancinjury. The Lisfranc ligament, whichextends from the medial cuneiformto the base of the second metatarsal,further enhances the stability ofthese joints.

Dr. Kay is Professor of Orthopaedic Surgery,University of Southern California School ofMedicine, Los Angeles, and Attending Surgeon,Childrens Hospital Los Angeles, Los Angeles,Calif. Dr. Tang is Resident, Department ofOrthopaedic Surgery, University of SouthernCalifornia, Los Angeles.

Reprint requests: Dr. Kay, Childrens HospitalLos Angeles, 4650 Sunset Boulevard, Mailstop69, Los Angeles, CA 90027.

Copyright 2001 by the American Academy ofOrthopaedic Surgeons.

Abstract

Foot fractures account for 5% to 8% of all pediatric fractures and for approxi-mately 7% of all physeal fractures. A thorough understanding of the anatomyof the child’s foot is of central importance when treating these injuries. Due tothe difficulties that may be encountered in obtaining an accurate physical exam-ination of a child with a foot injury and the complexities of radiographic evalua-tion of the immature foot, a high index of suspicion for the presence of a fracturefacilitates early and accurate diagnosis. Although the treatment results in pedi-atric foot trauma are generally good, potential pitfalls in the treatment ofLisfranc fractures, talar neck and body fractures, and lawn mower injuries tothe foot must be anticipated and avoided if possible.

J Am Acad Orthop Surg 2001;9:308-319

Pediatric Foot Fractures: Evaluation and Treatment

Robert M. Kay, MD, and Chris W. Tang, MD


Vol 9, No 5, September/October 2001 309

The Chopart transverse mid-tarsal joint separates the midfootfrom the hindfoot (talus and calca-neus). The talus is unusual in thata large portion of its surface is ar-ticular cartilage. Articulations ofthe talus include the talar bodywith the tibial plafond proximally,the inferior surface of the taluswith the calcaneal facets plantarly,and the head of the talus with thenavicular distally.

In contrast to the talus, the calca-neus has numerous muscle andtendon attachments. There arethree articulating facets on thesuperior surface of the calcaneus: alarge posterior facet, a concavemiddle facet, and an anterior facet.Together, these form a complex sub-talar joint with the correspondingtalar facets. The anterior facet alsoarticulates with the cuboid. TheAchilles tendon inserts on the poste-rior tubercle.

The lateral and medial plantarprocesses serve as points of originfor the plantar fascia and the smallmuscles of the plantar surface of thefoot. The plantar fascia has a thickcentral fibrous tissue encased bythinner lateral bands. The fasciaspreads into five sections distally,each travelling to a toe and strad-dling the flexor tendons. The super-ficial layers are attached to the deepskin fold between the toes and thesole of the foot.

There are nine compartments ofthe foot: the medial and lateral com-partments, the three central com-partments, and the four interosseouscompartments.5 The medial com-partment contains the abductor hal-lucis and flexor hallucis brevis mus-cles as well as the tendon of the flexorhallucis longus. The lateral com-partment contains the abductor digitiminimi and flexor digiti minimimuscles. The three central compart-ments contain the flexor digitorumbrevis and the four lumbrical mus-cles, along with the tendons of theflexor digitorum longus in the su-

perficial compartment, the adductorhallucis in the adductor compart-ment, and the quadratus plantae inthe calcaneal compartment. The cal-caneal compartment is limited to thehindfoot and is confluent with thedeep posterior compartment of theleg. Each interosseous compartmentcontains a plantar and a dorsal inter-osseous muscle.

The timing of the appearance ofthe ossification centers in the pedi-atric foot is quite variable. In youngchildren, these ossification centersrepresent only a small portion of thebone, as a large cartilage anlage ispresent. The calcaneus, cuboid, andtalus are the tarsal bones that aremost commonly ossified at the timeof birth, with the calcaneus begin-ning to ossify at around 5 months ofgestation, the cuboid at 9 months,and the talus at 8 to 9 months. Thephalanges also start ossifying at 2 to4 months of gestation. The lateralcuneiform starts to ossify 1 year afterbirth; the medial and middle cunei-forms, at 4 years. The secondary os-sification centers for the metatarsalsand the phalanges ossify at around 3years, as does the navicular. The secondary ossification center for thecalcaneus is the last to ossify, at 10years.

The presence of one or more ofthe various accessory ossicles mayconfound the radiographic diagnosisof a fracture (Fig. 1). The os vesa-lianum may be mistaken for a frac-ture of the base of the fifth meta-tarsal. The os fibulare and os tibiale(located at the lateral border of thecuboid and the proximal medialaspect of the navicular, respectively)are each present in 10% of the popu-lation. The os trigonum, located atthe posterior lip of the talus, is pres-ent in approximately 13% of thepopulation, and is commonly mis-taken for an avulsion fracture of thetalus.

The terminal branches of theanterior and posterior tibial arteriesprovide the blood supply to the

foot. The anterior tibial artery con-tinues as the dorsalis pedis artery,supplies the greater part of the dor-sum of the foot, and provides anas-tomosis with the deep plantar archand the arcuate artery (which latersupplies the dorsal metatarsal ar-tery). The posterior tibial arterydivides to become the lateral andmedial plantar arteries, with thelateral artery being dominant. Thelateral plantar artery also forms theplantar arch, which then gives riseto the plantar metatarsal arteriesand common digital arteries.

The blood supply to the talus islimited, making it prone to osteo-necrosis after a talar neck fracture.6The posterior tibial artery gives riseto the artery to the tarsal canal thatfeeds the deltoid branches, whichin turn supply parts of the talarbody. The dorsalis pedis arterygives off multiple arterioles thatpenetrate the superior surface ofthe head and neck of the talus, aswell as the artery of the sinus tarsi.The artery to the tarsal canal andthe artery of the sinus tarsi form ananastomotic arch that suppliesmost of the talus body by retro-grade fill. In the child’s foot, thereis less dominance of a single arteri-al system with retrograde flowfrom the neck, which may explain apotentially lower risk of osteone-crosis after talus fractures in chil-dren.

The posterior tibial nerve givesrise to the medial and lateral plantarnerves. The lateral plantar nerveinnervates the intrinsic musculatureof the plantar aspect of the foot aswell as the adductor hallucis. Thelateral plantar nerve also providessensation to the lateral one and ahalf toes, analogous to the ulnarnerve distribution in the upper ex-tremity. The medial plantar nervesupplies sensory branches to themedial three and a half toes, simi-lar to the sensory distribution ofthe median nerve in the upper ex-tremity.

Pediatric Foot Fractures


Diagnosis

Although most pediatric foot frac-tures are isolated injuries, someoccur in polytrauma patients, war-ranting serial examinations. In oneseries, 21 (17%) of 125 patients withpediatric ankle and foot injuries hadother skeletal injuries as well.7

Patients with massive soft-tissueinjury present special challenges. Acareful neurovascular examinationis essential, but often difficult in afrightened, uncooperative child.Palpation of pulses and assessmentof capillary refill are important.Doppler evaluation of a child with apulseless foot is often necessary.Noxious stimuli, including needlesticks, can be used to help assess

sensation in the child who will notcooperate with evaluation of lighttouch sensation distal to the injury.

As in adults, compartment syn-dromes may occur after crush orother high-energy injuries.8 Affectedfeet are quite swollen and generallyvery painful. Compartment pres-sure measurements are invaluablein the assessment of a child with asuspected compartment syndrome,especially one who is obtunded andhas significant swelling of a foot as-sociated with a fracture. Fasciotomyshould be performed if compart-ment pressures exceed 30 mm Hg.

Anteroposterior (AP), lateral, andoblique radiographs are most com-monly utilized to assess patientswith foot trauma. The oblique radio-

graphs are necessary to supplementthe AP and lateral views because ofthe significant osseous overlap on thelateral view. Other specialized viewsand/or computed tomographic (CT)and magnetic resonance (MR) imag-ing studies may be necessary to com-pletely evaluate specific fracture con-figurations. Comparison views arerarely necessary for the orthopaedistfamiliar with the normal radio-graphic appearance.9

Fractures and Dislocationsof the Talus

Fewer than 1% of all pediatric frac-tures and only 2% of all pediatricfoot fractures are talus fractures.1,10

Os cuboideum secundarium, 1%

Os tibiale externum, 10%

Os tibiale externum, 10%

Os intercuneiforme

Os sustentaculum, 5%

Talus secundarius

Os trigonum, 13%

Calcaneus secundarius, 4%

Os intercuneiforme

Os intermetatarseum, 9%

Os vesalianumOs peroneum

Pars fibularis ossis metatarsalis I

Os peroneum

Os vesalianum

A

B C

Figure 1 Accessory ossifications in the foot and their frequency of occurrence (if data are available). (Adapted with permission fromTachdjian MO [ed]: Pediatric Orthopedics, 2nd ed. Philadelphia: WB Saunders, 1990, p 471.)



In a series of 90 pediatric talus frac-tures, there were 50 avulsion frac-tures (56%), 18 osteochondral le-sions (20%), 17 talar neck fractures(19%), and 5 talar body fractures(6%).11

Avulsion fractures require onlysymptomatic treatment, often with ashort leg splint or short walking castfor 1 to 2 weeks until symptomssubside. There are generally nolong-term sequelae.

As in adults, talar neck and bodyfractures result from forceful dorsi-flexion of the ankle. However, inreported series dealing with chil-dren, the mechanism of injury was afall from a height or a motor vehicleaccident in approximately 70% to90% of cases.11,12 Of all talar neckand body fractures, only 10% occurin children.13 These fractures occurthroughout childhood and haveeven been reported in children lessthan 2 years old.11,12 Jensen et al11

reported that 6 (43%) of the 14 pa-tients in their series of pediatric talar

neck and body fractures had associ-ated fractures.

Signs and symptoms of talar frac-tures include ankle or hindfoot pain,local tenderness, and pain withankle dorsiflexion. Local swelling isvariable. Plain radiographs fre-quently delineate the fracture lineand the amount of displacement, al-though they may be read as normalinitially.12 Computed tomographymay aid in the assessment of frac-ture configuration and displace-ment.

The Hawkins classification sys-tem is most commonly used forclassifying talar neck fractures inchildren as well as in adults.14,15

Type I fractures are nondisplaced(Fig. 2). Type II fractures are dis-placed talar neck fractures in con-junction with subluxation or dislo-cation of the subtalar joint. Type IIIfractures are displaced talar neckfractures in conjunction with sub-luxation or dislocation of both thesubtalar and the tibiotalar joint. The

extremely rare type IV injuries arecharacterized by a displaced talarneck fracture, subluxation of thehead of the talus from the talonavic-ular joint, and subluxation or dislo-cation of the subtalar and/or anklejoints.

Osteonecrosis of the talar body iscommon after fractures of the talarneck and body due to disruption ofthe vascular ring surrounding thetalar neck as the fracture displaces.Because the surface of the talus ismostly articular cartilage, the talarblood supply is tenuous. Overall,the risk of osteonecrosis in reportedseries of talar neck fractures thatcombine adult and pediatric patientsis approximately 50%, and is highestfor type III and IV fractures and low-est for type I fractures. In one suchseries, Canale and Kelly16 reportedosteonecrosis in 15% of type I frac-tures, 50% of type II fractures, and84% of type III fractures. In anotherseries, Jensen et al11 reported nocases of osteonecrosis in 10 fractures

Figure 2 AP (A) and lateral (B) radiographs of a minimally displaced talar neck fracture (arrows) in a 4-year-old boy who sustained ipsi-lateral fractures of the distal tibial physis and distal fibular diaphysis. C, CT scan confirms minimal displacement. Fracture comminutionis evident. (Courtesy of J. Dominic Femino, MD.)

A B C



(3 of which were displaced). Lettsand Gibeault12 reported 3 cases ofosteonecrosis in 13 nondisplacedpediatric talar neck fractures (inci-dence of 23%).

The Hawkins sign (lucency inthe subchondral bone of the talardome, usually seen by 8 weeksafter injury) suggests that the talarbody is adequately vascularizedand the risk of osteonecrosis is low.Technetium bone scanning and,more commonly, MR imaging canbe useful to assess the presence ofosteonecrosis in borderline cases.

Treatment of nondisplaced talarneck and body fractures consists ofimmobilization in a non-weight-bearing long leg cast. After approxi-mately 2 months, a patient with apositive Hawkins sign (indicatingthat there is no osteonecrosis) maybegin weight bearing as tolerated.

A closed reduction should beattempted for displaced talar frac-tures, although the criteria for anacceptable reduction have not beenclearly defined. In general, however,the surgeon should attempt toachieve an intra-articular reductionwith less than 2 mm of residual dis-placement. These fractures are of-ten stable with the foot in a plantar-flexed position. If open reductionand internal fixation is performed,insertion of screws into the talusfrom posterior to anterior has beenshown to be biomechanically supe-rior to insertion from anterior toposterior.17

Long-term follow-up suggeststhat pain is common after displacedtalar fractures in children.11 Whetherthis pain is due to the initial high-energy injury and associated chon-dral damage or to residual intra-articular incongruity is unclear.11

Follow-up radiographic studies havedemonstrated the development ofarthrosis in the ankle joints, but notthe subtalar joints, of patients withdisplaced talar fractures.11

The duration of protected weightbearing for patients with osteone-

crosis remains controversial. Vari-ous mechanisms of unloading thetalus have been tried, including theuse of ambulatory aids, bracing,and casting. Letts and Gibeault12

reported on three pediatric patientswith osteonecrosis after talar neckfractures. Talar flattening and anklestiffness developed in two patientsafter bearing weight on the affectedextremity (due to a delay in diagno-sis). The patient whose weight bear-ing was limited until the osteone-crotic segment had healed did nothave such complications. Evenwhen weight bearing is not recom-mended, the long-term effect andthe influence of patient complianceon outcome are unclear.

Peritalar dislocations are definedas dislocations of the subtalar jointand talonavicular joint in the ab-sence of a talar fracture. These inju-ries are rare, accounting for only 4%of all pediatric talar fractures anddislocations.18 These are generallyhigh-energy injuries and were asso-ciated with ipsilateral foot fracturesin all 5 patients in the series ofDimentberg and Rosman.18 Closedreduction is generally feasible, butmay be impossible if diagnosis isdelayed or if there are interposedsoft-tissue or osseous structures.

Osteochondritis Dissecansof the Talus

The talus is the second most com-mon site for osteochondritis disse-cans (OCD). Osteochondritis disse-cans of the talus is analogous to thatfound in other anatomic locationsand is characterized by necroticbone underlying articular cartilage.In the talus, OCD usually occurseither anterolaterally or posterome-dially.

Children with OCD of the talusmay present with the acute onset ofpain after a traumatic incident (suchas an inversion injury) or with chron-ic ankle pain. Trauma to the ankle

has been reported in 46% to 63% ofchildren with OCD of the talus.19,20

The mean age of children with OCDof the talus is 13 to 14 years, al-though it may be seen in childrenless than 10 years old.19,20 Signs andsymptoms in the affected ankle mayinclude pain, swelling, instability,repetitive sprains, and decreasedrange of motion. In one series,20 theaverage duration of symptoms priorto diagnosis was 4.3 months. Lockingof the ankle joint is rarely reported.Physical examination usually dem-onstrates decreased range of motionof the ankle, which is often painful.Localized tenderness may be difficultto elicit, and the presence of synovitisis variable.

Grading of OCD of the talus isbased on the system described byBerndt and Harty in 1959.21 Type Ilesions are nondisplaced. Type IIlesions are partially detached. TypeIII lesions are detached but not dis-placed. Type IV lesions are detachedand displaced or rotated. Plain radio-graphs will often demonstrate a tri-angular sclerotic fragment separatedfrom the talar dome anterolaterallyor posteromedially (Fig. 3). Some-times, these lesions are hard to visu-alize on plain films, depending ontheir location in the sagittal plane.

Magnetic resonance imaging isthe most helpful radiologic studyfor assessing OCD of the talus.22

This modality can help delineatethe condition of the articular carti-lage, whether the articular cartilageis intact, the extent of the lesion, theextent of sclerosis of the fragment,and whether the fragment is dis-placed. Evidence of fluid under-neath the OCD fragment indicatesdisruption of the articular cartilage.The MR study should be used inconjunction with plain radiographsto classify these lesions.

The course of OCD of the talusappears to be more benign in chil-dren than in adults. Bauer et al23

reported on five children with OCDof the talus followed up for an aver-



age of 22 years: four of the lesionsregressed, the fifth did not progress,and no patient had radiographicevidence of osteoarthritis at long-term follow-up. The results of sur-gical treatment also appear to bebetter in children than in adults.19,23

Nonoperative management hasbeen recommended as the initialtreatment of choice for all but typeIV lesions,19,20 generally beginningwith immobilization and protectedweight bearing for 1 to 2 months.Activity modification and protectedweight bearing may continue for anadditional 2 to 3 months. If there isno symptomatic and radiographicimprovement by 3 to 4 months,drilling, debridement, or arthro-scopic fixation may be indicated.Greenspoon and Rosman24 reportedthat the results of bone graftingwere better than the results of OCDfragment excision. Arthrotomywith a medial malleolar osteotomyhas been used in various series, butoften can be avoided owing to ad-vances in arthroscopic technique.

Type IV lesions should be treatedoperatively.

Calcaneal Fractures

Approximately 5% of all patientswith calcaneal fractures are chil-dren25; however, calcaneal fracturesrepresent only 2% of pediatric footinjuries.10 Boys are more commonlyaffected than girls. Extra-articularfractures are more frequent in chil-dren than in adults, representing65% of pediatric calcaneal frac-tures.25,26 Fifty percent of pediatriccalcaneal injuries that occur afterfalls result in intra-articular frac-tures. In adolescents 15 years andolder, the fracture patterns are com-parable to those seen in adults.25

The mechanism of most calcanealfractures is axial loading, with thetalus being driven into the calcaneus.The fracture is most commonly dueto a fall from a height or a motorvehicle accident (incidence rates of40% and 15%, respectively, in two

studies25,26). Because these injuriesgenerally are the result of high-energytrauma, associated injuries are com-mon, occurring in approximatelyone third of children with calcanealfractures. These may be lacerationsof the ipsilateral lower extremity25,26

or even spine fractures (5% of thechildren in one study25). In an earlyseries before the advent of CT andMR imaging, 26% of calcaneal frac-tures were missed initially.25

A plain-radiographic study shouldinclude AP, lateral, and axial views.Oblique calcaneal views may also aidin the initial assessment of fractureconfiguration. The lateral view is im-portant because it allows measure-ment of the Böhler’s angle (Fig. 4).Böhler’s angle normally measures 25to 40 degrees in adults, but is less inchildren.14 The “crucial angle ofGisanne” is rarely measured in chil-dren because a large portion of thecalcaneus is not yet ossified. Theangle usually measures 125 to 140degrees in adolescents. A CT scanmay also be valuable in assessing the

A B C

Figure 3 AP (A) and lateral (B) radiographs of a 14-year-old boy with a 1-year history of ankle stiffness after an inversion ankle injurydemonstrate a large osteochondral lesion (arrows) of the anterolateral talar dome. At the time of presentation, the patient was fully activeand denied pain. C, CT scan demonstrates a type III lesion and significant sclerosis of the osteochondral fragment. Observation wasundertaken because of the minimal symptoms.



configuration of an intra-articularfracture.

There are several classification sys-tems for calcaneal fractures. TheEssex-Lopresti method is widelyused. This system categorizes injuriesas tongue-type or split-depressionfractures, but the most important dif-ferentiation is between intra-articular(Fig. 5) and extra-articular fractures.

Extra-articular fractures can betreated with a bulky Jones dressingfollowed by weight bearing in 3 to 4weeks. The long-term sequelae ofsuch fractures are rare, althoughthere may be some residual loss ofheel height and widening of the heel.

Some authors advocate surgicaltreatment for displaced intra-articularfractures in young patients. How-ever, Schantz and Rasmussen27

reported good results in pediatricpatients treated nonoperatively.Thomas28 reported good results evenin patients with a decreased Böhler’sangle who were treated nonopera-tively; these results were thought tobe secondary to potential talar re-modeling in the pediatric population.Although the optimal treatment foryounger patients remains controver-sial, open reduction and internal fixa-

tion is indicated for displaced intra-articular calcaneal fractures in adoles-cents, as it is in adults.

Other Tarsal Fractures

Tarsal fractures account for approxi-mately 1% of all pediatric fractures.1Fractures of the navicular, cuboid,and cuneiforms are reported to rep-resent 2% to 7% of pediatric footinjuries.10,29 Most tarsal fracturesare avulsion or stress fractures, bothof which can be treated in a shortwalking cast for 2 to 3 weeks. Thisis sufficient to allow healing, and nolong-term sequelae need be expected.

Complete displaced fractures ofthe navicular, cuneiforms, and cu-boid often result from high-energytrauma; therefore, associated injuries,such as those of the Lisfranc com-plex, are common. Because much ofthe surface of these bones is intra-articular, closed or open reductionand internal fixation may be neededfor displaced fractures. Assessmentof the soft-tissue envelope is impor-tant in these high-energy injuries,and compartment syndrome mustbe ruled out.

Lisfranc Injuries

Injuries of the tarsometatarsal jointcomplex are uncommon in children.The mechanism of injury is eitherforceful plantar-flexion of the foot,generally with axial loading, or adirect crush injury. Falls from aheight accounted for approximately60% of the pediatric Lisfranc inju-ries in the two largest series.30,31 Ofthe 34 patients in those studies, 21(62%) were boys. The age range inthe two studies differed consider-ably: Johnson30 reported that thefracture occurred most commonlyin children aged 3 to 6 years, butWiley31 reported a mean patient ageof 12 years. Johnson reported frac-tures of the proximal first metatarsalin all 16 of his patients, including 1with a concomitant second metatar-sal fracture.

Ligamentous injury may accom-pany fractures as the Lisfranc jointcomplex is loaded. Because the plan-tar ligaments of the tarsometatarsaljoint complex are stronger than thedorsal ligaments, the dorsal liga-ments rupture first. With continued

Figure 5 Lateral radiograph demonstratesa minimally displaced intra-articular cal-caneal fracture (split-depression type) in a4-year-old boy involved in a motor vehicleaccident. Associated injuries included anipsilateral femoral shaft fracture, contralat-eral distal femoral physeal fracture, and adegloving injury to the contralateral leg.Care for the calcaneal fracture consisted ofinitial splinting and a 3-week non-weight-bearing period. The dotted lines indicatethe fracture pattern.

Figure 4 Lateral view of the calcaneus depicts Bohler’s angle and Gissane’s angle.Böhler’s angle is defined as the angle between two lines as seen on the lateral view: thefirst connects the superior portion of the anterior and posterior calcaneal facets, and thesecond connects the superior portions of the posterior facet and the tuberosity. (Adaptedwith permission from Heckman JD: Fractures and dislocations of the foot, in RockwoodCA, Green DP, Bucholz RW, Heckman JD [eds]: Rockwood and Green’s Fractures in Adults,4th ed. Philadelphia: Raven Publishers, 1996, p 2326.)

Böhler’s angle

Lateral process

Navicular

Talus

CuboidCalcaneus

Crucial angle of Gissane



loading, the plantar ligaments thenrupture, after which plantar dis-placement of the metatarsal basesmay occur.

Children who sustain Lisfranc in-juries due to high-energy traumaoften have significant soft-tissueinjury and should be admitted to thehospital for observation overnight.Compartment syndrome may be her-alded by pain out of proportion tothe injury, as well as pain with pas-sive motion of the toes in the awakepatient. Compartment pressuresmust be measured if there is the pos-sibility of a compartment syndromein any patient, regardless of cognitivestatus. In patients with altered men-tal status, the physician should bemore inclined to measure compart-ment pressures, as clinical signs ofpain may not be easily appreciated inthe obtunded patient. Fasciotomy ofall compartments of the foot shouldbe performed if compartment pres-sures are greater than 30 mm Hg.5,8

Lisfranc injuries may involve theentire tarsometatarsal complex orany portion thereof. Diastasis fre-quently occurs between the bases ofthe first and second metatarsals, asthere is no intermetatarsal ligamentin that interval (Fig. 6). Alterna-tively, all five rays may be involved,either with all rays displacing in thesame direction (homolateral injury)or with the first ray displacing me-dially and the lateral four rays dis-placing laterally (divergent injury).32

The initial radiographic evalua-tion should consist of AP, oblique,and lateral radiographs. If possible,the AP and lateral films should beweight-bearing views, as subtleinjuries may not be evident on non-weight-bearing radiographs.33 Frac-tures of the base of the first meta-tarsal are common, but an isolatedfracture of the base of the secondmetatarsal may result from avulsionof the insertion of the Lisfranc liga-ment, heralding the presence of aninjury to the Lisfranc complex. If nofracture is evident on presentation,

the medial aspect of the base of thesecond metatarsal should line upwith the medial aspect of the mid-dle cuneiform, and the medial as-pect of the base of the fourth meta-tarsal should line up with the medialaspect of the cuboid.

Nondisplaced fractures at thelevel of the tarsometatarsal jointcomplex may actually be injuriesthat were initially displaced but thenspontaneously reduced. Patientswith such injuries may be treatedwith a bulky dressing or posteriorplaster splint for several days to 1week, followed by a non-weight-bearing short leg cast until 1 monthafter injury, and then a short walk-ing cast for an additional 2 weeks.

Patients with Lisfranc fracture-dislocations should be treated opera-tively. Closed reduction should beattempted in the operating room.Wiley31 reported that 7 (39%) of 18patients in his series required closed

reduction. Finger traps placed onthe toes facilitate reduction. If closedreduction is possible, internal fixa-tion should be performed. Kirschnerwires may be used in young chil-dren. Cannulated screws are pre-ferred for the older child with suffi-cient bone stock for screw fixation. Ifa nearly anatomic closed reduction isnot possible, open reduction shouldbe performed, with removal of anyimpediments to reduction (frequentlyosteocartilaginous fracture frag-ments), followed by internal fixation.The long-term results in children withLisfranc injuries are uncertain. Evenwith short-term follow-up, Wiley re-ported residual pain at the Lisfrancjoint in 4 (22%) of his 18 patients.

Metatarsal Fractures

Metatarsal physeal fractures repre-sent 1% to 2% of all physeal injuries

Figure 6 AP radiographs of both the uninjured left foot (A) and the injured right foot (B)of a 6-year-old boy whose right foot had been run over by a car the previous day.Diastasis is evident between the first and second rays proximally and distally in the rightfoot. Although the medial column is disrupted, the remainder of the Lisfranc complex isappropriately aligned. The patient underwent open reduction and pinning after an unsuc-cessful attempt at closed reduction in the operating room.

A B



in children and adolescents.1-3 Inone large series, metatarsal fracturesaccounted for approximately 60% ofpediatric foot fractures, with frac-tures of the base of the fifth metatar-sal accounting for 22%.10 Owen etal29 reported that first-metatarsalfractures accounted for 73% of alltarsal and metatarsal fractures inchildren younger than 5 years, butonly 12% of such fractures in chil-dren older than 5. In the same se-ries, 6.5% of all fractures and 20% ofall first-metatarsal fractures wereinitially unrecognized by the treat-ing physician.

The mechanism of metatarsal frac-ture may be either indirect or direct.Indirect injuries often result fromaxial loading, inversion, rotation, or acombination thereof (Fig. 7). Directinjuries often result from the impactof falling objects or crush injuries. Ifthese fractures occur proximally

rather than in the midshaft, evalua-tion of the tarsometatarsal joint com-plex for concomitant injury is impor-tant. Radiographs should consist of AP, lateral, and oblique views toassess fracture alignment. Medial-lateral displacement of the fracturemay be seen, but is acceptable in theabsence of displacement of the Lis-franc complex.

If these fractures are not proxi-mal, they can almost always betreated with weight bearing as toler-ated in a short walking cast or a castshoe. The duration of treatment isgenerally 3 weeks (until tendernessat the fracture site has subsided). Inchildren with marked swelling, acircumferential cast should not beapplied at the time of evaluation,and consideration should be givento admitting the child for overnightobservation. Compartment syn-dromes, though rare, may occur ifhigh-energy trauma has caused mul-tiple metatarsal fractures.

In the rare instance in whichthere is marked sagittal malalign-ment of the metatarsal heads, closedreduction and pinning of a metatar-sal fracture should be considered toavoid transfer lesions in the future.Finger traps are often helpful in re-ducing such fractures.

Growth disturbance may occuras a result of a metatarsal fracture.Physeal fractures of the base of thefirst metatarsal may potentiallycause a growth disturbance andshortening of the first ray. This com-plication is rare, but may result intransfer lesions. Overgrowth mayalso occur after metatarsal fractures.

Fractures of the Base ofthe Fifth Metatarsal

Approximately 40% of all metatar-sal fractures are fractures of thebase of the fifth metatarsal. In onelarge series,10 as many as 22% ofpediatric foot fractures were at thatsite. In that same series, 90% of

fifth-metatarsal fractures occurredin children older than 10 years. Asin adults, the location of the frac-ture, the fracture appearance, andthe duration of symptoms beforepresentation are important prog-nostic factors. The injury generallyoccurs with the foot in a weight-bearing position. Inversion hasbeen reported as the most commonmechanism of injury.29

The initial radiographic examina-tion should consist of AP, lateral,and oblique views. The location ofthe fracture is important to bothprognosis and treatment. Tuber-osity fractures are generally benignand heal with 6 weeks in a shortwalking cast. Although previouslythought to be due to avulsion at theinsertion of the peroneus brevis,tuberosity fractures now appear tobe due to avulsion at the origin ofthe abductor digiti minimi. Frac-tures at or distal to the metaphyseal-diaphyseal junction are more recal-citrant to treatment. These fracturesshould be treated with at least 6weeks in a non-weight-bearing cast.If the fracture is preceded by weeksto months of pain (or if there is radio-graphic evidence of a precedingstress injury), internal fixation shouldbe considered. Some authors advo-cate curettage and bone grafting inpatients with intramedullary sclero-sis indicative of a delayed union ornonunion.34,35

Phalangeal Fractures

Phalangeal fractures are commonin the pediatric population and of-ten do not even result in the childbeing seen by an orthopaedic sur-geon. Many of these fractures aretreated symptomatically by the pa-tient and family or by the primary-care physician. Phalangeal fracturesmay account for as many as 18% ofpediatric foot fractures.10 In threestudies,1-3 phalangeal fractures rep-resented 3% to 7% of all physeal

Figure 7 Displaced third- and fourth-metatarsal fractures and a nondisplacedsecond-metatarsal fracture sustained by a15-year-old boy due to an indirect mecha-nism of injury. The patient was treated in ashort walking cast for 2 weeks, followed bya cast boot for 2 additional weeks.



fractures and were usually Salter-Harris type I or type II injuries.

The examining physician mustclosely evaluate the toe for integrityof the skin and also make sure thatthere is not a nail-bed injury. Openfractures require irrigation anddebridement and intravenous anti-biotic therapy (Fig. 8). Nail-bed in-juries involving the germinal matrixshould be repaired.

Closed fractures rarely requirereduction. Buddy-taping of the toeswith weight bearing as toleratedalmost universally results in a well-healed and well-aligned fracturewithin 3 to 4 weeks. (A hard-soledshoe may be used for patient comfortuntil fracture healing has occurred.)Closed versus open reduction andpinning should be considered formarkedly angulated fractures or dis-placed intra-articular fractures of theproximal phalanx of the great toe(including Salter-Harris type III andtype IV fractures) involving morethan 25% of the joint surface andthose with more than 2 mm of dis-placement.

Growth arrest and stiffness areuncommon sequelae of phalangealfractures. When growth arrest oc-curs, it most commonly followsfractures of the great toe.

Lawn Mower Injuries

Lawn mowers have been reportedto cause as many as 160,000 injuriesannually, including approximately2,000 that result in permanent im-pairment in children.36-38 Accidentsoccur with all types of mowers, butthe most severe injuries usuallyoccur when young children arestruck by riding mowers. In fact, asmany as 72% of children who sus-tain severe lawn mower injuries arebystanders.37,38

A careful evaluation of the entirechild, including all extremities, isvital. In a study of 33 children withlawn mower injuries, Alonso and

Sanchez36 found that 8 (24%) hadhead and eye injuries, 12 (36%) hadupper-extremity injuries, and 13(39%) had lower-extremity injuries.Fractures must be evaluated in conjunction with the degree of soft-tissue damage and the integrity ofneurovascular structures.

These are high-energy injuriesthat frequently involve significantsoft-tissue and fracture contamina-tion. Initial treatment should consistof irrigation and debridement andtriple-antibiotic coverage. Internalfixation of fractures and/or externalfixation spanning the injured seg-ment may help stabilize the soft tis-sues, allow access to the zone ofinjury, and facilitate patient care.Repeat debridements should be per-formed at 2- to 3-day intervals untilthe wound is sufficiently clean.

Soft-tissue damage from lawnmower injuries is extensive, and thesoft-tissue envelope generally ap-pears better on presentation than itdoes in the ensuing days due to theinitial compromised soft-tissue per-fusion. Early involvement of theplastic surgery team is important tofacilitate coverage of these wounds

by 7 to 14 days after injury. Skingrafting or flap coverage is neededin more than 50% of patients.37 Un-like adults, children may do wellwith split-thickness skin graftsplaced on the plantar aspect of thefoot.38 Despite appropriate earlycare, amputation rates in childrenwith lower-extremity lawn mowerinjuries have ranged from 16% to78%.36-38 Even in salvaged extremi-ties, late deformity may occur dueto muscle imbalance resulting fromthe damage or loss of muscles, ten-dons, or nerves at the time of injury.

Occult Foot Fractures

Toddlers often present with theacute onset of a limp but without adefinite trauma history. Unlike a“toddler’s fracture,” there may be notenderness over the tibia. Tender-ness is often evident in the foot, butmay be hard to pinpoint. Typically,a child with an occult foot fracturewill be able to crawl without diffi-culty but will limp when walking.

Plain radiographs will rarelyreveal a fracture. A bone scan, how-

Figure 8 AP (left) and lateral (above) radiographs of a 12-year-old boy after an open Salter-Harris type II fracture ofthe distal phalanx of the great toe. The open fracture wasnot recognized on initial presentation. When the patientpresented to the author’s institution, purulent drainage andcellulitis were evident. Treatment consisted of irrigationand debridement, followed by open reduction and percuta-neous pinning of the fracture. (Courtesy of Richard A. K.Reynolds, MD, Los Angeles, Calif.)



ever, will often show increasedradionuclide uptake in the foot.Englaro et al39 reported that 16 (29%)of 56 preschool children with lower-extremity pain or limping of un-known origin had abnormal traceruptake localized to the foot on bonescans. Of those 16 patients, 9 hadabnormal uptake in the cuboid; 4, inthe calcaneus; 2, in multiple tarsalbones; and 1, in the tibiotalar joint.

If an occult foot fracture is sus-pected, a short walking cast can beused for 2 to 3 weeks. Repeat radio-graphs at the time of cast removalwill often reveal callus formationand confirm the diagnosis of occultfracture. If symptoms persist after

casting and radiographs do notdemonstrate callus formation, abone scan is indicated to identifythe site of injury.

Summary

Pediatric foot fractures often differsignificantly from foot fractures inadults with regard to frequency, frac-ture configuration, recommendedtreatment, and prognosis. Under-standing the local osseous and soft-tissue anatomy is vital in the assess-ment and treatment of these injuries.Clinical and radiographic examina-tion may be challenging in young

children, and a high index of suspi-cion is often the key to arriving at thecorrect diagnosis and treatment.

Most pediatric foot injuries healwell, with complete restoration offunction in a short period of time.Notable exceptions include Lisfrancinjuries, talar neck and body frac-tures, and fractures due to lawnmower trauma. Compartment syn-drome of the foot must be consideredin patients with crush injuries andother high-energy foot injuries.When a compartment syndrome ispresent, decompression of all com-partments of the foot should be per-formed emergently to minimize mor-bidity.

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