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

Pediatric and Pediatric and Adolescent Foot Adolescent Foot

InjuriesInjuriesRang’s Children’s FracturesRang’s Children’s Fractures

Wenger and PringWenger and Pring

20052005

IntroductionIntroduction

Injuries to children’s feet are Injuries to children’s feet are usually simple and easily usually simple and easily managedmanaged

Missed midfoot fracture-Missed midfoot fracture-dislocation may lead to disabilitydislocation may lead to disability

Magnitude of the soft tissue Magnitude of the soft tissue injury may be more significant injury may be more significant than the fracturethan the fracture

Phalangeal FracturesPhalangeal Fractures

Pain may be out of proportion Pain may be out of proportion to the x-ray findingsto the x-ray findings

Simple fractures may require Simple fractures may require a combination of:a combination of:Buddy taping Buddy taping Hard-sole shoeHard-sole shoeCastingCasting


Displaced fractureDisplaced fractureUsually Salter IIUsually Salter IIMay require digital block for May require digital block for

reductionreductionUse a pencil in the web space as Use a pencil in the web space as

a fulcrum to assist in the a fulcrum to assist in the reductionreduction

Confirm reduction with x-raysConfirm reduction with x-rays


Displaced fractureDisplaced fractureMay require open reduction if May require open reduction if

perisoteum or soft tissue is perisoteum or soft tissue is interposed in fracture site interposed in fracture site blocking reductionblocking reduction

K-wire or screw fixation may be K-wire or screw fixation may be required to maintain reductionrequired to maintain reduction

ORIF may be associated with long ORIF may be associated with long term stiffnessterm stiffness


Great ToeGreat ToeStubbed toe may suffer a Salter V Stubbed toe may suffer a Salter V

physeal injury with late growth physeal injury with late growth arrestarrest

Open Salter I or II fracture with Open Salter I or II fracture with damage to nail bed and matrixdamage to nail bed and matrixDebride fracture siteDebride fracture siteOral antibiotic coverageOral antibiotic coverageMay require pinning if unstableMay require pinning if unstable

Phalangeal FracturesPhalangeal Fractures Great ToeGreat Toe

Displaced Salter III or IV fracture Displaced Salter III or IV fracture of the base of the proximal of the base of the proximal phalanx common in sportsphalanx common in sportsFracture requires accurate Fracture requires accurate reductionreduction

Non-surgical management for Non-surgical management for fracture displacementfracture displacement <2mm <2mm

Cast Cast Non-weight bearing for 3 weeksNon-weight bearing for 3 weeks


Great ToeGreat Toe Displaced Salter III or IV fracture Displaced Salter III or IV fracture

of the base of the proximal phalanxof the base of the proximal phalanx Symptomatic non-unionSymptomatic non-union

>2-3mm displacement consider >2-3mm displacement consider operative reduction with K-wire or screw operative reduction with K-wire or screw fixation fixation

CastCast ORIFORIF

Metatarsal FracturesMetatarsal Fractures

Common with:Common with:High energy traumaHigh energy traumaSkateboardingSkateboardingDirt-bike racingDirt-bike racingFall from heightFall from height


Neck and shaft fractureNeck and shaft fractureModerate to severe Moderate to severe swellingswelling

Dependent edemaDependent edemaCompartment syndromeCompartment syndrome


Neck and shaft fractureNeck and shaft fractureObtain 3 x-ray views to Obtain 3 x-ray views to evaluate fractureevaluate fracture

Most may be treated with Most may be treated with short leg walking cast for 3-6 short leg walking cast for 3-6 weeksweeksSplit castSplit castCompression dressing and splint for Compression dressing and splint for severe swellingsevere swelling


Multiple fracturesMultiple fracturesDisplaced fracture may Displaced fracture may require reduction and require reduction and fixationfixation

Consider age of patientConsider age of patient


Multiple fracturesMultiple fractures22ndnd ,3 ,3rdrd & 4 & 4thth metatarsal metatarsal displacement is better displacement is better tolerated than 1tolerated than 1stst and 5 and 5th th

metatarsal displacementmetatarsal displacementMay accept up to 45May accept up to 45oo of of angulation at the metatarsal angulation at the metatarsal neck fracture site due to neck fracture site due to remodeling in younger childrenremodeling in younger children


Less angulation may be accepted as Less angulation may be accepted as child reaches skeletal maturitychild reaches skeletal maturity

May require operative reduction and May require operative reduction and fixation of displaced and angulated fixation of displaced and angulated fractures as child reaches skeletal fractures as child reaches skeletal maturitymaturity

Prevent: Prevent: Splayfoot deformity Splayfoot deformity Asymmetric loading of metatarsal headsAsymmetric loading of metatarsal heads


Operative reduction and fixation of Operative reduction and fixation of displaced and angulated fracturesdisplaced and angulated fractures TractionTraction ManipulationManipulation Percutaneous pinning if reduction Percutaneous pinning if reduction

unstableunstable Possible ORIFPossible ORIF Maintain length and alignmentMaintain length and alignment


Operative reduction and internal Operative reduction and internal fixation of displaced and fixation of displaced and angulated fracturesangulated fractures Irreducible fracturesIrreducible fractures Dorsal longitudinal incisionDorsal longitudinal incision Intramedullary or bicortical Intramedullary or bicortical

placement of K-wireplacement of K-wire Monitor for compartment syndromeMonitor for compartment syndrome


Proximal first metatarsal fractureProximal first metatarsal fracture Physeal damage may result in Physeal damage may result in

shortening of the medial side of shortening of the medial side of the footthe foot

Lisfranc type injury with fracture Lisfranc type injury with fracture of the physis at the base of the first of the physis at the base of the first metatarsal and injury to the medial metatarsal and injury to the medial cuneiform bonecuneiform bone


Proximal first metatarsal Proximal first metatarsal fracturefractureCrush injury may result in Crush injury may result in shortening of the first shortening of the first metatarsalmetatarsalPin the 1Pin the 1stst metatarsal to the 2 metatarsal to the 2ndnd metatarsal to maintain length of metatarsal to maintain length of the 1the 1stst metatarsal metatarsal


Fifth metatarsal base fractureFifth metatarsal base fracture Inversion injury to ankle and Inversion injury to ankle and

foot during sports activitiesfoot during sports activities Avulsion as a result of pull ofAvulsion as a result of pull of

Lateral head of plantar fasciaLateral head of plantar fasciaPeroneus brevis tendonPeroneus brevis tendonAbductor digiti minimi tendon Abductor digiti minimi tendon


Fifth metatarsal base fractureFifth metatarsal base fracture Direction of fracture line different that Direction of fracture line different that

apophyseal growth center (os apophyseal growth center (os vesalianum)vesalianum) Fracture line transverseFracture line transverse Apophysis parallel to the shaft of the Apophysis parallel to the shaft of the

metatarsalmetatarsal Apophysis appears around the age of 8Apophysis appears around the age of 8 Apophysis unites to the shaft at 12 years-Apophysis unites to the shaft at 12 years-

old in girlsold in girls Apophysis unites to the shaft at 15 years-Apophysis unites to the shaft at 15 years-

old in boysold in boys


Fifth metatarsal base fractureFifth metatarsal base fractureDirection of fracture line Direction of fracture line

different that apophyseal growth different that apophyseal growth center (os vesalianum)center (os vesalianum)Apophysis may be traumatically Apophysis may be traumatically avulsed with little or no avulsed with little or no displacementdisplacement

Treat true fractures and Treat true fractures and apophyseal avulsions with short-apophyseal avulsions with short-leg-weight-bearing cast for 3-6 leg-weight-bearing cast for 3-6 weeksweeks


Fifth metatarsal base fractureFifth metatarsal base fracture Jones FractureJones Fracture

Not involving the tuberosityNot involving the tuberosityHigher incidence of non-unionHigher incidence of non-unionMore long term problemsMore long term problemsResult from vertical or Result from vertical or mediolateral ground forces on the mediolateral ground forces on the weight-bearing footweight-bearing foot



Limited blood supply to fracture Limited blood supply to fracture sitesite

Looks like greenstick fractureLooks like greenstick fractureTreat non-weight bearing in castTreat non-weight bearing in castBone grafting, bone stimulator or Bone grafting, bone stimulator or intramedullary screw fixation for intramedullary screw fixation for delayed on non-uniondelayed on non-union



In athletes this may represent a In athletes this may represent a stress fracture or an acute fracture stress fracture or an acute fracture superimposed on a chronic stress superimposed on a chronic stress reactionreaction

For acute fractures in athletes For acute fractures in athletes considerconsider

Intramedullary screw fixationIntramedullary screw fixation


Fifth metatarsal base fractureFifth metatarsal base fractureJones FractureJones Fracture

Other treatment optionsOther treatment optionsExternal fixation with distraction of External fixation with distraction of medical cortex to complete fracture medical cortex to complete fracture followed by compression of fracture followed by compression of fracture sitesite

Casting with low dose pulsed Casting with low dose pulsed ultrasound bone stimulator ultrasound bone stimulator incorporated into castincorporated into cast


Stress FracturesStress Fractures March fractures-military recruitsMarch fractures-military recruits AthletesAthletes Following surgery to correct clubfoot, Following surgery to correct clubfoot,

hallux valgus and hallux rigidus with hallux valgus and hallux rigidus with redistribution of the weight-bearing to redistribution of the weight-bearing to the lesser metatarsal headsthe lesser metatarsal heads

Repetitive microstress to bone at a Repetitive microstress to bone at a level greater than the bone’s ability to level greater than the bone’s ability to healheal

Metatarsal FracturesMetatarsal Fractures Stress FracturesStress Fractures

May present with foot pain with normal x-May present with foot pain with normal x-raysrays

Follow-up x-rays show periosteal new bone Follow-up x-rays show periosteal new bone or fractureor fracture

Second and third metatarsals most Second and third metatarsals most commonly involvedcommonly involved

Consider a bone scan or MRIConsider a bone scan or MRI Consider evaluation for reduced bone Consider evaluation for reduced bone

densitydensity Treat with short-leg cast 3-6 weeksTreat with short-leg cast 3-6 weeks Correct training errors and biomechanicsCorrect training errors and biomechanics

Tarsometatarsal InjuriesTarsometatarsal Injuries Indirect trauma more common than Indirect trauma more common than

direct traumadirect trauma Force applied to forefoot Force applied to forefoot

Violent abduction Violent abduction Forced plantarflexionForced plantarflexion

Midfoot swellingMidfoot swelling May have spontaneous reduction of May have spontaneous reduction of

deformitydeformity Look for fracture of second Look for fracture of second

metatarsal base and cuboidmetatarsal base and cuboid CT scan to evaluate footCT scan to evaluate foot

Tarsometatarsal InjuriesTarsometatarsal Injuries

Non-displaced Non-displaced tarsometatarsal dislocationtarsometatarsal dislocationInitial treatment with Initial treatment with compression dressing and compression dressing and elevationelevation

Short leg cast for 4-6 weeksShort leg cast for 4-6 weeks


Displaced tarsometatarsal dislocation Displaced tarsometatarsal dislocation patternspatterns All metatarsal as a unit undergo medial All metatarsal as a unit undergo medial

or lateral displacement or lateral displacement Medially displaced first metatarsal or all Medially displaced first metatarsal or all

lesser metatarsals laterally displaced lesser metatarsals laterally displaced (homolateral)(homolateral)

Divergent between first metatarsal Divergent between first metatarsal medially and lesser metatarsals laterally medially and lesser metatarsals laterally displaceddisplaced


Displaced tarsometatarsal dislocationDisplaced tarsometatarsal dislocation Manipulation, closed reduction, Manipulation, closed reduction,

percutaneous K-wire fixation with percutaneous K-wire fixation with stabilization of the second metatarsal stabilization of the second metatarsal base base Splint first week post-op to allow for swellingSplint first week post-op to allow for swelling Non-weight bearing cast for 4-6 weeksNon-weight bearing cast for 4-6 weeks Remove K-wires at 4-6 weeks post-opRemove K-wires at 4-6 weeks post-op Weight bearing in a cast of hard-sole shoe Weight bearing in a cast of hard-sole shoe

for additional 2-4 weeks after pin removalfor additional 2-4 weeks after pin removal

Midfoot FracturesMidfoot Fractures

Lesser tarsal bonesLesser tarsal bones NavicularNavicular CuneiformsCuneiforms CuboidCuboid

May be consequence of crush injury May be consequence of crush injury such as a heavy object falling onto such as a heavy object falling onto the foot from a heightthe foot from a height

Associated with severe injury to footAssociated with severe injury to foot

Midfoot FracturesMidfoot Fractures

Compression of cuboid bone from Compression of cuboid bone from a jumping injury is a common a jumping injury is a common injury and diagnosed as spraininjury and diagnosed as sprain

Monitor x-rays for radiodense Monitor x-rays for radiodense healing linehealing line

Treat isolated nondisplaced Treat isolated nondisplaced fractures with weight-bearing cast fractures with weight-bearing cast for 3-6 weeks for 3-6 weeks

Calcaneal FracturesCalcaneal Fractures

Children seldom fracture the os calcisChildren seldom fracture the os calcis Usual mechanism is a fall from a heightUsual mechanism is a fall from a height Open fractures from lawn mower injuriesOpen fractures from lawn mower injuries Bohler’s angle reduced form normal 20Bohler’s angle reduced form normal 20oo--

4040oo in the lateral x-ray view in the lateral x-ray view Evaluate Harris axial view of os calcisEvaluate Harris axial view of os calcis Obtain CT scan of os calcisObtain CT scan of os calcis


Most fractures in children involve Most fractures in children involve the tuberosity and heal the tuberosity and heal uneventfullyuneventfully

Non-displaced fractureNon-displaced fracture Short-leg cast 4-6 weeksShort-leg cast 4-6 weeks Initially split cast for swellingInitially split cast for swelling Begin weight bearing on second Begin weight bearing on second

week after cast repaired or replacedweek after cast repaired or replaced


Displaced fracturesDisplaced fractures Avulsions of tuberosityAvulsions of tuberosity Significant displacementSignificant displacement Consider ORIF by experience Consider ORIF by experience

surgeonsurgeon Non-weight bearing casting for 6 Non-weight bearing casting for 6

weeks will provide favorable results weeks will provide favorable results in most cases due to remodeling in most cases due to remodeling potential in the growing childpotential in the growing child


Extra-articular fracturesExtra-articular fractures Usually do well with non-surgical Usually do well with non-surgical

treatmenttreatment ORIF for displaced anterior process ORIF for displaced anterior process

fractures at the calcaneocuboid jointfractures at the calcaneocuboid joint Open fractures require Open fractures require

debridement, irrigation and debridement, irrigation and fixation in the operating roomfixation in the operating room

Subtalar DislocationSubtalar Dislocation

Rare injury in childrenRare injury in children May be associated with May be associated with

Talar neck fracturesTalar neck fractures Other fractures around the foot Other fractures around the foot

and ankleand ankle Reduction usually can be Reduction usually can be

accomplished by closed methodsaccomplished by closed methods

Talar FracturesTalar Fractures

Unusual in childrenUnusual in childrenTalus anatomyTalus anatomy

Saddle shapedSaddle shapedNeck, body and headNeck, body and head


Talus anatomyTalus anatomyAlmost entirely articularAlmost entirely articular

Limited blood supplyLimited blood supplySinus TarsiSinus TarsiDorsum aspect of talar neckDorsum aspect of talar neckDeep to deltoid ligament Deep to deltoid ligament mediallymedially


Mechanism of injuryMechanism of injuryForced dorsiflexion of footForced dorsiflexion of foot

Obtain x-rays in 3 views Obtain x-rays in 3 views centered on the hindfootcentered on the hindfoot

CT ScanCT Scan


Talar neckTalar neckMajority of fractures are Majority of fractures are undisplacedundisplacedLong leg non-weight bearing Long leg non-weight bearing cast with the knee flexed for 6-8 cast with the knee flexed for 6-8 weeksweeks

Followed by 2-4 weeks in a Followed by 2-4 weeks in a weight bearing short leg castweight bearing short leg cast


Talar neckTalar neckMajority of fractures are Majority of fractures are undisplacedundisplacedRarely associated with Rarely associated with osteonecrosisosteonecrosis

Severe injuries may disrupt Severe injuries may disrupt blood supply and result in AVN blood supply and result in AVN of talar domeof talar dome


Talar neckTalar neckDisplaced fracturesDisplaced fractures

Urgent reduction within 5mm of Urgent reduction within 5mm of displacement and 5displacement and 5oo of of angulationangulation

Reduce closed in plantarflexionReduce closed in plantarflexionCast in dorsiflexion if reduction Cast in dorsiflexion if reduction is stableis stable


Talar neckTalar neck Displaced fracturesDisplaced fractures

Cast in plantarflexion with Cast in plantarflexion with inversion or eversion position inversion or eversion position based on instabilitybased on instability

K-wire percutaneous fixation if K-wire percutaneous fixation if unstableunstable

ORIF if ankle mortise is displacedORIF if ankle mortise is displaced



ORIF if ankle mortise is displacedORIF if ankle mortise is displacedPosterior-lateral approach Posterior-lateral approach adjacent to Achilles tendonadjacent to Achilles tendon

Add anterior approach Add anterior approach dorsomedial dorsomedial ( medial to EHL) if indicated( medial to EHL) if indicated



K-wires, 2-4mm screws or K-wires, 2-4mm screws or single larger screw for single larger screw for fixationfixation

Monitor vascular status of Monitor vascular status of talus for 6 monthstalus for 6 months

Follow patient for 1-2 yearsFollow patient for 1-2 years


Talar bodyTalar bodyRareRareRequires ORIFRequires ORIFSame surgical approach Same surgical approach as talar neck fractureas talar neck fracture


Lateral wall and processLateral wall and process Snowboarder’s talusSnowboarder’s talus Osteochondral avulsion by Osteochondral avulsion by

anterior talofibular ligamentanterior talofibular ligament Dorsiflexion of inverted footDorsiflexion of inverted foot Evaluate oblique x-ray and CT Evaluate oblique x-ray and CT

scanscan May require ORIF or excisionMay require ORIF or excision


Os TrigonumOs TrigonumNormal variantNormal variantMay be confused with a May be confused with a fracture of the posterior fracture of the posterior process of the talusprocess of the talus

Unlike a fracture it appears Unlike a fracture it appears rounded and smoothrounded and smooth


Os TrigonumOs TrigonumAccessory center of Accessory center of ossification that appears ossification that appears around the age of around the age of 8 to 10 in girls 8 to 10 in girls 11-13 in boys11-13 in boys


Os TrigonumOs TrigonumOssification center may be Ossification center may be injured and chronic movement injured and chronic movement through the fibrous union my through the fibrous union my cause symptomscause symptomsBallet dancersBallet dancersSurgical excision resolves Surgical excision resolves problemsproblems

Puncture Wounds of the Puncture Wounds of the FootFoot

PseudomonasPseudomonas found in socks and found in socks and inside shoesinside shoes

A nail penetrating the shoe my A nail penetrating the shoe my inoculate inoculate Pseudomonas Pseudomonas and and produce osteomyelitisproduce osteomyelitis 0.06% of puncture wounds result in a 0.06% of puncture wounds result in a

Pseudomonas Pseudomonas abscessabscess Infection becomes apparent 1-2 weeks Infection becomes apparent 1-2 weeks

following puncturefollowing puncture


PseudomonasPseudomonas infectioninfectionPainPainSwellingSwellingErythemaErythema


PseudomonasPseudomonas infection infectionSeptic arthritis if joint punctured Septic arthritis if joint punctured

Common at metatarsophalangeal Common at metatarsophalangeal jointjoint

Radiographic changes may take Radiographic changes may take 3-4 weeks3-4 weeks

Obtain triple phase bone scan orObtain triple phase bone scan or MRIMRI


PseudomonasPseudomonas infection infection Debridement in OR in general Debridement in OR in general

anesthesiaanesthesia Antibiotic coverage for Antibiotic coverage for PseudomonasPseudomonas

-gentamycin-gentamycin Antibiotic coverage for Antibiotic coverage for

Staphylococcus Aureus (MRSA)Staphylococcus Aureus (MRSA) Joint and physis may be permanently Joint and physis may be permanently

damageddamaged Chronic infection rareChronic infection rare

Questions?Questions?

Date post:	15-Jan-2016
Category:	Documents
Upload:	diana-boone
View:	220 times
Download:	0 times

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

Documents