1. science
2. medicine
3. orthopedics

Pediatric Foot Fractures:
Evaluation and Treatment
Robert M. Kay, MD, and Chris W. Tang, MD
Abstract
Foot fractures account for 5% to 8% of all pediatric fractures and for approximately 7% of all physeal fractures. A thorough understanding of the anatomy
of the child’s foot is of central importance when treating these injuries. Due to
the difficulties that may be encountered in obtaining an accurate physical examination of a child with a foot injury and the complexities of radiographic evaluation of the immature foot, a high index of suspicion for the presence of a fracture
facilitates early and accurate diagnosis. Although the treatment results in pediatric foot trauma are generally good, potential pitfalls in the treatment of
Lisfranc fractures, talar neck and body fractures, and lawn mower injuries to
the foot must be anticipated and avoided if possible.
J Am Acad Orthop Surg 2001;9:308-319
Foot fractures account for 5% to 8%
of pediatric fractures and approximately 7% of all physeal injuries.1-4
These fractures are very rare in
infants and toddlers due to the
large cartilage component of their
feet (hence the relative resistance to
fracture), but the incidence increases
with age. The more elastic and compressible nature of cartilage in comparison to bone partly explains why
foot fractures are less common in
children than in adults. As with most
traumatic injuries, pediatric foot
fractures occur more commonly in
boys than in girls.
The child’s foot is generally a forgiving location for fractures. The
vast majority of pediatric foot fractures do well with nonoperative
management. There are, however, a
group of these fractures that may
have poor results even with anatomic reduction and internal fixation. A comprehensive understanding of the anatomy of the foot, especially the location and nature of
308
injury to the physes, is requisite for
optimal evaluation and treatment of
children with these injuries.
Anatomy
As with other musculoskeletal injuries, a thorough understanding of
the relevant anatomy is crucial in
the diagnosis and treatment of pediatric foot fractures. The foot can
be thought of as consisting of three
main subdivisions: the forefoot,
the midfoot, and the hindfoot. The
forefoot consists of the metatarsals
and phalanges. The phalangeal
physes are located proximally, but
the metatarsal physes are located
distally in all but the first metatarsal. The forefoot is separated
from the midfoot by the tarsometatarsal (Lisfranc) joint.
The tarsometatarsal joints have
tremendous intrinsic stability as a
result of both the osseous architecture and the associated ligamentous
structures. The recessed base of the
second metatarsal locks between
the medial and lateral cuneiforms,
limiting medial-lateral translation
of the metatarsals. Another anatomic consideration is the trapezoidal shape of the middle three
metatarsal bases, which form a
“Roman arch” configuration when
they are positioned side by side,
affording stability in the sagittal
plane. The metatarsals are held
together by the transverse metatarsal ligaments distally. In addition,
the bases of the lateral four metatarsals are secured by the intermetatarsal ligaments. There is no intermetatarsal ligament between the
first and second metatarsals, which
can predispose to a medial Lisfranc
injury. The Lisfranc ligament, which
extends from the medial cuneiform
to the base of the second metatarsal,
further enhances the stability of
these joints.
Dr. Kay is Professor of Orthopaedic Surgery,
University of Southern California School of
Medicine, Los Angeles, and Attending Surgeon,
Childrens Hospital Los Angeles, Los Angeles,
Calif. Dr. Tang is Resident, Department of
Orthopaedic Surgery, University of Southern
California, Los Angeles.
Reprint requests: Dr. Kay, Childrens Hospital
Los Angeles, 4650 Sunset Boulevard, Mailstop
69, Los Angeles, CA 90027.
Copyright 2001 by the American Academy of
Orthopaedic Surgeons.
Journal of the American Academy of Orthopaedic Surgeons
Robert M. Kay, MD, and Chris W. Tang, MD
The Chopart transverse midtarsal joint separates the midfoot
from the hindfoot (talus and calcaneus). The talus is unusual in that
a large portion of its surface is articular cartilage. Articulations of
the talus include the talar body
with the tibial plafond proximally,
the inferior surface of the talus
with the calcaneal facets plantarly,
and the head of the talus with the
navicular distally.
In contrast to the talus, the calcaneus has numerous muscle and
tendon attachments. There are
three articulating facets on the
superior surface of the calcaneus: a
large posterior facet, a concave
middle facet, and an anterior facet.
Together, these form a complex subtalar joint with the corresponding
talar facets. The anterior facet also
articulates with the cuboid. The
Achilles tendon inserts on the posterior tubercle.
The lateral and medial plantar
processes serve as points of origin
for the plantar fascia and the small
muscles of the plantar surface of the
foot. The plantar fascia has a thick
central fibrous tissue encased by
thinner lateral bands. The fascia
spreads into five sections distally,
each travelling to a toe and straddling the flexor tendons. The superficial layers are attached to the deep
skin fold between the toes and the
sole of the foot.
There are nine compartments of
the foot: the medial and lateral compartments, the three central compartments, and the four interosseous
compartments.5 The medial compartment contains the abductor hallucis and flexor hallucis brevis muscles as well as the tendon of the flexor
hallucis longus. The lateral compartment contains the abductor digiti
minimi and flexor digiti minimi
muscles. The three central compartments contain the flexor digitorum
brevis and the four lumbrical muscles, along with the tendons of the
flexor digitorum longus in the su-
Vol 9, No 5, September/October 2001
perficial compartment, the adductor
hallucis in the adductor compartment, and the quadratus plantae in
the calcaneal compartment. The calcaneal compartment is limited to the
hindfoot and is confluent with the
deep posterior compartment of the
leg. Each interosseous compartment
contains a plantar and a dorsal interosseous muscle.
The timing of the appearance of
the ossification centers in the pediatric foot is quite variable. In young
children, these ossification centers
represent only a small portion of the
bone, as a large cartilage anlage is
present. The calcaneus, cuboid, and
talus are the tarsal bones that are
most commonly ossified at the time
of birth, with the calcaneus beginning to ossify at around 5 months of
gestation, the cuboid at 9 months,
and the talus at 8 to 9 months. The
phalanges also start ossifying at 2 to
4 months of gestation. The lateral
cuneiform starts to ossify 1 year after
birth; the medial and middle cuneiforms, at 4 years. The secondary ossification centers for the metatarsals
and the phalanges ossify at around 3
years, as does the navicular. The
secondary ossification center for the
calcaneus is the last to ossify, at 10
years.
The presence of one or more of
the various accessory ossicles may
confound the radiographic diagnosis
of a fracture (Fig. 1). The os vesalianum may be mistaken for a fracture of the base of the fifth metatarsal. The os fibulare and os tibiale
(located at the lateral border of the
cuboid and the proximal medial
aspect of the navicular, respectively)
are each present in 10% of the population. The os trigonum, located at
the posterior lip of the talus, is present in approximately 13% of the
population, and is commonly mistaken for an avulsion fracture of the
talus.
The terminal branches of the
anterior and posterior tibial arteries
provide the blood supply to the
foot. The anterior tibial artery continues as the dorsalis pedis artery,
supplies the greater part of the dorsum of the foot, and provides anastomosis with the deep plantar arch
and the arcuate artery (which later
supplies the dorsal metatarsal artery). The posterior tibial artery
divides to become the lateral and
medial plantar arteries, with the
lateral artery being dominant. The
lateral plantar artery also forms the
plantar arch, which then gives rise
to the plantar metatarsal arteries
and common digital arteries.
The blood supply to the talus is
limited, making it prone to osteonecrosis after a talar neck fracture.6
The posterior tibial artery gives rise
to the artery to the tarsal canal that
feeds the deltoid branches, which
in turn supply parts of the talar
body. The dorsalis pedis artery
gives off multiple arterioles that
penetrate the superior surface of
the head and neck of the talus, as
well as the artery of the sinus tarsi.
The artery to the tarsal canal and
the artery of the sinus tarsi form an
anastomotic arch that supplies
most of the talus body by retrograde fill. In the child’s foot, there
is less dominance of a single arterial system with retrograde flow
from the neck, which may explain a
potentially lower risk of osteonecrosis after talus fractures in children.
The posterior tibial nerve gives
rise to the medial and lateral plantar
nerves. The lateral plantar nerve
innervates the intrinsic musculature
of the plantar aspect of the foot as
well as the adductor hallucis. The
lateral plantar nerve also provides
sensation to the lateral one and a
half toes, analogous to the ulnar
nerve distribution in the upper extremity. The medial plantar nerve
supplies sensory branches to the
medial three and a half toes, similar to the sensory distribution of
the median nerve in the upper extremity.
309
Pediatric Foot Fractures
Os cuboideum
secundarium, 1%
Os peroneum
Os tibiale externum, 10%
Os vesalianum
Os intercuneiforme
Pars fibularis ossis
metatarsalis I
A
Calcaneus secundarius, 4%
Talus secundarius
Os intercuneiforme
Os sustentaculum, 5%
Os trigonum, 13%
B
Os tibiale externum, 10%
C
Os intermetatarseum, 9%
Os peroneum
Os vesalianum
Figure 1 Accessory ossifications in the foot and their frequency of occurrence (if data are available). (Adapted with permission from
Tachdjian MO [ed]: Pediatric Orthopedics, 2nd ed. Philadelphia: WB Saunders, 1990, p 471.)
Diagnosis
Although most pediatric foot fractures are isolated injuries, some
occur in polytrauma patients, warranting serial examinations. In one
series, 21 (17%) of 125 patients with
pediatric ankle and foot injuries had
other skeletal injuries as well.7
Patients with massive soft-tissue
injury present special challenges. A
careful neurovascular examination
is essential, but often difficult in a
frightened, uncooperative child.
Palpation of pulses and assessment
of capillary refill are important.
Doppler evaluation of a child with a
pulseless foot is often necessary.
Noxious stimuli, including needle
sticks, can be used to help assess
310
sensation in the child who will not
cooperate with evaluation of light
touch sensation distal to the injury.
As in adults, compartment syndromes may occur after crush or
other high-energy injuries.8 Affected
feet are quite swollen and generally
very painful. Compartment pressure measurements are invaluable
in the assessment of a child with a
suspected compartment syndrome,
especially one who is obtunded and
has significant swelling of a foot associated with a fracture. Fasciotomy
should be performed if compartment pressures exceed 30 mm Hg.
Anteroposterior (AP), lateral, and
oblique radiographs are most commonly utilized to assess patients
with foot trauma. The oblique radio-
graphs are necessary to supplement
the AP and lateral views because of
the significant osseous overlap on the
lateral view. Other specialized views
and/or computed tomographic (CT)
and magnetic resonance (MR) imaging studies may be necessary to completely evaluate specific fracture configurations. Comparison views are
rarely necessary for the orthopaedist
familiar with the normal radiographic appearance.9
Fractures and Dislocations
of the Talus
Fewer than 1% of all pediatric fractures and only 2% of all pediatric
foot fractures are talus fractures.1,10
Journal of the American Academy of Orthopaedic Surgeons
Robert M. Kay, MD, and Chris W. Tang, MD
In a series of 90 pediatric talus fractures, there were 50 avulsion fractures (56%), 18 osteochondral lesions (20%), 17 talar neck fractures
(19%), and 5 talar body fractures
(6%).11
Avulsion fractures require only
symptomatic treatment, often with a
short leg splint or short walking cast
for 1 to 2 weeks until symptoms
subside. There are generally no
long-term sequelae.
As in adults, talar neck and body
fractures result from forceful dorsiflexion of the ankle. However, in
reported series dealing with children, the mechanism of injury was a
fall from a height or a motor vehicle
accident in approximately 70% to
90% of cases.11,12 Of all talar neck
and body fractures, only 10% occur
in children.13 These fractures occur
throughout childhood and have
even been reported in children less
than 2 years old.11,12 Jensen et al11
reported that 6 (43%) of the 14 patients in their series of pediatric talar
neck and body fractures had associated fractures.
Signs and symptoms of talar fractures include ankle or hindfoot pain,
local tenderness, and pain with
ankle dorsiflexion. Local swelling is
variable. Plain radiographs frequently delineate the fracture line
and the amount of displacement, although they may be read as normal
initially.12 Computed tomography
may aid in the assessment of fracture configuration and displacement.
The Hawkins classification system is most commonly used for
classifying talar neck fractures in
children as well as in adults. 14,15
Type I fractures are nondisplaced
(Fig. 2). Type II fractures are displaced talar neck fractures in conjunction with subluxation or dislocation of the subtalar joint. Type III
fractures are displaced talar neck
fractures in conjunction with subluxation or dislocation of both the
subtalar and the tibiotalar joint. The
extremely rare type IV injuries are
characterized by a displaced talar
neck fracture, subluxation of the
head of the talus from the talonavicular joint, and subluxation or dislocation of the subtalar and/or ankle
joints.
Osteonecrosis of the talar body is
common after fractures of the talar
neck and body due to disruption of
the vascular ring surrounding the
talar neck as the fracture displaces.
Because the surface of the talus is
mostly articular cartilage, the talar
blood supply is tenuous. Overall,
the risk of osteonecrosis in reported
series of talar neck fractures that
combine adult and pediatric patients
is approximately 50%, and is highest
for type III and IV fractures and lowest for type I fractures. In one such
series, Canale and Kelly16 reported
osteonecrosis in 15% of type I fractures, 50% of type II fractures, and
84% of type III fractures. In another
series, Jensen et al 11 reported no
cases of osteonecrosis in 10 fractures
A
B
C
Figure 2 AP (A) and lateral (B) radiographs of a minimally displaced talar neck fracture (arrows) in a 4-year-old boy who sustained ipsilateral fractures of the distal tibial physis and distal fibular diaphysis. C, CT scan confirms minimal displacement. Fracture comminution
is evident. (Courtesy of J. Dominic Femino, MD.)
Vol 9, No 5, September/October 2001
311
Pediatric Foot Fractures
(3 of which were displaced). Letts
and Gibeault12 reported 3 cases of
osteonecrosis in 13 nondisplaced
pediatric talar neck fractures (incidence of 23%).
The Hawkins sign (lucency in
the subchondral bone of the talar
dome, usually seen by 8 weeks
after injury) suggests that the talar
body is adequately vascularized
and the risk of osteonecrosis is low.
Technetium bone scanning and,
more commonly, MR imaging can
be useful to assess the presence of
osteonecrosis in borderline cases.
Treatment of nondisplaced talar
neck and body fractures consists of
immobilization in a non-weightbearing long leg cast. After approximately 2 months, a patient with a
positive Hawkins sign (indicating
that there is no osteonecrosis) may
begin weight bearing as tolerated.
A closed reduction should be
attempted for displaced talar fractures, although the criteria for an
acceptable reduction have not been
clearly defined. In general, however,
the surgeon should attempt to
achieve an intra-articular reduction
with less than 2 mm of residual displacement. These fractures are often stable with the foot in a plantarflexed position. If open reduction
and internal fixation is performed,
insertion of screws into the talus
from posterior to anterior has been
shown to be biomechanically superior to insertion from anterior to
posterior.17
Long-term follow-up suggests
that pain is common after displaced
talar fractures in children.11 Whether
this pain is due to the initial highenergy injury and associated chondral damage or to residual intraarticular incongruity is unclear.11
Follow-up radiographic studies have
demonstrated the development of
arthrosis in the ankle joints, but not
the subtalar joints, of patients with
displaced talar fractures.11
The duration of protected weight
bearing for patients with osteone-
312
crosis remains controversial. Various mechanisms of unloading the
talus have been tried, including the
use of ambulatory aids, bracing,
and casting. Letts and Gibeault12
reported on three pediatric patients
with osteonecrosis after talar neck
fractures. Talar flattening and ankle
stiffness developed in two patients
after bearing weight on the affected
extremity (due to a delay in diagnosis). The patient whose weight bearing was limited until the osteonecrotic segment had healed did not
have such complications. Even
when weight bearing is not recommended, the long-term effect and
the influence of patient compliance
on outcome are unclear.
Peritalar dislocations are defined
as dislocations of the subtalar joint
and talonavicular joint in the absence of a talar fracture. These injuries are rare, accounting for only 4%
of all pediatric talar fractures and
dislocations.18 These are generally
high-energy injuries and were associated with ipsilateral foot fractures
in all 5 patients in the series of
Dimentberg and Rosman.18 Closed
reduction is generally feasible, but
may be impossible if diagnosis is
delayed or if there are interposed
soft-tissue or osseous structures.
Osteochondritis Dissecans
of the Talus
The talus is the second most common site for osteochondritis dissecans (OCD). Osteochondritis dissecans of the talus is analogous to that
found in other anatomic locations
and is characterized by necrotic
bone underlying articular cartilage.
In the talus, OCD usually occurs
either anterolaterally or posteromedially.
Children with OCD of the talus
may present with the acute onset of
pain after a traumatic incident (such
as an inversion injury) or with chronic ankle pain. Trauma to the ankle
has been reported in 46% to 63% of
children with OCD of the talus.19,20
The mean age of children with OCD
of the talus is 13 to 14 years, although it may be seen in children
less than 10 years old.19,20 Signs and
symptoms in the affected ankle may
include pain, swelling, instability,
repetitive sprains, and decreased
range of motion. In one series,20 the
average duration of symptoms prior
to diagnosis was 4.3 months. Locking
of the ankle joint is rarely reported.
Physical examination usually demonstrates decreased range of motion
of the ankle, which is often painful.
Localized tenderness may be difficult
to elicit, and the presence of synovitis
is variable.
Grading of OCD of the talus is
based on the system described by
Berndt and Harty in 1959.21 Type I
lesions are nondisplaced. Type II
lesions are partially detached. Type
III lesions are detached but not displaced. Type IV lesions are detached
and displaced or rotated. Plain radiographs will often demonstrate a triangular sclerotic fragment separated
from the talar dome anterolaterally
or posteromedially (Fig. 3). Sometimes, these lesions are hard to visualize on plain films, depending on
their location in the sagittal plane.
Magnetic resonance imaging is
the most helpful radiologic study
for assessing OCD of the talus. 22
This modality can help delineate
the condition of the articular cartilage, whether the articular cartilage
is intact, the extent of the lesion, the
extent of sclerosis of the fragment,
and whether the fragment is displaced. Evidence of fluid underneath the OCD fragment indicates
disruption of the articular cartilage.
The MR study should be used in
conjunction with plain radiographs
to classify these lesions.
The course of OCD of the talus
appears to be more benign in children than in adults. Bauer et al23
reported on five children with OCD
of the talus followed up for an aver-
Journal of the American Academy of Orthopaedic Surgeons
Robert M. Kay, MD, and Chris W. Tang, MD
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 injury
demonstrate a large osteochondral lesion (arrows) of the anterolateral talar dome. At the time of presentation, the patient was fully active
and denied pain. C, CT scan demonstrates a type III lesion and significant sclerosis of the osteochondral fragment. Observation was
undertaken because of the minimal symptoms.
age of 22 years: four of the lesions
regressed, the fifth did not progress,
and no patient had radiographic
evidence of osteoarthritis at longterm follow-up. The results of surgical treatment also appear to be
better in children than in adults.19,23
Nonoperative management has
been recommended as the initial
treatment of choice for all but type
IV lesions,19,20 generally beginning
with immobilization and protected
weight bearing for 1 to 2 months.
Activity modification and protected
weight bearing may continue for an
additional 2 to 3 months. If there is
no symptomatic and radiographic
improvement by 3 to 4 months,
drilling, debridement, or arthroscopic fixation may be indicated.
Greenspoon and Rosman24 reported
that the results of bone grafting
were better than the results of OCD
fragment excision. Arthrotomy
with a medial malleolar osteotomy
has been used in various series, but
often can be avoided owing to advances in arthroscopic technique.
Vol 9, No 5, September/October 2001
Type IV lesions should be treated
operatively.
Calcaneal Fractures
Approximately 5% of all patients
with calcaneal fractures are children25; however, calcaneal fractures
represent only 2% of pediatric foot
injuries.10 Boys are more commonly
affected than girls. Extra-articular
fractures are more frequent in children than in adults, representing
65% of pediatric calcaneal fractures.25,26 Fifty percent of pediatric
calcaneal injuries that occur after
falls result in intra-articular fractures. In adolescents 15 years and
older, the fracture patterns are comparable to those seen in adults.25
The mechanism of most calcaneal
fractures is axial loading, with the
talus being driven into the calcaneus.
The fracture is most commonly due
to a fall from a height or a motor
vehicle accident (incidence rates of
40% and 15%, respectively, in two
studies25,26). Because these injuries
generally are the result of high-energy
trauma, associated injuries are common, occurring in approximately
one third of children with calcaneal
fractures. These may be lacerations
of the ipsilateral lower extremity25,26
or even spine fractures (5% of the
children in one study25). In an early
series before the advent of CT and
MR imaging, 26% of calcaneal fractures were missed initially.25
A plain-radiographic study should
include AP, lateral, and axial views.
Oblique calcaneal views may also aid
in the initial assessment of fracture
configuration. The lateral view is important because it allows measurement of the Böhler’s angle (Fig. 4).
Böhler’s angle normally measures 25
to 40 degrees in adults, but is less in
children. 14 The “crucial angle of
Gisanne” is rarely measured in children because a large portion of the
calcaneus is not yet ossified. The
angle usually measures 125 to 140
degrees in adolescents. A CT scan
may also be valuable in assessing the
313
Pediatric Foot Fractures
Lisfranc Injuries
Navicular
Talus
Böhler’s angle
Cuboid
Calcaneus
Lateral process
Crucial angle
of Gissane
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: the
first connects the superior portion of the anterior and posterior calcaneal facets, and the
second connects the superior portions of the posterior facet and the tuberosity. (Adapted
with permission from Heckman JD: Fractures and dislocations of the foot, in Rockwood
CA, Green DP, Bucholz RW, Heckman JD [eds]: Rockwood and Green’s Fractures in Adults,
4th ed. Philadelphia: Raven Publishers, 1996, p 2326.)
configuration of an intra-articular
fracture.
There are several classification systems for calcaneal fractures. The
Essex-Lopresti method is widely
used. This system categorizes injuries
as tongue-type or split-depression
fractures, but the most important differentiation is between intra-articular
(Fig. 5) and extra-articular fractures.
Extra-articular fractures can be
treated with a bulky Jones dressing
followed by weight bearing in 3 to 4
weeks. The long-term sequelae of
such fractures are rare, although
there may be some residual loss of
heel height and widening of the heel.
Some authors advocate surgical
treatment for displaced intra-articular
fractures in young patients. However, Schantz and Rasmussen 27
reported good results in pediatric
patients treated nonoperatively.
Thomas28 reported good results even
in patients with a decreased Böhler’s
angle who were treated nonoperatively; these results were thought to
be secondary to potential talar remodeling in the pediatric population.
Although the optimal treatment for
younger patients remains controversial, open reduction and internal fixa-
314
tion is indicated for displaced intraarticular calcaneal fractures in adolescents, as it is in adults.
Other Tarsal Fractures
Tarsal fractures account for approximately 1% of all pediatric fractures.1
Fractures of the navicular, cuboid,
and cuneiforms are reported to represent 2% to 7% of pediatric foot
injuries.10,29 Most tarsal fractures
are avulsion or stress fractures, both
of which can be treated in a short
walking cast for 2 to 3 weeks. This
is sufficient to allow healing, and no
long-term sequelae need be expected.
Complete displaced fractures of
the navicular, cuneiforms, and cuboid often result from high-energy
trauma; therefore, associated injuries,
such as those of the Lisfranc complex, are common. Because much of
the surface of these bones is intraarticular, closed or open reduction
and internal fixation may be needed
for displaced fractures. Assessment
of the soft-tissue envelope is important in these high-energy injuries,
and compartment syndrome must
be ruled out.
Injuries of the tarsometatarsal joint
complex are uncommon in children.
The mechanism of injury is either
forceful plantar-flexion of the foot,
generally with axial loading, or a
direct crush injury. Falls from a
height accounted for approximately
60% of the pediatric Lisfranc injuries in the two largest series.30,31 Of
the 34 patients in those studies, 21
(62%) were boys. The age range in
the two studies differed considerably: Johnson30 reported that the
fracture occurred most commonly
in children aged 3 to 6 years, but
Wiley31 reported a mean patient age
of 12 years. Johnson reported fractures of the proximal first metatarsal
in all 16 of his patients, including 1
with a concomitant second metatarsal fracture.
Ligamentous injury may accompany fractures as the Lisfranc joint
complex is loaded. Because the plantar ligaments of the tarsometatarsal
joint complex are stronger than the
dorsal ligaments, the dorsal ligaments rupture first. With continued
Figure 5 Lateral radiograph demonstrates
a minimally displaced intra-articular calcaneal fracture (split-depression type) in a
4-year-old boy involved in a motor vehicle
accident. Associated injuries included an
ipsilateral femoral shaft fracture, contralateral distal femoral physeal fracture, and a
degloving injury to the contralateral leg.
Care for the calcaneal fracture consisted of
initial splinting and a 3-week non-weightbearing period. The dotted lines indicate
the fracture pattern.
Journal of the American Academy of Orthopaedic Surgeons
Robert M. Kay, MD, and Chris W. Tang, MD
loading, the plantar ligaments then
rupture, after which plantar displacement of the metatarsal bases
may occur.
Children who sustain Lisfranc injuries due to high-energy trauma
often have significant soft-tissue
injury and should be admitted to the
hospital for observation overnight.
Compartment syndrome may be heralded by pain out of proportion to
the injury, as well as pain with passive motion of the toes in the awake
patient. Compartment pressures
must be measured if there is the possibility of a compartment syndrome
in any patient, regardless of cognitive
status. In patients with altered mental status, the physician should be
more inclined to measure compartment pressures, as clinical signs of
pain may not be easily appreciated in
the obtunded patient. Fasciotomy of
all compartments of the foot should
be performed if compartment pressures are greater than 30 mm Hg.5,8
Lisfranc injuries may involve the
entire tarsometatarsal complex or
any portion thereof. Diastasis frequently occurs between the bases of
the first and second metatarsals, as
there is no intermetatarsal ligament
in that interval (Fig. 6). Alternatively, all five rays may be involved,
either with all rays displacing in the
same direction (homolateral injury)
or with the first ray displacing medially and the lateral four rays displacing laterally (divergent injury).32
The initial radiographic evaluation should consist of AP, oblique,
and lateral radiographs. If possible,
the AP and lateral films should be
weight-bearing views, as subtle
injuries may not be evident on nonweight-bearing radiographs.33 Fractures of the base of the first metatarsal are common, but an isolated
fracture of the base of the second
metatarsal may result from avulsion
of the insertion of the Lisfranc ligament, heralding the presence of an
injury to the Lisfranc complex. If no
fracture is evident on presentation,
Vol 9, No 5, September/October 2001
A
B
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 right
foot. Although the medial column is disrupted, the remainder of the Lisfranc complex is
appropriately aligned. The patient underwent open reduction and pinning after an unsuccessful attempt at closed reduction in the operating room.
the medial aspect of the base of the
second metatarsal should line up
with the medial aspect of the middle cuneiform, and the medial aspect of the base of the fourth metatarsal should line up with the medial
aspect of the cuboid.
Nondisplaced fractures at the
level of the tarsometatarsal joint
complex may actually be injuries
that were initially displaced but then
spontaneously reduced. Patients
with such injuries may be treated
with a bulky dressing or posterior
plaster splint for several days to 1
week, followed by a non-weightbearing short leg cast until 1 month
after injury, and then a short walking cast for an additional 2 weeks.
Patients with Lisfranc fracturedislocations should be treated operatively. Closed reduction should be
attempted in the operating room.
Wiley31 reported that 7 (39%) of 18
patients in his series required closed
reduction. Finger traps placed on
the toes facilitate reduction. If closed
reduction is possible, internal fixation should be performed. Kirschner
wires may be used in young children. Cannulated screws are preferred for the older child with sufficient bone stock for screw fixation. If
a nearly anatomic closed reduction is
not possible, open reduction should
be performed, with removal of any
impediments to reduction (frequently
osteocartilaginous fracture fragments), followed by internal fixation.
The long-term results in children with
Lisfranc injuries are uncertain. Even
with short-term follow-up, Wiley reported residual pain at the Lisfranc
joint in 4 (22%) of his 18 patients.
Metatarsal Fractures
Metatarsal physeal fractures represent 1% to 2% of all physeal injuries
315
Pediatric Foot Fractures
in children and adolescents.1-3 In
one large series, metatarsal fractures
accounted for approximately 60% of
pediatric foot fractures, with fractures of the base of the fifth metatarsal accounting for 22%.10 Owen et
al 29 reported that first-metatarsal
fractures accounted for 73% of all
tarsal and metatarsal fractures in
children younger than 5 years, but
only 12% of such fractures in children older than 5. In the same series, 6.5% of all fractures and 20% of
all first-metatarsal fractures were
initially unrecognized by the treating physician.
The mechanism of metatarsal fracture may be either indirect or direct.
Indirect injuries often result from
axial loading, inversion, rotation, or a
combination thereof (Fig. 7). Direct
injuries often result from the impact
of falling objects or crush injuries. If
these fractures occur proximally
rather than in the midshaft, evaluation of the tarsometatarsal joint complex for concomitant injury is important. Radiographs should consist
of AP, lateral, and oblique views to
assess fracture alignment. Mediallateral displacement of the fracture
may be seen, but is acceptable in the
absence of displacement of the Lisfranc complex.
If these fractures are not proximal, they can almost always be
treated with weight bearing as tolerated in a short walking cast or a cast
shoe. The duration of treatment is
generally 3 weeks (until tenderness
at the fracture site has subsided). In
children with marked swelling, a
circumferential cast should not be
applied at the time of evaluation,
and consideration should be given
to admitting the child for overnight
observation. Compartment syndromes, though rare, may occur if
high-energy trauma has caused multiple metatarsal fractures.
In the rare instance in which
there is marked sagittal malalignment of the metatarsal heads, closed
reduction and pinning of a metatarsal fracture should be considered to
avoid transfer lesions in the future.
Finger traps are often helpful in reducing such fractures.
Growth disturbance may occur
as a result of a metatarsal fracture.
Physeal fractures of the base of the
first metatarsal may potentially
cause a growth disturbance and
shortening of the first ray. This complication is rare, but may result in
transfer lesions. Overgrowth may
also occur after metatarsal fractures.
Fractures of the Base of
the Fifth Metatarsal
Figure 7 Displaced third- and fourthmetatarsal fractures and a nondisplaced
second-metatarsal fracture sustained by a
15-year-old boy due to an indirect mechanism of injury. The patient was treated in a
short walking cast for 2 weeks, followed by
a cast boot for 2 additional weeks.
316
Approximately 40% of all metatarsal fractures are fractures of the
base of the fifth metatarsal. In one
large series, 10 as many as 22% of
pediatric foot fractures were at that
site. In that same series, 90% of
fifth-metatarsal fractures occurred
in children older than 10 years. As
in adults, the location of the fracture, the fracture appearance, and
the duration of symptoms before
presentation are important prognostic factors. The injury generally
occurs with the foot in a weightbearing position. Inversion has
been reported as the most common
mechanism of injury.29
The initial radiographic examination should consist of AP, lateral,
and oblique views. The location of
the fracture is important to both
prognosis and treatment. Tuberosity fractures are generally benign
and heal with 6 weeks in a short
walking cast. Although previously
thought to be due to avulsion at the
insertion of the peroneus brevis,
tuberosity fractures now appear to
be due to avulsion at the origin of
the abductor digiti minimi. Fractures at or distal to the metaphysealdiaphyseal junction are more recalcitrant to treatment. These fractures
should be treated with at least 6
weeks in a non-weight-bearing cast.
If the fracture is preceded by weeks
to months of pain (or if there is radiographic evidence of a preceding
stress injury), internal fixation should
be considered. Some authors advocate curettage and bone grafting in
patients with intramedullary sclerosis indicative of a delayed union or
nonunion.34,35
Phalangeal Fractures
Phalangeal fractures are common
in the pediatric population and often do not even result in the child
being seen by an orthopaedic surgeon. Many of these fractures are
treated symptomatically by the patient and family or by the primarycare physician. Phalangeal fractures
may account for as many as 18% of
pediatric foot fractures.10 In three
studies,1-3 phalangeal fractures represented 3% to 7% of all physeal
Journal of the American Academy of Orthopaedic Surgeons
Robert M. Kay, MD, and Chris W. Tang, MD
fractures and were usually SalterHarris type I or type II injuries.
The examining physician must
closely evaluate the toe for integrity
of the skin and also make sure that
there is not a nail-bed injury. Open
fractures require irrigation and
debridement and intravenous antibiotic therapy (Fig. 8). Nail-bed injuries involving the germinal matrix
should be repaired.
Closed fractures rarely require
reduction. Buddy-taping of the toes
with weight bearing as tolerated
almost universally results in a wellhealed and well-aligned fracture
within 3 to 4 weeks. (A hard-soled
shoe may be used for patient comfort
until fracture healing has occurred.)
Closed versus open reduction and
pinning should be considered for
markedly angulated fractures or displaced intra-articular fractures of the
proximal phalanx of the great toe
(including Salter-Harris type III and
type IV fractures) involving more
than 25% of the joint surface and
those with more than 2 mm of displacement.
Growth arrest and stiffness are
uncommon sequelae of phalangeal
fractures. When growth arrest occurs, it most commonly follows
fractures of the great toe.
Lawn Mower Injuries
Lawn mowers have been reported
to cause as many as 160,000 injuries
annually, including approximately
2,000 that result in permanent impairment in children.36-38 Accidents
occur with all types of mowers, but
the most severe injuries usually
occur when young children are
struck by riding mowers. In fact, as
many as 72% of children who sustain severe lawn mower injuries are
bystanders.37,38
A careful evaluation of the entire
child, including all extremities, is
vital. In a study of 33 children with
lawn mower injuries, Alonso and
Vol 9, No 5, September/October 2001
Figure 8 AP (left) and lateral (above) radiographs of a 12year-old boy after an open Salter-Harris type II fracture of
the distal phalanx of the great toe. The open fracture was
not recognized on initial presentation. When the patient
presented to the author’s institution, purulent drainage and
cellulitis were evident. Treatment consisted of irrigation
and debridement, followed by open reduction and percutaneous pinning of the fracture. (Courtesy of Richard A. K.
Reynolds, MD, Los Angeles, Calif.)
Sanchez36 found that 8 (24%) had
head and eye injuries, 12 (36%) had
upper-extremity injuries, and 13
(39%) had lower-extremity injuries.
Fractures must be evaluated in
conjunction with the degree of softtissue damage and the integrity of
neurovascular structures.
These are high-energy injuries
that frequently involve significant
soft-tissue and fracture contamination. Initial treatment should consist
of irrigation and debridement and
triple-antibiotic coverage. Internal
fixation of fractures and/or external
fixation spanning the injured segment may help stabilize the soft tissues, allow access to the zone of
injury, and facilitate patient care.
Repeat debridements should be performed at 2- to 3-day intervals until
the wound is sufficiently clean.
Soft-tissue damage from lawn
mower injuries is extensive, and the
soft-tissue envelope generally appears better on presentation than it
does in the ensuing days due to the
initial compromised soft-tissue perfusion. Early involvement of the
plastic surgery team is important to
facilitate coverage of these wounds
by 7 to 14 days after injury. Skin
grafting or flap coverage is needed
in more than 50% of patients.37 Unlike adults, children may do well
with split-thickness skin grafts
placed on the plantar aspect of the
foot.38 Despite appropriate early
care, amputation rates in children
with lower-extremity lawn mower
injuries have ranged from 16% to
78%.36-38 Even in salvaged extremities, late deformity may occur due
to muscle imbalance resulting from
the damage or loss of muscles, tendons, or nerves at the time of injury.
Occult Foot Fractures
Toddlers often present with the
acute onset of a limp but without a
definite trauma history. Unlike a
“toddler’s fracture,” there may be no
tenderness over the tibia. Tenderness is often evident in the foot, but
may be hard to pinpoint. Typically,
a child with an occult foot fracture
will be able to crawl without difficulty but will limp when walking.
Plain radiographs will rarely
reveal a fracture. A bone scan, how-
317
Pediatric Foot Fractures
ever, will often show increased
radionuclide uptake in the foot.
Englaro et al39 reported that 16 (29%)
of 56 preschool children with lowerextremity pain or limping of unknown origin had abnormal tracer
uptake localized to the foot on bone
scans. Of those 16 patients, 9 had
abnormal uptake in the cuboid; 4, in
the calcaneus; 2, in multiple tarsal
bones; and 1, in the tibiotalar joint.
If an occult foot fracture is suspected, a short walking cast can be
used for 2 to 3 weeks. Repeat radiographs at the time of cast removal
will often reveal callus formation
and confirm the diagnosis of occult
fracture. If symptoms persist after
casting and radiographs do not
demonstrate callus formation, a
bone scan is indicated to identify
the site of injury.
Pediatric foot fractures often differ
significantly from foot fractures in
adults with regard to frequency, fracture configuration, recommended
treatment, and prognosis. Understanding the local osseous and softtissue anatomy is vital in the assessment and treatment of these injuries.
Clinical and radiographic examination may be challenging in young
children, and a high index of suspicion is often the key to arriving at the
correct diagnosis and treatment.
Most pediatric foot injuries heal
well, with complete restoration of
function in a short period of time.
Notable exceptions include Lisfranc
injuries, talar neck and body fractures, and fractures due to lawn
mower trauma. Compartment syndrome of the foot must be considered
in patients with crush injuries and
other high-energy foot injuries.
When a compartment syndrome is
present, decompression of all compartments of the foot should be performed emergently to minimize morbidity.
das JC, Darling DB, Bankoff MS, Swan
CS II: Comparison views in extremity
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Crawford AH: Fractures and dislocations of the foot and ankle, in Green
NE, Swiontkowski MF (eds): Skeletal
Trauma in Children. Philadelphia: WB
Saunders, 1994, pp 449-516.
Jensen I, Wester JU, Rasmussen F,
Lindequist S, Schantz K: Prognosis of
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Letts RM, Gibeault D: Fractures of the
neck of the talus in children. Foot
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Kenwright J, Taylor RG: Major injuries of the talus. J Bone Joint Surg Br
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Gross RH: Fractures and dislocations
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Hawkins LG: Fractures of the neck of
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991-1002.
Canale ST, Kelly FB Jr: Fractures of
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Swanson TV, Bray TJ, Holmes GB Jr:
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Dimentberg R, Rosman M: Peritalar
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Bruns J, Rosenbach B: Osteochondrosis dissecans of the talus: Comparison of results of surgical treatment in
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Summary
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