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 approxi- structures. The recessed base of the
mately 7% of all physeal fractures. A thorough understanding of the anatomy second metatarsal locks between
of the child’s foot is of central importance when treating these injuries. Due to the medial and lateral cuneiforms,
the difficulties that may be encountered in obtaining an accurate physical exam- limiting medial-lateral translation
ination of a child with a foot injury and the complexities of radiographic evalua- of the metatarsals. Another ana-
tion of the immature foot, a high index of suspicion for the presence of a fracture tomic consideration is the trape-
facilitates early and accurate diagnosis. Although the treatment results in pedi- zoidal shape of the middle three
atric foot trauma are generally good, potential pitfalls in the treatment of metatarsal bases, which form a
Lisfranc fractures, talar neck and body fractures, and lawn mower injuries to “Roman arch” configuration when
the foot must be anticipated and avoided if possible. they are positioned side by side,
J Am Acad Orthop Surg 2001;9:308-319 affording stability in the sagittal
plane. The metatarsals are held
together by the transverse metatar-
sal ligaments distally. In addition,
Foot fractures account for 5% to 8% injury to the physes, is requisite for the bases of the lateral four metatar-
of pediatric fractures and approxi- optimal evaluation and treatment of sals are secured by the intermeta-
mately 7% of all physeal injuries.1-4 children with these injuries. tarsal ligaments. There is no inter-
These fractures are very rare in metatarsal ligament between the
infants and toddlers due to the first and second metatarsals, which
large cartilage component of their Anatomy can predispose to a medial Lisfranc
feet (hence the relative resistance to injury. The Lisfranc ligament, which
fracture), but the incidence increases As with other musculoskeletal inju- extends from the medial cuneiform
with age. The more elastic and com- ries, a thorough understanding of to the base of the second metatarsal,
pressible nature of cartilage in com- the relevant anatomy is crucial in further enhances the stability of
parison to bone partly explains why the diagnosis and treatment of pe- these joints.
foot fractures are less common in diatric foot fractures. The foot can
children than in adults. As with most be thought of as consisting of three
traumatic injuries, pediatric foot main subdivisions: the forefoot,
fractures occur more commonly in the midfoot, and the hindfoot. The Dr. Kay is Professor of Orthopaedic Surgery,
boys than in girls. forefoot consists of the metatarsals University of Southern California School of
Medicine, Los Angeles, and Attending Surgeon,
The child’s foot is generally a for- and phalanges. The phalangeal Childrens Hospital Los Angeles, Los Angeles,
giving location for fractures. The physes are located proximally, but Calif. Dr. Tang is Resident, Department of
vast majority of pediatric foot frac- the metatarsal physes are located Orthopaedic Surgery, University of Southern
tures do well with nonoperative distally in all but the first meta- California, Los Angeles.
management. There are, however, a tarsal. The forefoot is separated
group of these fractures that may from the midfoot by the tarsometa- Reprint requests: Dr. Kay, Childrens Hospital
Los Angeles, 4650 Sunset Boulevard, Mailstop
have poor results even with ana- tarsal (Lisfranc) joint. 69, Los Angeles, CA 90027.
tomic reduction and internal fixa- The tarsometatarsal joints have
tion. A comprehensive understand- tremendous intrinsic stability as a Copyright 2001 by the American Academy of
ing of the anatomy of the foot, espe- result of both the osseous architec- Orthopaedic Surgeons.
cially the location and nature of ture and the associated ligamentous

308 Journal of the American Academy of Orthopaedic Surgeons


The Chopart transverse mid-
tarsal joint separates the midfoot
from the hindfoot (talus and calca-
neus). The talus is unusual in that
a large portion of its surface is ar-
ticular 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 calca-
neus 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 sub-
talar joint with the corresponding
talar facets. The anterior facet also
articulates with the cuboid. The
Achilles tendon inserts on the poste-
rior 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 strad-
dling the flexor tendons. The super-
ficial 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 com-
partments, the three central com-
partments, and the four interosseous
compartments.5 The medial com-
partment contains the abductor hal-
lucis and flexor hallucis brevis mus-
cles as well as the tendon of the flexor
hallucis longus. The lateral com-
partment contains the abductor digiti
minimi and flexor digiti minimi
muscles. The three central compart-
ments contain the flexor digitorum
brevis and the four lumbrical mus-
cles, along with the tendons of the
flexor digitorum longus in the su-
Vol 9, No 5, September/October 2001
Robert M. Kay, MD, and Chris W. Tang, MD
perficial compartment, the adductor
hallucis in the adductor compart-
ment, and the quadratus plantae in
the calcaneal compartment. The cal-
caneal 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 inter-
osseous muscle.
The timing of the appearance of
the ossification centers in the pedi-
atric 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 begin-
ning 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 cunei-
forms, at 4 years. The secondary os-
sification 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 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 the
cuboid and the proximal medial
aspect of the navicular, respectively)
are each present in 10% of the popu-
lation. The os trigonum, located at
the posterior lip of the talus, is pres-
ent in approximately 13% of the
population, and is commonly mis-
taken 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 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 arch
and the arcuate artery (which later
supplies the dorsal metatarsal ar-
tery). 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 osteo-
necrosis 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 retro-
grade fill. In the child’s foot, there
is less dominance of a single arteri-
al system with retrograde flow
from the neck, which may explain a
potentially lower risk of osteone-
crosis after talus fractures in chil-
dren.
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 ex-
tremity. The medial plantar nerve
supplies sensory branches to the
medial three and a half toes, simi-
lar to the sensory distribution of
the median nerve in the upper ex-
tremity.
309
Pediatric Foot Fractures

Os cuboideum
secundarium, 1%

Os peroneum
Os tibiale externum, 10%

Os vesalianum
Os intercuneiforme

Pars fibularis ossis

metatarsalis I

Calcaneus secundarius, 4%
Talus secundarius
Os sustentaculum, 5% Os intercuneiforme

Os trigonum, 13%
Os intermetatarseum, 9%

Os tibiale externum, 10%

B C 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 frac-
tures are isolated injuries, some
occur in polytrauma patients, war-
ranting 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
sensation in the child who will not
cooperate with evaluation of light
touch sensation distal to the injury.
As in adults, compartment syn-
dromes may occur after crush or
other high-energy injuries.8 Affected
feet are quite swollen and generally
very painful. Compartment pres-
sure 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 as-
sociated with a fracture. Fasciotomy
should be performed if compart-
ment pressures exceed 30 mm Hg.
Anteroposterior (AP), lateral, and
oblique radiographs are most com-
monly 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) imag-
ing studies may be necessary to com-
pletely evaluate specific fracture con-
figurations. Comparison views are
rarely necessary for the orthopaedist
familiar with the normal radio-
graphic appearance.9
Fractures and Dislocations
of the Talus
Fewer than 1% of all pediatric frac-
tures and only 2% of all pediatric
foot fractures are talus fractures.1,10

310 Journal of the American Academy of Orthopaedic Surgeons

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

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 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 dorsi-
flexion of the ankle. However, in
reported series dealing with chil-
dren, 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 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 with
ankle dorsiflexion. Local swelling is
variable. Plain radiographs fre-
quently delineate the fracture line
and the amount of displacement, al-
though they may be read as normal
initially.12 Computed tomography
may aid in the assessment of frac-
ture configuration and displace-
ment.
The Hawkins classification sys-
tem 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 dis-
placed talar neck fractures in con-
junction with subluxation or dislo-
cation of the subtalar joint. Type III
fractures are displaced talar neck
fractures in conjunction with sub-
luxation 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 talonavic-
ular joint, and subluxation or dislo-
cation 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 low-
est for type I fractures. In one such
series, Canale and Kelly16 reported
osteonecrosis in 15% of type I frac-
tures, 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 ipsi-
lateral 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 (inci-
dence 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-weight-
bearing long leg cast. After approxi-
mately 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 frac-
tures, 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 dis-
placement. These fractures are of-
ten stable with the foot in a plantar-
flexed 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 supe-
rior 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 high-
energy injury and associated chon-
dral damage or to residual intra-
articular 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. Vari-
ous 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 diagno-
sis). The patient whose weight bear-
ing was limited until the osteone-
crotic segment had healed did not
have such complications. Even
when weight bearing is not recom-
mended, 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 ab-
sence of a talar fracture. These inju-
ries are rare, accounting for only 4%
of all pediatric talar fractures and
dislocations.18 These are generally
high-energy injuries and were asso-
ciated 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 com-
mon site for osteochondritis disse-
cans (OCD). Osteochondritis disse-
cans 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 posterome-
dially.
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 chron-
ic ankle pain. Trauma to the ankle
Journal of the American Academy of Orthopaedic Surgeons
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, al-
though 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 dem-
onstrates 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 dis-
placed. Type IV lesions are detached
and displaced or rotated. Plain radio-
graphs will often demonstrate a tri-
angular sclerotic fragment separated
from the talar dome anterolaterally
or posteromedially (Fig. 3). Some-
times, these lesions are hard to visu-
alize 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 carti-
lage, whether the articular cartilage
is intact, the extent of the lesion, the
extent of sclerosis of the fragment,
and whether the fragment is dis-
placed. Evidence of fluid under-
neath 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 chil-
dren than in adults. Bauer et al23
reported on five children with OCD
of the talus followed up for an aver-
 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 long-
term follow-up. The results of sur-
gical 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 arthro-
scopic 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 ad-
vances in arthroscopic technique.
Type IV lesions should be treated
operatively.
Calcaneal Fractures
Approximately 5% of all patients
with calcaneal fractures are chil-
dren25; 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 chil-
dren than in adults, representing
65% of pediatric calcaneal frac-
tures.25,26 Fifty percent of pediatric
calcaneal injuries that occur after
falls result in intra-articular frac-
tures. In adolescents 15 years and
older, the fracture patterns are com-
parable 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 com-
mon, 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 frac-
tures 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 im-
portant because it allows measure-
ment 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 chil-
dren 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

Vol 9, No 5, September/October 2001 313

Pediatric Foot Fractures

Lisfranc Injuries
Navicular
Injuries of the tarsometatarsal joint
Talus
complex are uncommon in children.
The mechanism of injury is either
forceful plantar-flexion of the foot,
Böhler’s angle generally with axial loading, or a
Cuboid direct crush injury. Falls from a
Calcaneus Lateral process
height accounted for approximately
60% of the pediatric Lisfranc inju-
ries in the two largest series.30,31 Of
Crucial angle the 34 patients in those studies, 21
of Gissane (62%) were boys. The age range in
the two studies differed consider-
Figure 4 Lateral view of the calcaneus depicts Bohler’s angle and Gissane’s angle. ably: Johnson30 reported that the
Böhler’s angle is defined as the angle between two lines as seen on the lateral view: the fracture occurred most commonly
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 in children aged 3 to 6 years, but
with permission from Heckman JD: Fractures and dislocations of the foot, in Rockwood Wiley31 reported a mean patient age
CA, Green DP, Bucholz RW, Heckman JD [eds]: Rockwood and Green’s Fractures in Adults, of 12 years. Johnson reported frac-
4th ed. Philadelphia: Raven Publishers, 1996, p 2326.)
tures of the proximal first metatarsal
in all 16 of his patients, including 1
with a concomitant second metatar-
configuration of an intra-articular tion is indicated for displaced intra- sal fracture.
fracture. articular calcaneal fractures in adoles- Ligamentous injury may accom-
There are several classification sys- cents, as it is in adults. pany fractures as the Lisfranc joint
tems for calcaneal fractures. The complex is loaded. Because the plan-
Essex-Lopresti method is widely tar ligaments of the tarsometatarsal
used. This system categorizes injuries Other Tarsal Fractures joint complex are stronger than the
as tongue-type or split-depression dorsal ligaments, the dorsal liga-
fractures, but the most important dif- Tarsal fractures account for approxi- ments rupture first. With continued
ferentiation is between intra-articular mately 1% of all pediatric fractures.1
(Fig. 5) and extra-articular fractures. Fractures of the navicular, cuboid,
Extra-articular fractures can be and cuneiforms are reported to rep-
treated with a bulky Jones dressing resent 2% to 7% of pediatric foot
followed by weight bearing in 3 to 4 injuries.10,29 Most tarsal fractures
weeks. The long-term sequelae of are avulsion or stress fractures, both
such fractures are rare, although of which can be treated in a short
there may be some residual loss of walking cast for 2 to 3 weeks. This
heel height and widening of the heel. is sufficient to allow healing, and no
Some authors advocate surgical long-term sequelae need be expected.
treatment for displaced intra-articular Complete displaced fractures of
fractures in young patients. How- the navicular, cuneiforms, and cu-
ever, Schantz and Rasmussen 27 boid often result from high-energy
reported good results in pediatric trauma; therefore, associated injuries,
patients treated nonoperatively. such as those of the Lisfranc com- Figure 5 Lateral radiograph demonstrates
a minimally displaced intra-articular cal-
Thomas28 reported good results even plex, are common. Because much of caneal fracture (split-depression type) in a
in patients with a decreased Böhler’s the surface of these bones is intra- 4-year-old boy involved in a motor vehicle
angle who were treated nonopera- articular, closed or open reduction accident. Associated injuries included an
ipsilateral femoral shaft fracture, contralat-
tively; these results were thought to and internal fixation may be needed eral distal femoral physeal fracture, and a
be secondary to potential talar re- for displaced fractures. Assessment degloving injury to the contralateral leg.
modeling in the pediatric population. of the soft-tissue envelope is impor- Care for the calcaneal fracture consisted of
initial splinting and a 3-week non-weight-
Although the optimal treatment for tant in these high-energy injuries, bearing period. The dotted lines indicate
younger patients remains controver- and compartment syndrome must the fracture pattern.
sial, open reduction and internal fixa- be ruled out.

314 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 dis-
placement of the metatarsal bases
may occur.
Children who sustain Lisfranc in-
juries 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 her-
alded by pain out of proportion to
the injury, as well as pain with pas-
sive motion of the toes in the awake
patient. Compartment pressures
must be measured if there is the pos-
sibility of a compartment syndrome
in any patient, regardless of cognitive
status. In patients with altered men-
tal status, the physician should be
more inclined to measure compart-
ment pressures, as clinical signs of A B
pain may not be easily appreciated in
Figure 6 AP radiographs of both the uninjured left foot (A) and the injured right foot (B)
the obtunded patient. Fasciotomy of of a 6-year-old boy whose right foot had been run over by a car the previous day.
all compartments of the foot should Diastasis is evident between the first and second rays proximally and distally in the right
be performed if compartment pres- 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 unsuc-
sures are greater than 30 mm Hg.5,8 cessful attempt at closed reduction in the operating room.
Lisfranc injuries may involve the
entire tarsometatarsal complex or
any portion thereof. Diastasis fre-
quently occurs between the bases of the medial aspect of the base of the reduction. Finger traps placed on
the first and second metatarsals, as second metatarsal should line up the toes facilitate reduction. If closed
there is no intermetatarsal ligament with the medial aspect of the mid- reduction is possible, internal fixa-
in that interval (Fig. 6). Alterna- dle cuneiform, and the medial as- tion should be performed. Kirschner
tively, all five rays may be involved, pect of the base of the fourth meta- wires may be used in young chil-
either with all rays displacing in the tarsal should line up with the medial dren. Cannulated screws are pre-
same direction (homolateral injury) aspect of the cuboid. ferred for the older child with suffi-
or with the first ray displacing me- Nondisplaced fractures at the cient bone stock for screw fixation. If
dially and the lateral four rays dis- level of the tarsometatarsal joint a nearly anatomic closed reduction is
placing laterally (divergent injury).32 complex may actually be injuries not possible, open reduction should
The initial radiographic evalua- that were initially displaced but then be performed, with removal of any
tion should consist of AP, oblique, spontaneously reduced. Patients impediments to reduction (frequently
and lateral radiographs. If possible, with such injuries may be treated osteocartilaginous fracture frag-
the AP and lateral films should be with a bulky dressing or posterior ments), followed by internal fixation.
weight-bearing views, as subtle plaster splint for several days to 1 The long-term results in children with
injuries may not be evident on non- week, followed by a non-weight- Lisfranc injuries are uncertain. Even
weight-bearing radiographs.33 Frac- bearing short leg cast until 1 month with short-term follow-up, Wiley re-
tures of the base of the first meta- after injury, and then a short walk- ported residual pain at the Lisfranc
tarsal are common, but an isolated ing cast for an additional 2 weeks. joint in 4 (22%) of his 18 patients.
fracture of the base of the second Patients with Lisfranc fracture-
metatarsal may result from avulsion dislocations should be treated opera-
of the insertion of the Lisfranc liga- tively. Closed reduction should be Metatarsal Fractures
ment, heralding the presence of an attempted in the operating room.
injury to the Lisfranc complex. If no Wiley31 reported that 7 (39%) of 18 Metatarsal physeal fractures repre-
fracture is evident on presentation, patients in his series required closed sent 1% to 2% of all physeal injuries

Vol 9, No 5, September/October 2001 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 frac-
tures of the base of the fifth metatar-
sal 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 chil-
dren older than 5. In the same se-
ries, 6.5% of all fractures and 20% of
all first-metatarsal fractures were
initially unrecognized by the treat-
ing physician.
The mechanism of metatarsal frac-
ture 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
Figure 7 Displaced third- and fourth-
metatarsal fractures and a nondisplaced
second-metatarsal fracture sustained by a
15-year-old boy due to an indirect mecha-
nism of injury. The patient was treated in a
short walking cast for 2 weeks, followed by
a cast boot for 2 additional weeks.
316
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 to
assess fracture alignment. Medial-
lateral displacement of the fracture
may be seen, but is acceptable in the
absence of displacement of the Lis-
franc complex.
If these fractures are not proxi-
mal, they can almost always be
treated with weight bearing as toler-
ated 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 syn-
dromes, though rare, may occur if
high-energy trauma has caused mul-
tiple metatarsal fractures.
In the rare instance in which
there is marked sagittal malalign-
ment of the metatarsal heads, closed
reduction and pinning of a metatar-
sal fracture should be considered to
avoid transfer lesions in the future.
Finger traps are often helpful in re-
ducing 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 com-
plication is rare, but may result in
transfer lesions. Overgrowth may
also occur after metatarsal fractures.
Fractures of the Base of
the Fifth Metatarsal
Approximately 40% of all metatar-
sal 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
Journal of the American Academy of Orthopaedic Surgeons
fifth-metatarsal fractures occurred
in children older than 10 years. As
in adults, the location of the frac-
ture, the fracture appearance, and
the duration of symptoms before
presentation are important prog-
nostic factors. The injury generally
occurs with the foot in a weight-
bearing position. Inversion has
been reported as the most common
mechanism of injury.29
The initial radiographic examina-
tion should consist of AP, lateral,
and oblique views. The location of
the fracture is important to both
prognosis and treatment. Tuber-
osity 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. Frac-
tures at or distal to the metaphyseal-
diaphyseal junction are more recal-
citrant 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 radio-
graphic evidence of a preceding
stress injury), internal fixation should
be considered. Some authors advo-
cate curettage and bone grafting in
patients with intramedullary sclero-
sis indicative of a delayed union or
nonunion.34,35
Phalangeal Fractures
Phalangeal fractures are common
in the pediatric population and of-
ten do not even result in the child
being seen by an orthopaedic sur-
geon. Many of these fractures are
treated symptomatically by the pa-
tient and family or by the primary-
care physician. Phalangeal fractures
may account for as many as 18% of
pediatric foot fractures.10 In three
studies,1-3 phalangeal fractures rep-
resented 3% to 7% of all physeal

fractures and were usually Salter-
Harris 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 anti-
biotic therapy (Fig. 8). Nail-bed in-
juries 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 well-
healed 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 dis-
placed 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 dis-
placement.
Growth arrest and stiffness are
uncommon sequelae of phalangeal
fractures. When growth arrest oc-
curs, 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 im-
pairment 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 sus-
tain 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
Robert M. Kay, MD, and Chris W. Tang, MD
Figure 8 AP (left) and lateral (above) radiographs of a 12-
year-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 percuta-
neous pinning of the fracture. (Courtesy of Richard A. K.
Reynolds, MD, Los Angeles, Calif.)
Sanchez36 found that 8 (24%) had by 7 to 14 days after injury. Skin
head and eye injuries, 12 (36%) had grafting or flap coverage is needed
upper-extremity injuries, and 13 in more than 50% of patients.37 Un-
(39%) had lower-extremity injuries. like adults, children may do well
Fractures must be evaluated in with split-thickness skin grafts
conjunction with the degree of soft- placed on the plantar aspect of the
tissue damage and the integrity of foot.38 Despite appropriate early
neurovascular structures. care, amputation rates in children
These are high-energy injuries with lower-extremity lawn mower
that frequently involve significant injuries have ranged from 16% to
soft-tissue and fracture contamina- 78%.36-38 Even in salvaged extremi-
tion. Initial treatment should consist ties, late deformity may occur due
of irrigation and debridement and to muscle imbalance resulting from
triple-antibiotic coverage. Internal the damage or loss of muscles, ten-
fixation of fractures and/or external dons, or nerves at the time of injury.
fixation spanning the injured seg-
ment may help stabilize the soft tis-
sues, allow access to the zone of Occult Foot Fractures
injury, and facilitate patient care.
Repeat debridements should be per- Toddlers often present with the
formed at 2- to 3-day intervals until acute onset of a limp but without a
the wound is sufficiently clean. definite trauma history. Unlike a
Soft-tissue damage from lawn “toddler’s fracture,” there may be no
mower injuries is extensive, and the tenderness over the tibia. Tender-
soft-tissue envelope generally ap- ness is often evident in the foot, but
pears better on presentation than it may be hard to pinpoint. Typically,
does in the ensuing days due to the a child with an occult foot fracture
initial compromised soft-tissue per- will be able to crawl without diffi-
fusion. Early involvement of the culty but will limp when walking.
plastic surgery team is important to Plain radiographs will rarely
facilitate coverage of these wounds 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 lower-
extremity pain or limping of un-
known 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 sus-
pected, a short walking cast can be
used for 2 to 3 weeks. Repeat radio-
graphs at the time of cast removal
will often reveal callus formation
and confirm the diagnosis of occult
fracture. If symptoms persist after
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