Fractures and Dislocations of the Foot

The child’s foot is different to the adult foot in that
the bones are largely cartilaginous until adolescence. Although the
mechanisms of injury are similar, the resulting fracture is usually
less severe in the child as the energy of the injury is dissipated by
the elasticity of the cartilage. The cartilage also makes
interpretation of imaging more difficult and fractures may not be
appreciated on plain radiograph. Computed tomography (CT) and magnetic
resonance imaging (MRI) scans assist in clarification of anatomy and
identification of fractures. The remodeling potential of cartilage
allows some displacement and angulation of fractures to be accepted in
children, whereas in adults it may be unacceptable.

Secondary areas of ossification, accessory bones, and
growth plates also make fracture recognition more difficult. The
appearance of the ossification centers are summarized in Figure 27-1.⁵
The calcaneus and talus are usually ossified at birth and the cuboid
ossification center usually becomes evident shortly after. The
navicular does not develop its primary ossification center until the
child is around 3 years of age. Figure 27-2
shows the accessory ossicles and sesamoid bones in the foot which can
also be confused with fractures especially if they are bipartite or if
the accessory bones are closely adhered. It is useful clinically to
radiograph the opposite foot if any doubt exists as to what may be
normal or pathologic.

Fractures of the talus are very rare in children and adolescents.³⁵,¹¹⁸
Talus fractures most commonly occur through the neck and occasionally
the body. Although rare, talus fractures are important to recognize due
to the possible complication of avascular necrosis (AVN). This can
occur due to the precarious blood supply and fracture patterns. In
children, AVN seems more prevalent in innocuous fractures when compared
to adults with similar injuries.¹³⁴
The majority of talus fractures in children can be treated with cast
immobilization whereas displaced fractures in adolescents need to be
treated operatively similar to an adult fracture.

The history of forced dorsiflexion of the ankle
especially associated with a fall from a height should lead to a
suspicion of a talus fracture. The same mechanism of injury can cause
other foot fractures and dislocations as well. The ankle and foot are
extremely swollen and the foot is usually held plantarflexed. Due to
this soft tissue swelling, the foot needs to be examined closely for
increased compartment pressure. As with all fractures, the soft tissues
need to be inspected for any puncture wounds, abrasions, or fracture
blisters as these are important in determining the management of the
patient.

In these patients, there may be less swelling so careful palpation around the talus is needed to detect the source of the pain.

Once the foot has been clinically assessed, the appropriate radiographic investigations can be performed.

Due to the level of force that is often required to fracture a talus, other injuries often coexist.¹²⁵
A number of studies have found fractures of the calcaneus, malleoli,
tibia, and lumbar spine in the presence of a talus fracture.²⁰,²⁶,⁶¹,¹²¹,¹²² Hawkins,⁶¹ in his study, on adult talus fractures found 64% of the patients had an associated musculoskeletal injury.

The routine radiographs for a fractured talus include an anteroposterior (AP), lateral, and oblique views. Canale and Kelly²⁶
have described a pronated oblique view of the talus which may
demonstrate the fracture more clearly. The fractures are not always
easy to see in young children, as the talus is largely cartilaginous
until the second decade.¹⁰⁵ The
cartilage anlage often leads to an underestimation of fracture
displacement. Some authors have even suggested the use of MRI to show
the morphology better in children less than 10 years old.¹¹⁸,¹⁶⁶

Once the fracture is identified, a CT scan is useful in
assessing the fracture plane, communition, degree of displacement, and
any other associated foot or ankle fractures. This is particularly
useful preoperatively when pain prohibits the full range of radiographs
mentioned above to be taken. If an open reduction is planned, the CT
scan will also aid in the preoperative planning of the size and
placement of the screws. Hawkins⁶¹
described an x-ray classification to define the different types of
fractures of the talar neck and used it to predict the risk of AVN (Fig. 27-3):

Type I fracture: undisplaced talar neck fracture

Type II fracture: displaced talar neck fracture with subtalar subluxation or dislocation

Type III fracture: displaced fracture of the talar neck with dislocation of both the subtalar and ankle joints

Hawkins⁶¹ also
described a subchondral lucent line, the “Hawkins sign,” that indicates
normal bloodflow to the talar body. The absence of this lucency may
indicate the development of osteonecrosis (see complications of talar
fractures).

Fractures of the talus can be classified as occurring
either in the body or the neck. Some authors suggest classifying talar
fractures based on the age of the patient as children less than 6 years
of age generally have a better prognosis.¹⁰⁵

The treatment of talar fractures is based on the
severity of the fracture and the age of the child. The Hawkins
classification system is useful in directing the treatment. In a child
less than 8 years of age, a less than perfect reduction of the fracture
can be accepted due to the remodeling potential.⁷⁴,⁹²,¹⁰⁵ Adolescent fractures should be treated the same way as an adult injury.

The talus is comprised of three parts: a body, neck, and
head. Ossification starts from one center that appears in the sixth
intrauterine month. The talus ossification process starts in the head
and neck and proceeds in a retrograde direction towards the subchondral
bone of the body. Approximately two thirds

of
the talar body is articular cartilage with just a small area of bare
bone on the neck where the bone receives its nutrient blood supply.
There are no tendon insertions into the talus. The stability is
provided by the capsular and ligamentous attachments to the surrounding
bones.

The superior articular surface of the talus is wider
anteriorly than it is posteriorly. Traditional teaching suggests the
foot should generally be immobilized in neutral dorsiflexion so this
widest part of the talus is engaged in the ankle mortise to help
prevent an equinus contracture. This is of less importance in younger
children who are less likely to develop equinus contractures. The
lateral wall of the superior articular surface curves posteriorly
whereas the medial wall is straight. The two walls converge posteriorly
to form the posterior tubercle of the talus. Often, there is a separate
ossification centre (os trigonum) that appears here on radiographs at
11 to 13 years of age in boys and 8 to 10 years of age in girls. It
usually fuses to the talus 1 year after it appears (Fig. 27-6).¹⁰⁷

The short neck of the talus is medially deviated
approximately 10 to 44 degrees and plantarflexed between 5 and 50
degrees in relation to the axis of the body.⁵²
Beneath the talar neck is the tarsal canal, a funnel shaped area that
contains the anastomotic ring formed between the artery of the tarsal
canal and the artery of the tarsal sinus.¹¹² The broad interosseous ligament joining the calcaneus and talus is also within the canal.

The tarsal canal is conical in shape and runs from
posteromedial (apex) to anterolateral where the base of the cone is
known as the sinus tarsi (Fig. 27-7).

The lateral process of the talus is a large
wedged-shaped process that is covered in articular cartilage. It
articulates with the fibular superiorly and laterally and with the
subtalar joint inferiorly. The lateral talocalcaneal ligament is
attached to the most distal part of the process.⁶⁰,⁶²

The head of the talus is entirely cartilaginous, convex,
and articulates with the concave surface of the navicular. The
undersurface of the talus is comprised of three articulating surfaces
for the calcaneus: the posterior, middle, and anterior facet. Between
the posterior and middle facets is a transverse groove which forms the
roof of the tarsal canal.

Berndt and Harty¹² classified osteochondral fractures of the talar dome into four stages based on radiographic criteria (Fig. 27-11):

Stage I: subchondral trabecular compression fracture (not seen radiographically)

Stage II: incomplete separation of an osteochondral fragment

Stage III: the osteochondral fragment is unattached but undisplaced

Stage IV: a displaced osteochondral fragment

Anderson et al.⁸
modified this classification after correlating clinical findings with
radiographs and MRI scans. They described the stage I lesion as not
visible on plain radiographs

but
visible on an MRI scan. They also introduced a stage IIa lesion, which
is an undisplaced osteochondral lesion with a subchondral cyst adjacent
to the floor of the lesion. Anderson and his colleagues⁸ felt a atage IIa lesion should be treated surgically whereas a atage II lesion can initially be treated nonoperatively (Fig. 27-12).

A further classification was proposed by Pritsch et al.¹²⁹
in 1986 based on the arthroscopic appearance of the articular cartilage
at the time of surgery. The quality of the articular cartilage was
placed into one of three grades:

Grade I: intact, firm, and shiny articular cartilage

Grade II: intact but soft articular cartilage

Grade III:frayed articular cartilage

They used this classification to determine which lesions
should be treated with activity modification (grade I), who should have
arthroscopic drilling (grade II), and finally which patients require
arthroscopic curettage and microfracture (grade III).

The treatment of osteochondral lesions of the talus in
children is challenging. Only a few papers purely address this
condition in children,⁶⁵,⁹¹,¹²³
and the rest of the literature is a combination of adult and childhood
lesions. It is important to distinguish between an acute osteochondral
fracture and a chronic osteochondral lesion as the two may require
different treatment strategies.

To enable thorough assessment, these patients need to be
followed up for a minimum of 2 years as it takes this long for the
lesion to become radiographically healed despite the child often being
clinically normal.¹²³

Fractures of the calcaneus are rare in children with an incidence of only 1 in 100,000 fractures.¹⁷⁴
The treatment of these fractures has historically been nonoperative,
relying on the largely cartilaginous bone to remodel with time. The
majority of fractures in children less than 14 years old are
extra-articular whereas in older children the fracture pattern
resembles those in adults. Children appear to have more coexisting
lower limb fractures than adults but fewer fractures of the axial
skeleton.¹⁵⁰

Calcaneal fractures in young children are often missed
or are diagnosed late on radiographs or bone scan when the child is
still limping long after the injury. At the other end of the spectrum,
the adolescent patient has often had a major fall and has a displaced
intra-articular fracture. This older age group should be treated like
the adult population with open reduction and internal fixation
restoring the joint congruity and calcaneal height and width. The
challenge for the surgeon is at what age and what degree of
displacement is this more aggressive treatment indicated in a group of
patients traditionally treated nonoperatively.

Any child who has fallen from a height and landed on
their feet should be examined carefully for a calcaneal fracture.
Associated injuries should also be evaluated with a thorough secondary
survey, especially of the lower limbs and spine.

The foot will often be extremely swollen with bruising
around the heel and dorsum of the foot. Symptoms and signs of
compartment syndrome, including excessive pain, pallor, parasthesia,
and pulselessness should be assessed. In more subtle injuries, careful
palpation is necessary to elucidate areas of pain which may disclose an
underlying undisplaced fracture.

Many calcaneal fractures in children are initially
missed and diagnosed late. Often, the fracture line is not evident on
the initial radiographs. Inokuchi et al.⁷¹ reported that 44% of fractures in their series were initially missed, as were 55% of those reported by Schantz and Rasmussen¹⁴⁸ and 44% of those reported by Wiley and Profitt.¹⁷⁴

A differential diagnosis must be kept in mind for other
causes of heel pain in a child. These include Sever disease,
osteomyelitis, a unicameral bone cyst, or a stress fracture.

Schmidt and Weiner¹⁵⁰
reviewed 59 children with 62 calcaneal fractures and found a number of
associated injuries. These included fractures of the lumbar spine,
lower limb fractures, a pelvic fracture, and upper extremity fractures.
These other skeletal

injuries
were more frequent in children over 13 years of age. Associated lower
limb fractures occurred twice as frequently as in adults; however,
injuries to the axial skeleton occurred half as often as in adults.
Wiley and Profitt,¹⁷⁴ however, only had 2 patients with accompanying significant injuries in their series of 32 pediatric calcaneal fractures.

Children’s calcaneal fractures were traditionally classified according to their adult counterparts using the Essex-Lopresti⁴⁷ and Letournal⁹⁰ classifications. Schmidt and Weiner¹⁵⁰ reviewed 62 calcaneal fractures in children and compared them to the adult literature.¹⁴¹ They used the classification systems of Essex-Lopresti⁴⁷ and Chapman and Galway³²
and added a new fracture type (type VI) to develop a classification for
pediatric calcaneal fractures which is in routine use today (Fig. 27-16).

For adolescent fractures, it is probably more appropriate to use Sanders classification.¹⁴⁶
This is an adult classification system that was developed after
reviewing the CT scans on 120 cases preoperatively and at minimum
1-year follow-up. The follow up CT scans were correlated with the
clinical outcome scores to help validate the classification system used.

The calcaneus is the largest tarsal bone and has quite
an unusual shape. It has three articular facets (anterior, middle, and
posterior) on the superior surface where it articulates with the talus
to form the subtalar joint (see Fig. 27-7) and
anteriorly there is a saddle-shaped articular surface for the cuboid.
The posterior facet is the largest facet and is slightly convex. The
middle facet is anterior and medial to the posterior facet lying on the
sustenaculum tali. It is concave like the anterior facet with which it
is often contiguous. Between the middle and posterior facets lies the
calcaneal groove, which forms the inferior wall of the sinus

tarsi.
Posteriorly, the tendoachilles inserts into the tuberosity of the
calcaneus which is the whole area behind the posterior facet. On the
lateral surface of the calcaneus are two shallow grooves with a small
ridge in between (the peroneal trochlea). The peroneus longus and
brevis run either side of this trochlea. The medial side is concave and
is structurally stronger than the lateral side. The sustentaculum tali
projects from the medial wall and supports the middle articular facet
on its surface. The tendon of flexor hallucis longus runs on the
undersurface of the sustenaculum. On the plantar surface are the medial
and lateral processes for the origin of the abductor hallucis and
abductor digiti minimi muscles, respectively (Fig. 24-17).

Secondary ossification occurs in the calcaneal apophysis
between the ages of 6 and 10 years. Inflammation in the apophysis
around this age causes heel pain and is referred to as Sever’s disease.

The use of CT scans has defined the surgical anatomy of
the calcaneus to help make treatment decisions. The coronal views show
the important posterior facet and the sustenaculum tali and the height
and width of the heel. The position of the peroneal tendons and flexor
hallucis tendon can also be seen. The sagittal views provide additional
information about the posterior facet and also show the anterior
process well. The axial views visualize the calcaneocuboid joint well,
the anteriorinferior aspect of the posterior facet, and the
sustenaculum tali. This information can then be used in planning the
reconstruction of the calcaneus.¹⁴⁴,¹⁴⁵

Calcaneal fractures in growing children are usually less
severe than in the adult population and often do well without operative
intervention. The adolescent, on the other hand, often has fracture
patterns similar to adults and requires open reduction and internal
fixation. The challenge to the orthopaedic surgeon is to recognize the
patient that requires this form of surgery. There is a degree of
remodeling that will take place in the child and hence the amount of
growth remaining, degree of ossification,

and difference in morphology from the contralateral side all need to be considered in making the treatment decisions.

Extra-articular fractures of the calcaneus are treated
by cast immobilization for 6 weeks. The child can start weight bearing
in this cast when comfortable and can be changed to a Cam walker for
the final few weeks if necessary.¹⁹,⁷¹

Tongue-type fractures can be treated nonoperatively if
the posterior gap is less than 1 cm and the Achilles tendon has not
been significantly shortened by bringing the fragment up proximally.
Occasionally, the technique described by Essex-Lopresti⁴⁷ for percutaneous reduction of tongue-type fractures (Fig. 27-18) is useful.

Open reduction and internal fixation is reserved for the
severe intra-articular fractures with displacement of the fragments and
depression of the joint surfaces. These fractures occur almost
exclusively in the adolescent patient where the ossification process is
complete. The adult literature abounds with indications for internal
fixation, surgical approaches, rehabilitation, complications, and
outcome measures (Fig. 27-19).¹⁰,¹²⁶,¹⁴³,¹⁴⁴,¹⁴⁵,¹⁴⁶
These series only have a few adolescent fractures among them, and
therefore it is difficult to draw any conclusions specifically about
children’s calcaneal fractures. The literature on the management of
displaced intra-articular fractures in children is somewhat conflicting
in the indications for surgery. Schantz and Rasmussen¹⁴⁸
reported on the outcome of displaced intra-articular fractures in
children less than 15 years old treated nonoperatively. The majority of
the patients had a good outcome; however, 4 complained of pain an
average of 12 years after injury.¹⁴⁸,¹⁶² Brunet¹⁹
believes the outcome does not correlate to the severity of the
fracture. This is most likely due to the remodeling potential of the
calcaneus in this age group. This concept also was supported by Mora et
al.,¹¹¹ who concluded that open
reduction may be suitable only for severely displaced fractures in
adolescents. The difficulty is defining the age or maturity of the
patient that may predict a poor outcome if the fracture is left
unreduced. Using validated quality-of-life scales 2 to 8 years after
surgery, Buckley et al.²¹ found that
younger patients (adults under the age of 30 years) who had operative
treatment had better gait satisfaction scores than those who did not
have surgery. Allmacher et al.⁶
questioned whether short-term or intermediate results of displaced
intra-articular calcaneal fractures can predict long-term functional
outcome. Using validated outcome instruments, they studied adult
patients treated nonoperatively and found that nonoperative treatment
often led to pain and loss of function, which increased in the second
decade after injury.

Pickle et al.¹²⁶
reviewed the results of open reduction with internal fixation of
displaced intra-articular calcaneal fractures in 6 adolescent patients
(average age, 13 years) and found good short-term results at an average
of 30 months after injury. None of the 6 patients (seven calcaneal
fractures) developed any of the serious complications reported in
adults. Four of the seven feet were completely pain-free, and three had
some minor pain with sports or hard floors. Ceccarelli²⁸
found that adolescents with displaced intra-articular fractures had
better clinical and radiologic outcomes if treated by open reduction
rather than nonoperatively. Buckingham et al.²⁰
reviewed 10 adolescent patients and reported good or excellent outcomes
in 8 patients. They had no wound complications and the range in motion
was hardly affected in 7 patients. They recommended the routine removal
of the screws and plates after fracture healing as this had improved
the symptoms in 6 of 8 patients.²⁰

The surgery for these fractures is technically
demanding, and if the treating surgeon is not experienced with the
approach, the child is best referred to a colleague who is.

Cuboid fractures were considered a rare foot injury in
children and were usually associated with other foot fractures. Recent
literature, however, reveals that this fracture may occur more often
than we thought and commonly in isolation. Senaran et al.¹⁵²
reported on 28 consecutive cuboid fractures in preschool children from
1998 to 2004. They found most patients had an avoidance gait pattern
and walked on the outside of their foot. They used the “nutcracker”
maneuver to help diagnose the fracture. To perform this test, the heel
is stabilized by the examiner and the forefoot is abducted. Pain in the
lateral aspect of the foot usually confirms a fracture of the cuboid.
The diagnosis was then confirmed on initial or subsequent radiographs.
A below-knee cast or Cam walker was used for 2 to 3 weeks and all
fractures healed without complications. Six patients had ipsilateral
fractures in the tibia or foot. Interestingly, 8 patients had an
associated genetic or systemic abnormality.¹⁵² Cuboid fractures have been classified by Weber and Locher¹⁶⁹ into distal impaction shear-type fractures (type 1) and burst fractures (type 2).

Ceroni et al.³⁰
reported on 4 female teenagers who had equestrian injuries and cuboid
fractures. The mechanism of the injury in all cases was a crush to the
foot when the horse fell and abduction of the forefoot while it was
still in the stirrup. All four cuboid fractures were associated with
multiple midfoot fractures and the authors recommend CT scans in all
patients in this age group with a cuboid fracture. Two patients
required surgical reconstruction. This was performed through a lateral
incision from the tip of the fibula to the base of the fifth
metatarsal. The interval is then developed between the peroneal tendons
and the extensor digitorum brevis. The lateral column length of is then
restored using an allograft block.³⁰

The diagnosis of these injuries may be difficult, and in adults as many as 20% of injuries are misdiagnosed or over-looked.²³,¹³⁸
Some of the injuries are subtle and will present with minor pain and
swelling at the base of the first and second metatarsals. This can be
accompanied by ecchymosis on the plantar aspect of the midfoot where
the TMT ligaments have been torn (Fig. 27-27).¹³⁹ This can be confirmed by gently abducting and pronating the forefoot while the hindfoot is held fixed with the other hand,¹¹⁴
though this would be quite painful acutely. Alternatively, the child
can be asked to try and perform a single limb heel lift. Pain in the
midfoot often implies a TMT joint injury. With significant trauma,
there is greater ligamentous injury and the resulting swelling makes it
difficult to recognize

any
bony anatomy. It is important to assess the foot for a compartment
syndrome in such circumstances, particularly when the foot has been
crushed as part of the mechanism of injury.

The examiner of any child’s foot following trauma needs
to have a high level of suspicion for a Lisfranc injury as they are
uncommon and difficult to diagnose but have a poor prognosis if left
untreated.

Hardcastle et al.⁵⁹ developed a classification system based on the one developed by Queno and Kuss¹³¹ in 1909 (Fig. 27-28). The classification comprises three types upon which treatment can be based.

Type A: Total incongruity. There is total incongruity of
the entire metatarsal joint in a single plane. This can be either
coronal or sagittal or combined.

Type B: Partial incongruity. Only partial incongruity of
the joint is seen involving either medial displacement of the first
metatarsal or lateral displacement to the four lateral metatarsals. The
medial dislocation involves displacement of the first metatarsal from
the first cuneiform because of disruption of the Lisfranc ligament or
fracture at the base of the metatarsal, which remains attached to the
ligament.

Type C: Divergent pattern. The first metatarsal is displaced medially; any combination of the lateral four metatarsals may

be displaced laterally. This is associated with partial or total incongruity.

This classification does not address the nondisplaced TMT joint injury which can often be overlooked on initial assessment.

Most children’s injuries are type B with minimal displacement, whereas types A and C are rare.⁵⁹,¹³¹,¹⁷³

The initial x-ray evaluation includes AP, lateral, and
oblique views of the foot. These should be performed weight bearing if
possible to stress the joint complex.

On the AP radiograph, the lateral border of the first
metatarsal should be in line with the lateral border of the medial
cuneiform and the medial border of the second metatarsal should line up
with the medial border of the middle cuneiform. On the oblique
radiograph, the medial border of the fourth metatarsal should be in
line with the medial border of the cuboid. The examiner looks for a
disruption in these lines or diastases of greater than 2 mm between the
base of the first and second metatarsals. It is very useful to obtain a
weight-bearing radiograph of the opposite foot for comparison (Fig. 27-29).
When the radiographs appear normal or minimally displaced and a
Lisfranc injury is still suspected, alternative imaging with CT or MRI
scans is strongly recommended. The CT scan will often show a small
avulsion fracture of the first TMT ligament and will show any other
associated fractures in the foot.⁵⁵,⁸⁷,⁹⁹ The MRI scan can accurately visualize a partial tear or complete rupture of the first TMT ligament.¹²⁸

A fracture of the base of the second metatarsal should
alert the examiner to the possibility of a TMT dislocation because
these injuries can spontaneously reduce. Likewise, a cuboid fracture in
combination with a fracture of the base of the second metatarsal is
highly suspicious for a Lisfranc injury (Fig. 27-30).

If weight-bearing radiographs are not possible, an
abduction stress view can be obtained; however, in children these are
difficult to obtain without general anesthesia. Bone scans may be
helpful in the diagnosis of this injury when radiographs are normal,
although they are not specific for the severity of the injury⁵⁷ and less useful than MRI or CT.

The TMT joint complex comprises the TMT joints, the intertarsal joints, and the intermetatarsal joints. The area represents

the apex of the longitudinal and transverse arches of the foot and
therefore its structural integrity is crucial in maintaining normal
foot function. At the same time, there needs to be enough motion
between the joints to allow the transfer of weight evenly from the
hindfoot to the forefoot during the walking cycle. This intricate
relationship is achieved by the anatomy of the tarsal and metatarsal
bones and the arrangement of the ligaments. These midfoot bones are
trapezoidal in cross section with their base dorsal. This creates a
“Roman arch” effect, which is structurally very strong and helps
maintain the transverse arch in the midfoot. The TMT joint complex can
be divided up into a medial column and a lateral column. The medial
column is a continuation of the talus and navicular and includes the
cuneiforms and the medial three metatarsals. The lateral column is a
continuation of the calcaneus and comprises the cuboid and the fourth
and fifth metatarsals which articulate with it. The medial column has
far less mobility than the lateral column, reflecting the increased
need for stability on the medial side of the foot to maintain the
longitudinal arch. This stability is also provided by the second
metatarsal which is “keyed” into the step formed by the cuneiforms.
This explains why the second metatarsal is usually fractured when a
dislocation occurs across the TMT joint. The ligaments also play a big
role in maintaining stability medially and movement laterally. The
plantar ligaments are extremely strong compared to the weaker dorsal
ligaments. The intermetatarsal ligaments help bind the lateral four
metatarsals together but are absent between the first and second
metatarsals. Instead, the second metatarsal is connected to the medial
cuneiform by Lisfranc’s ligament (medial interosseous ligament) and an
avulsion fracture of this strong ligament can sometimes be seen on
radiograph (Fig. 27-31).¹⁷³

The dorsalis pedis artery crosses the cuneiforms before
it courses between the first and second metatarsals to form the plantar
arterial branch. The deep peroneal nerve travels beside the artery but
continues on to supply sensation to the first web space. This
neurovascular bundle can be damaged by the injury and care must be
taken protect these structures when internally fixing these
fracture-dislocations. The tibialis anterior tendon inserts into the
base of the first metatarsal and medial cuneiform. The peroneous longus
tendon inserts into the plantar surface of the base of the first
metatarsal and acts as a flexor of this bone. Together, these two
muscles and their tendon insertions give added stability to the medial
column of the foot.

The key to treating these TMT injuries is to recognize
the extent of the injury and the degree of instability. Once this is
established, the appropriate treatment can be instigated. In all these
injuries, a weight-bearing radiograph at the end of treatment should
confirm anatomic congruency of the TMT joint complex.

When a clinical diagnosis of a “sprain” is made, the
foot should be immobilized in a below-knee cast for 6 weeks. The MRI
scan may confirm a partial tear of the first TMT ligament, but
regardless this painful injury takes time to heal and immobilization is
the best treatment. In young adult athletes, these injuries can take a
long time to heal.¹⁰⁸ When there is
complete intraligamentous rupture or an avulsion fracture of the first
TMT ligament and no displacement of the joint surfaces, a below-knee

cast for 6 weeks is advised. Whether the patient should be weight bearing or not for the entire 6 weeks is debatable. Wiley¹⁷³ treated the children with undisplaced TMT joint injuries in his series with 3 to 4 weeks of immobilization with good results.

Displaced fractures of the TMT joint need to be anatomically reduced and stabilized. Meyerson et al.¹¹⁴
found that following a closed reduction greater than 2-mm displacement
or a talometatarsal angle of greater than 15 degrees would lead to a
poor outcome. A closed reduction is best carried out under a general
anesthetic when the acute swelling has subsided. “Finger traps” can
help with traction on the toes while the displaced metatarsals are
manipulated into place. If a stable anatomic reduction is achieved
clinically and this is confirmed radiologically, a well molded
below-knee cast can be applied. Radiographs in the cast should also be
taken while the patient is under anesthesia to confirm the reduction
has been held. The nonweight-bearing cast is worn for 6 weeks with
radiographs taken at 1 and 2 weeks to confirm the fracture-dislocation
has remained reduced.

If the closed reduction results in an anatomic reduction
but the fragments are unstable, then K-wire fixation is used to hold
the alignment of the foot. Stout 0.062 in smooth K-wires should be
used. Their placement is determined by the direction of displacement of
the metatarsals and how many are involved. The most important wire is
used to stabilize the second metatarsal to the medial cuneiform.
Additional wires can be used between the first metatarsal and the
medial cuneiform, and between the lesser metatarsals and their
corresponding tarsal bones. A useful wire can also be passed form the
first metatarsal to the second metatarsal. These K-wires are left bent
over outside of the skin and are removed at 4 to 6 weeks when
mobilization is initiated if the radiographs confirm healing. Again,
full weight-bearing radiographs are necessary when comfort allows and
after K-wire removal to confirm adequate stability. Wiley¹⁷³
used K-wire fixation in 4 patients. He removed these at 3 to 4 weeks
and the alignment was maintained in all the children. There were some
joint incongruities from intra-articular fractures that were not
surgically addressed but they did not seem to alter the clinical
outcome.

Open reduction and internal fixation is rarely required
for these fractures. It is indicated if there is greater than 1 to 2 mm
of joint displacement. The impediments to reduction are

The entire TMT joint complex can be visualized using two longitudinal incisions.¹⁴⁹
One is made over the first-second metatarsal space and the second in
line with the fourth metatarsal. The medial incision allows
identification of the neurovascular bundle and access to the first and
second metatarsalcuneiform joints. The lateral incision allows the
joints of the lesser TMT joints to be clearly seen. After anatomic
reduction, the joints can held reduced with K-wires or internally fixed
with 3.5 mm screws (Fig. 27-32). Small chondral
defects can be excised and larger ones repaired. Care must be taken to
avoid the proximal growth plate of the first metatarsal if screw
fixation is used. The adult literature supports the use of K-wire
stabilization of the lesser metatarsals rather than screws as it is
important to maintain the mobility in these joints long-term.⁴³
Debate exists as to when to remove the screws across these
weightbearing joints. In a child, it would seem appropriate to remove
the screws once pain free weight bearing is established as the
ligaments and bone would have healed by this stage and further
displacement is unlikely. Leaving the screws in longer than 3 months
risks damage to the joint and possible screw breakage.

The most common complication following TMT injuries is
posttraumatic arthritis. This can often occur because the injury is
“missed” and the subtle fracture-dislocation remains displaced. Another
cause is a loss of reduction. Lastly, the trauma itself can damage the
articular cartilage and, despite an anatomic reduction, arthritis can
develop.

Hardcastle et al.⁵⁹ showed that the outcomes are poor if the diagnosis is made more than 6 weeks after the injury. Curtis et al.³⁶
found similar results in athletes who had a delayed diagnosis. This
reinforces the importance of making the diagnosis early and treating
appropriately.

Posttraumatic arthritis is known to occur after TMT
injuries in a significant percentage of adults, and this is best
prevented by achieving an anatomic reduction.¹¹⁴ Wiss et al.¹⁷⁶
performed gait analysis on 11 adult patients with TMT joint
fracture-dislocations and found that no patient walked normally after a
displaced TMT fracture-dislocation. In Wiley’s¹⁷³
series of 18 children, none of whom required open reduction, 14
patients were asymptomatic 3 to 8 months postinjury. Four patients had
persisting pain of minor severity at the TMT joint 1 year following
injury. Two of these patients had residual angulation at the injury
site. One patient had an unrecognized dislocation and had not been
treated; the other had not had an anatomic reduction due to extensive
intra-articular fractures. One 16-year-old patient developed
asymptomatic osteonecrosis of the second metatarsal head, and this was
attributed to a possible compromise of the blood supply at the time of
injury as the nutrient vessel to this area is a terminal branch of the
dorsalis pedis. Buoncristiani et al.²²
followed 8 children (3 to 10 years old) with indirect TMT joint
injuries treated in a below-knee cast and found 7 were asymptomatic at
an average follow-up of 32 months. The one patient who had midfoot pain
had developed early degenerative changes on the plain radiographs.

The treatment for painful TMT joint arthritis is
arthrodesis if conservative care has failed. In children this would be
extremely unusual. An arthrodesis often requires extensive soft tissue
release to allow anatomic reduction of the joint and then rigid
internal fixation with screws. It is important not to fuse the lesser
TMT joints as mobility here is important for the long-term function of
the foot.

Direct injuries can result in significant swelling and
bruising of the foot due to the extensive soft tissue injury as well as
the metatarsal fractures. Careful evaluation of a compartment syndrome
should take place. An indirect injury usually has more subtle clinical
findings and careful palpation will usually locate the site of the
fracture. The infant with a metatarsal fracture due to an unwitnessed
injury may present with minimal swelling but an inability to bear
weight.

Proximal fractures of the metatarsals are often
associated with tarsal fractures or fracture-dislocations, and this
should be evaluated

further
with a CT scan. A fracture of the second metatarsal and a cuboid
fracture is highly suggestive of a TMT joint dislocation rather than
two isolated fractures. Singer et al.¹⁵⁵
found that the first and fifth metatarsals were usually isolated
fractures, whereas if multiple metatarsals were fractured, they were
always contiguous bones and involved the second, third, and fourth
metatarsals.

Radiographic evaluation should consist of AP, lateral,
and oblique views of the whole foot. The AP view often gives the
impression that the fractures are minimally displaced; however, the
lateral view often shows significant plantar or dorsal displacement.
Other associated fractures may be apparent on the plain radiographs and
if any doubt exists, especially if there has been significant trauma, a
CT scan is advised. In a young child, if a fractured metatarsal is
suspected but not visible on the initial radiograph, a repeat film can
be taken 10 to 14 days later that often shows the fracture line or
early callus.

No classification system exists for fractures of the
first through fourth metatarsals. Fractures of the fifth metatarsal are
classified according to their location along the bone (see section on
treatment of the fifth metatarsal below).

The majority of metatarsal fractures in children can be
treated nonoperatively in a below-knee cast. The child with a displaced
fracture often needs to be admitted overnight in the hospital for pain
relief and observation for compartment syndrome.The initial treatment
includes elevation for the severe swelling that coexists with the
fractures. Immobilization may be performed by a well padded cast,
splint, or a Cam walker.. Once the swelling subsides, a molded
below-knee cast can be applied. Weight bearing can be initiated when
pain allows, and the cast can usually be removed at 3 to 4 weeks at
which time the patient can be transitioned to a Cam walker.

The amount of angulation or shortening to accept in a
child has not been determined. A closed reduction of the central
metatarsals is indicated in an adult if there is more than 10 degrees
angulation in the dorsal plain or more than 4 mm of translation in any
plane.¹⁵³ These criteria may be
appropriate for an older adolescent whose growth plates had closed but
are far too stringent for a skeletally immature patient. If there is
severe dorsal angulation of greater than 20 degrees or “tenting” of the
skin and shortening of greater than 5 mm, then a closed reduction is
indicated. This is best performed under a general anesthetic when the
swelling has subsided. Finger traps have been advocated by some
surgeons to help with traction while the metatarsals are manipulated. A
below-knee cast can be molded with pressure applied to both the dorsal
and plantar aspects of the foot; however, the need to allow for
swelling suggests implants should be used to hold fracture reduction
rather than molding of a cast. To accomodate the swelling and to relax
the plantar fascia, the cast can be applied with the ankle in slight
equinus and when it is changed 2 weeks later, it can be bought up into
a neutral position.

Fractures of the first metatarsal need careful attention
especially in the adolescent patient. The first ray is important in
maintaining the longitudinal arch of the foot and the position of the
first metatarsal head in relation to the lesser metatarsal heads is
also vitally important. A closed reduction should be considered if
there is greater than 10 degrees of dorsal angulation or any shortening
of the first metatarsal. It is unusual to have angulation in the
coronal plane if the second metatarsal is intact and transverse
displacement is acceptable if there is no shortening.

If a closed reduction is performed, K-wire fixation is
at times required. Intramedullary placement is difficult to perform
without opening the fracture and passing the wires under direct vision.
Small, dorsal, longitudinal incisions are made over the fracture sites
and dissection is carefully carried out down to the fracture. The wire
is drilled down the distal fragment to exit the plantar skin. The wire
is then withdrawn enough to allow the fracture to be reduced, then the
wire is driven retrograde across the fracture site and sufficiently far
enough into the proximal fragment. Another technique is to hold
fracture reduction by placing K-wires across the fractured metatarsal
to an adjacent nonfractured metatarsal both proximal and distal to the
fracture. The K-wire is cut and bent outside the skin to facilitate
removal in the outpatient clinic in 3 to 4 weeks when the patient can
be placed in a walking cast for 2 further weeks to allow fracture
consolidation. This is the same technique that can be used on the rare
occurrence an open reduction is required for an irreducible fracture or
when the fracture is open.

Fractures of the fifth metatarsal are the most common
metatarsal fracture in children, comprising almost 50% of all
metatarsal fractures in some series.⁶⁴,¹¹⁹,¹⁵⁵
Traditionally, treatment has been based on treatment algorithms from
the adult literature. Fractures of the base of the fifth metatarsal are
discussed separately from the other metatarsal fractures as the
anatomy, fracture patterns, and treatment indications are quite
different.

The great toe is injured by the same mechanisms as the
lesser toes. Standard AP and lateral radiographs are taken; however, it
is useful to have the patient hold the lesser toes dorsiflexed with a
small towel to maximize visualization on the lateral view.
Intra-articular fractures of the proximal phalanx are more common in
the great toe than the other toes. They are usually Salter-Harris type
III or IV fractures (Fig. 27-40). Most of these fractures

can be managed with “buddy-strapping” to the second toe; however, if
greater than 25% of the joint surface is involved and there is
displacement of more than 2 to 3 mm of the joint surface, reduction
should be performed. Fracture reduction may be held by strapping to the
second toe or a percutaneous K-wire. In the rare occasion that this is
not successful, an open reduction can be performed either through a
midlateral or dorsal incision. With diaphyseal fractures, axial
alignment and rotation both need to be addressed with the closed
reduction. Often, the clinical appearance of the toe following the
reduction is more useful than the postreduction radiograph as the toe
usually looks “fine” even though the radiograph shows malalignment.

The initial treatment for these children is a thorough
assessment of the injuries suffered and appropriate resuscitation.
Often, a large volume of blood has been lost from the time of the
accident to arriving in the emergency department. Once the child is
stabilized, a secondary survey can be conducted to assess the extent of
the injury to each limb. With regard to the foot, these injuries are
mutilating and heavily contaminated with soil and grass. After
inspection, the wound should be dressed and a firm bandage applied to
prevent further bleeding. Antibiotics need to be administered as soon
as possible and include a cephalosporin, aminoglycoside, and
penicillin. The patient’s tetanus status should be ascertained and
tetanus prophylaxis administered if unknown.

The child then needs to be taken urgently to the
operating room for the initial débridement. Considerable time should be
spent removing the foreign material as meticulously as possible. A
water jet lavage system can be useful, but should be used with care as
it can force debris further in to the soft tissue envelopes.
Devitilized tissue should be débrided; however, questionable tissue
should be left as there will be multiple return trips to the operating
room when further débridements can take place. It is useful to involve
a plastic surgeon even at this initial surgery so they can see the
extent of the damage and start planning for definitive coverage. The
child will generally need at least three trips to the operating room
and some cases many more.⁴² These return trips should be every 24 to 48 hours depending

on the state of the wound. Each débridement is important and should not
be left to the most junior member of the surgical team to perform.
Every piece of viable skin is vital and may be the difference between a
primary closure over an amputation stump or a skin graft or tissue
transfer. There is no hurry to close the wound until the soft tissue
and bone is completely free of foreign material and the tissues are
well perfused. Shilt and colleagues¹⁵⁴
have found the use of VAC safe and effective in managing these types of
lawnmower injuries. Fractures need to be stabilized and initially
external fixation is useful. This allows plenty of room for further
débridements and does not compromise later internal fixation once the
soft tissue coverage has been determined.

Skin grafting or flap coverage of lawnmower injuries is required in approximately 50% of cases.⁴² Unlike adults, splitthickness skin grafting can function very well on the weightbearing surfaces in children.⁴²,¹⁶⁸
When the soft tissue defect is large or there is exposed bone that
would be better to preserve than excise, a free tissue transfer is
helpful.⁴⁶,⁹⁴ Lin et al.⁹⁵
recently reviewed 93 microsurgical reconstructions of soft tissue
defects of the pediatric foot. They reported excellent results with
free musculocutaneous flaps or skin grafted muscle flaps. For plantar
foot reconstructions, the musculocutaneous flaps had better results
with fewer tropic ulcers and fewer resurfacing procedures. They also
found that reconstruction of the tendons in the immediate setting led
to fewer subsequent operations than staged tendon reconstructions.⁹⁵

One of the most difficult decisions to make while
treating these severe injuries is whether to salvage the affected part
of the limb or amputate the questionable part. This decision is largely
based on what the functional outcome will be with either treatment and
what effect prolonged treatments and hospitalizations will have on the
child. Amputation rates vary between 16% and 78% in the literature.⁷,⁴²,¹⁶⁸ A mangled extremity severity score (MESS) has been developed in adults to help surgeons make these decisions.⁷⁵. The MESS score was validated in children by Fagelman and coworkers⁴⁸;
however, they did not include fractures below the ankle. It is useful
to ask for a colleague’s advice when contemplating an amputation so the
advantages and disadvantages can be freely debated. If an amputation is
performed, as much length of the bone should be preserved as possible,
and transdiaphyseal amputation should generally be avoided to prevent
problems with stump overgrowth.²,⁹⁸

The functional outcome for these patients is generally satisfactory. Vosburgh and colleagues¹⁶⁸
reviewed the functional outcome of 21 children with lawnmower accidents
and found that patients who had their injury confined to the forefoot
had 88% of normal function compared to 72% of normal function in
patients who had sustained injuries to the posterior and plantar
aspects of their foot.