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Pediatric Foot

Ovid: Handbook of Fractures

Authors: Koval, Kenneth J.; Zuckerman, Joseph D.
Title: Handbook of Fractures, 3rd Edition
> Table of Contents > V – Pediatric Fractures and Dislocations > 52 – Pediatric Foot

Pediatric Foot
  • Extremely rare in children (0.01% to 0.08% of all pediatric fractures).
  • Most represent fractures through the talar neck.
  • The ossification center of the talus appears at 8 months in utero (Fig. 52.1).
  • Two thirds of the talus is covered with articular cartilage.
  • The body of the talus is covered
    superiorly by the trochlear articular surface through which the body
    weight is transmitted. The anterior aspect is wider than the posterior
    aspect, which confers intrinsic stability to the ankle.
  • Arterial supply to the talus is from two main sources:
    • Artery to the tarsal canal: This arises
      from the posterior tibial artery 1 cm proximal to the origin of the
      medial and lateral plantar arteries. It gives off a deltoid branch
      immediately after its origin that anastomoses with branches from the
      dorsalis pedis over the talar neck.
    • Artery of the tarsal sinus: This
      originates from the anastomotic loop of the perforating peroneal and
      lateral tarsal branches of the dorsalis pedis artery.
  • An os trigonum is present in up to 50% of
    normal feet. It arises from a separate ossification center just
    posterior to the lateral tubercle of the posterior talar process.
Mechanism of Injury
  • Forced dorsiflexion of the ankle from
    motor vehicle accident or fall represents the most common mechanism of
    injury in children. This typically results in a fracture of the talar
  • Isolated fractures of the talar dome and body have been described but are extremely rare.
Clinical Evaluation
  • Patients typically present with pain on weight bearing on the affected extremity.
  • Ankle range of motion is typically painful, especially with dorsiflexion, and may elicit crepitus.
  • Diffuse swelling of the hindfoot may be present, with tenderness to palpation of the talus and subtalar joint.
  • A neurovascular examination should be performed.
Radiographic Evaluation
  • Standard anteroposterior (AP), mortise,
    and lateral radiographs of the ankle should be obtained, as well as AP,
    lateral, and oblique views of the foot.
  • P.630

  • The Canale view provides an optimum view
    of the talar neck. With the ankle in maximum equinus, the foot is
    placed on a cassette, pronated 15 degrees, and the x-ray tube is
    directed cephalad 75 degrees from the horizontal.
    52.1. Time of appearance and fusion of ossification centers of the
    foot. Figures in parentheses indicate the time of fusion of primary and
    secondary ossification centers (y., years; m.i.u, months in utero).

    (Redrawn from Aitken JT, Joseph J, Causey G, et al. A Manual of Human Anatomy, 2nd ed, vol. IV. London: E & S Livingstone, 1966:80.)
  • Computed tomographic scanning may be useful for preoperative planning.
  • Magnetic resonance imaging may be used to
    identify occult injuries in children <10 years old owing to limited
    ossification at this age.
  • Location: most talar fractures in children occur through the talar neck
  • P.631

  • Angulation
  • Displacement
  • Dislocation: subtalar, talonavicular or ankle joints
  • Pattern: presence of comminution
Hawkins Talar Neck Fractures
This classification is for adults, but it is often used for children.

Type I: Nondisplaced
Type II: Displaced with associated subtalar subluxation or dislocation
Type III: Displaced with associated subtalar and ankle dislocation
Type IV: Type III with associated talonavicular subluxation or dislocation
See Chapter 40 for figures.
  • Nondisplaced fractures may be managed in
    a long leg cast with the knee flexed 30 degrees to prevent weight
    bearing. This is maintained for 6 to 8 weeks with serial radiographs to
    assess healing status. The patient may then be advanced to weight
    bearing in a short leg walking cast for an additional 2 to 3 weeks.
  • Indicated for displaced fractures (defined as >5 mm displacement or >5-degree malalignment on the AP radiograph).
  • Minimally displaced fractures can often
    be treated successfully with closed reduction with plantar flexion of
    the forefoot as well as hindfoot eversion or inversion, depending on
    the displacement.
    • A long leg cast is placed for 6 to 8
      weeks; this may require plantar flexion of the foot to maintain
      reduction. If the reduction cannot be maintained by simple positioning,
      operative fixation is indicated.
  • Displaced fractures are usually amenable
    to internal fixation using a posterolateral approach and 4.0 mm
    cannulated screws or Kirschner wires placed from a posterior to
    anterior direction. In this manner, dissection around the talar neck is
  • Postoperatively, the patient is maintained in a short leg cast for 6 to 8 weeks, with removal of pins at 3 to 4 weeks.
  • Osteonecrosis: may occur with disruption
    or thrombosis of the tenuous vascular supply to the talus. This is
    related to the initial degree of displacement and angulation and,
    theoretically, the time until fracture reduction. It tends to occur
    within 6 months of injury.
  • Hawkins sign represents subchondral
    osteopenia in the vascularized, non–weight-bearing talus at 6 to 8
    weeks; although this tends to indicate talar viability, the presence of
    this sign does not rule out osteonecrosis.


Type I fractures: 0% to 27% incidence of osteonecrosis reported
Type II fractures: 42% incidence
Type III, IV fractures: >90% incidence
  • A rare injury, typically involving older children (>9 years) and adolescents.
  • Most are extraarticular, involving the apophysis or tuberosity.
  • Of these, 33% are associated with other injuries, including lumbar vertebral and ipsilateral lower extremity injuries.
  • The primary ossification center appears
    at 7 months in utero; a secondary ossification center appears at age 10
    years and fuses by age 16 years.
  • The calcaneal fracture patterns in children differ from that of adults, primarily for three reasons:
    • The lateral process, which is responsible
      for calcaneal impaction resulting in joint depression injury in adults,
      is diminutive in the immature calcaneus.
    • The posterior facet is parallel to the ground, rather than inclined as it is in adults.
    • In children, the calcaneus is composed of a ossific nucleus surrounded by cartilage.
These are responsible for the dissipation of the injurious forces that produce classic fracture patterns in adults.
Mechanism of Injury
  • Most calcaneal fractures occur as a
    result of a fall or a jump from a height, although typically a
    lower-energy injury occurs than seen with adult fractures.
  • Open fractures may result from lawnmower injuries.
Clinical Evaluation
  • Patients typically are unable to walk secondary to hindfoot pain.
  • On physical examination, pain, swelling, and tenderness can usually be appreciated at the site of injury.
  • Examination of the ipsilateral lower extremity and lumbar spine is essential, because associated injuries are common.
  • A careful neurovascular examination should be performed.
  • Injury is initially missed in 44% to 55% of cases.
Radiographic Evaluation
  • Dorsoplantar, lateral, axial, and lateral oblique views should be obtained for evaluation of pediatric calcaneal fractures.
  • The Böhler tuber joint angle: This is
    represented by the supplement (180 degree measured angle) of two lines:
    a line from the highest point of the anterior process of the calcaneus
    to the highest point of the posterior articular surface and a line
    drawn between the same point on the posterior articular surface and the
    most superior point of the tuberosity. Normally, this angle is between
    25 and 40 degrees; flattening of this angle indicates collapse of the
    posterior facet (Fig. 52.2).
  • P.633

  • Comparison views of the contralateral foot may help detect subtle changes in the Böhler angle.
    52.2. The landmarks for measuring the Böhler angle are the anterior and
    posterior facets of the calcaneus and the superior border of the
    tuberosity. The neutral triangle, largely occupied by blood vessels,
    offers few supporting trabeculae directly beneath the lateral process
    of the talus.

    (From Harty MJ. Anatomic considerations in injuries of the calcaneus. Orthop Clin North Am 1973;4:180.)
  • Technetium bone scanning may be utilized when calcaneal fracture is suspected but is not appreciated on standard radiographs.
  • Computed tomography may aid in fracture
    definition, particularly in intraarticular fractures in which
    preoperative planning may be facilitated by three-dimensional
    characterization of fragments.
Schmidt and Weiner (Fig. 52.3)

Type I: A. Fracture of the tuberosity or apophysis
B. Fracture of the sustentaculum
C. Fracture of the anterior process
D. Fracture of the anterior inferolateral process
E. Avulsion fracture of the body
Type II: Fracture of the posterior and/or superior parts of the tuberosity
Type III: Fracture of the body not involving the subtalar joint
Type IV: Nondisplaced or minimally displaced fracture through the subtalar joint
Type V: Displaced fracture through the subtalar joint
A. Tongue type
B. Joint depression type
Type VI: Either unclassified (Rasmussen
and Schantz) or serious soft tissue injury, bone loss, and loss of the
insertions of the Achilles tendon
52.3. Classification used to evaluate calcaneal fracture pattern in
children. (A) Extraarticular fractures. (B) Intraarticular fractures.
(C) Type VI injury with significant bone loss, soft tissue injury, and
loss of insertion of Achilles tendon.

(From Schmidt TL, Weiner DS. Calcaneus fractures in children: an evaluation of the nature of injury in 56 children. Clin Orthop 1982;171:150.)



  • Cast immobilization is recommended for
    pediatric patients with extraarticular fractures as well as
    nondisplaced (<4 mm) intraarticular fractures of the calcaneus.
    Weight bearing is restricted for 6 weeks, although some authors have
    suggested that in the case of truly nondisplaced fractures in a very
    young child, weight bearing may be permitted with cast immobilization.
  • Mild degrees of joint incongruity tend to
    remodel well, although severe joint depression is an indication for
    operative management.
  • Operative treatment is indicated for displaced articular fractures, particularly in older children and adolescents.
  • Displaced fractures of the anterior
    process of the calcaneus represent relative indications for open
    reduction and internal fixation, because up to 30% may result in
  • Anatomic reconstitution of the articular surface is imperative, with lag screw technique for operative fixation.
  • Posttraumatic osteoarthritis: This may be
    secondary to residual or unrecognized articular incongruity. Although
    younger children remodel very well, this emphasizes the need for
    anatomic reduction and reconstruction of the articular surface in older
    children and adolescents.
  • Heel widening: This is not as significant
    a problem in children as it is in adults because the mechanisms of
    injury tend not to be as high energy (i.e., falls from lower heights
    with less explosive impact to the calcaneus) and remodeling can
    partially restore architectural integrity.
  • Nonunion: This rare complication most
    commonly involves displaced anterior process fractures treated
    nonoperatively with cast immobilization. This is likely caused by the
    attachment of the bifurcate ligament that tends to produce a displacing
    force on the anterior fragment with motions of plantar flexion and
    inversion of the foot.
  • Compartment syndrome: Up to 10% of
    patients with calcaneal fractures have elevated hydrostatic pressure in
    the foot; half of these patients (5%) will develop claw toes if
    surgical compartment release is not performed.
  • Extremely uncommon in children.
  • They tend to occur in older children and adolescents (>10 years of age).
Anatomy (Fig. 52.4)
  • The base of the second metatarsal is the “keystone” of an arch that is interconnected by tough, plantar ligaments.
  • P.636

  • The plantar ligaments tend to be much stronger than the dorsal ligamentous complex.
    52.4. The ligamentous attachments at the tarsometatarsal joints. There
    is only a flimsy connection between the bases of the first and second
    metatarsals (not illustrated). The second metatarsal is recessed and
    firmly anchored.

    (From Wiley JJ. The mechanism of tarsometatarsal joint injuries. J Bone Joint Surg Br 1971;53:474.)
  • The ligamentous connection between the
    first and second metatarsal bases is weak relative to those between the
    second through fifth metatarsal bases.
  • Lisfranc ligament attaches the base of the second metatarsal to the medial cuneiform.
Mechanism of Injury
  • Direct: Secondary to a heavy object
    impacting the dorsum of the foot, causing plantar displacement of the
    metatarsals with compromise of the intermetatarsal ligaments.
  • Indirect: More common and results from violent abduction, forced plantar flexion, or twisting of the forefoot.
    • Abduction tends to fracture the recessed
      base of the second metatarsal, with lateral displacement of the
      forefoot variably causing a “nutcracker” fracture of the cuboid.
    • Plantar flexion is often accompanied by fractures of the metatarsal shafts, as axial load is transmitted proximally.
    • Twisting may result in purely ligamentous injuries.
Clinical Evaluation
  • Patients typically present with swelling over the dorsum of the foot with either an inability to ambulate or painful ambulation.
  • Deformity is variable, because spontaneous reduction of the ligamentous injury is common.
  • Tenderness over the tarsometatarsal joint
    can usually be elicited; this may be exacerbated by maneuvers that
    stress the tarsometatarsal articulation.
  • Of these injuries, 20% are missed initially
Radiographic Evaluation
  • AP, lateral, and oblique views of the foot should be obtained.
  • AP radiograph


    • The medial border of the second metatarsal should be colinear with the medial border of the middle cuneiform.
    • A fracture of the base of the second
      metatarsal should alert the examiner to the likelihood of a
      tarsometatarsal dislocation, because often the dislocation will have
      spontaneously reduced. One may only see a “fleck sign,” indicating an
      avulsion of the Lisfranc ligament.
    • The combination of a fracture at the base
      of the second metatarsal with a cuboid fracture indicates severe
      ligamentous injury, with dislocation of the tarsometatarsal joint.
    • More than 2 to 3 mm of diastasis between the first and second metatarsal bases indicates ligamentous compromise.
  • Lateral radiograph
    • Dorsal displacement of the metatarsals indicates ligamentous compromise.
    • Plantar displacement of the medial
      cuneiform relative to the fifth metatarsal on a weight-bearing lateral
      view may indicate subtle ligamentous injury.
  • Oblique radiograph
    • The medial border of the fourth metatarsal should be colinear with the medial border of the cuboid.
Quenu and Kuss (Fig. 52.5)

Type A: Incongruity of the entire tarsometatarsal joint
Type B: Partial instability, either medial or lateral
Type C: Divergent partial or total instability
  • Minimally displaced tarsometatarsal
    dislocations (<2 to 3 mm) may be managed with elevation and a
    compressive dressing until swelling subsides. This is followed by short
    leg casting for 5 to 6 weeks until symptomatic improvement. The patient
    may then be placed in a hard-soled shoe or cast boot until ambulation
    is tolerated well.
  • Displaced dislocations often respond well to closed reduction using general anesthesia.
    • This is typically accomplished with patient supine, finger traps on the toes, and 10 lb of traction.
    • If the reduction is determined to be
      stable, a short leg cast is placed for 4 to 6 weeks, followed by a
      hard-soled shoe or cast boot until ambulation is well tolerated.
  • Surgical management is indicated with displaced dislocations when reduction cannot be achieved or maintained.
  • Closed reduction may be attempted as
    described earlier, with placement of percutaneous Kirschner wires to
    maintain the reduction.
  • In the rare case when closed reduction
    cannot be obtained, open reduction using a dorsal incision may be
    performed. Kirschner wires are utilized to maintain reduction; these
    are typically left protruding through the skin to facilitate removal.
    Figure 52.5. Quenu and Kuss classification of tarsometatarsal injuries.

    (From Hardcastle
    PH, Reschauer R, Kitscha-Lissberg E, et al. Injuries to the
    tarsometatarsal joint: incidence, classification and treatment. J Bone Joint Surg Br 1982;64B:349.
  • P.638


  • A short leg cast is placed
    postoperatively; this is maintained for 4 weeks, at which time the
    wires and cast may be discontinued and the patient placed in a
    hard-soled shoe or cast boot until ambulation is well tolerated.
  • Persistent pain: May result from
    unrecognized or untreated injuries to the tarsometatarsal joint caused
    by ligamentous compromise and residual instability.
  • Angular deformity: May result despite
    treatment and emphasizes the need for reduction and immobilization by
    surgical intervention if indicated.
  • Very common injury in children and accounts for up to 60% of pediatric foot fractures.
  • The metatarsals are involved in only 2%
    of stress fractures in children; in adults, the metatarsals are
    involved in 14% of stress fractures.
  • Ossification of the metatarsals is apparent by 2 months in utero.
  • The metatarsals are interconnected by tough intermetatarsal ligaments at their bases.
  • The configuration of the metatarsals in
    coronal section forms an arch, with the second metatarsal representing
    the “keystone” of the arch.
  • Fractures through the metatarsal neck most frequently result from their relatively small diameter.
  • Fractures at the base of the fifth
    metatarsal must be differentiated from an apophyseal growth center or
    an os vesalianum, a sesamoid proximal to the insertion of the peroneus
    brevis. The apophysis is not present before age 8 years and usually
    unites to the shaft by 12 years in girls and 15 years in boys.
Mechanism of Injury
  • Direct: Trauma to the dorsum of the foot, mainly from heavy falling objects.
  • Indirect: More common and results from
    axial loading with force transmission through the plantar flexed ankle
    or by torsional forces as the forefoot is twisted.
  • Avulsion at the base of the fifth
    metatarsal may result from tension at the insertion of the peroneus
    brevis muscle, the tendinous portion of the abductor digiti minimi, or
    the insertion of the strong lateral cord of the plantar aponeurosis.
  • “Bunk-bed fracture”: This fracture of the
    proximal first metatarsal is caused by jumping from a bunk bed landing
    on the plantar flexed foot.
  • Stress fractures may occur with repetitive loading, such as long-distance running.


Clinical Evaluation
  • Patients typically present with swelling, pain, and ecchymosis, and they may be unable to ambulate on the affected foot.
  • Minimally displaced fractures may present with minimal swelling and tenderness to palpation.
  • A careful neurovascular examination should be performed.
  • The presence of compartment syndrome of
    the foot should be ruled out in cases of dramatic swelling, pain,
    venous congestion in the toes, or history of a crush mechanism of
    injury. The interossei and short plantar muscles are contained in
    closed fascial compartments.
Radiographic Evaluation
  • AP, lateral, and oblique views of the foot should be obtained.
  • Bone scans may be useful in identifying
    occult fractures in the appropriate clinical setting or stress
    fractures with apparently negative plain radiographs.
  • With conventional radiographs of the
    foot, exposure sufficient for penetration of the tarsal bones typically
    results in overpenetration of the metatarsal bones and phalanges;
    therefore, when injuries to the forefoot are suspected, optimal
    exposure of this region may require underpenetration of the hindfoot.
  • Location: metatarsal number, proximal, midshaft, distal
  • Pattern: spiral, transverse, oblique
  • Angulation
  • Displacement
  • Comminution
  • Articular involvement
  • Most fractures of the metatarsals may be
    treated initially with splinting, followed by a short-leg walking cast
    once swelling subsides. If severe swelling is present, the ankle should
    be splinted in slight equinus to minimize neurovascular compromise at
    the ankle. Care must be taken to ensure that circumferential dressings
    are not constrictive at the ankle, causing further congestion and
    possible neurovascular compromise.
  • Alternatively, in cases of truly
    nondisplaced fractures with no or minimal swelling, a cast may be
    placed initially. This is typically maintained for 3 to 6 weeks until
    radiographic evidence of union.
  • Fractures at the base of the fifth
    metatarsal may be treated with a short-leg walking cast for 3 to 6
    weeks until radiographic evidence of union. Fractures occurring at the
    metaphyseal-diaphyseal junction have lower rates of healing and should
    be treated with a non–weight-bearing short leg cast for 6 weeks; open
    reduction and intramedullary screw fixation may be considered,
    especially if a history of pain was present for


    3 months or more before injury, which indicates a chronic stress injury.

  • Stress fractures of the metatarsal shaft
    may be treated with a short leg walking cast for 2 weeks, at which time
    it may be discontinued if tenderness has subsided and walking is
    painless. Pain from excessive metatarsophalangeal motion may be
    minimized by the use of a metatarsal bar placed on the sole of the shoe.
  • If a compartment syndrome is identified, release of all nine fascial compartments of the foot should be performed.
  • Unstable fractures may require
    percutaneous pinning with Kirschner wires for fixation, particularly
    with fractures of the first and fifth metatarsals. Considerable lateral
    displacement and dorsal angulation may be accepted in younger patients,
    because remodeling will occur.
  • Open reduction and pinning are indicated
    when reduction cannot be achieved or maintained. The standard technique
    includes dorsal exposure, Kirschner wire placement in the distal
    fragment, fracture reduction, and intramedullary introduction of the
    wire in a retrograde fashion to achieve fracture fixation.
  • Postoperatively, the patient should be
    placed in a short leg, non–weight-bearing cast for 3 weeks, at which
    time the pins are removed and the patient is changed to a walking cast
    for an additional 2 to 4 weeks.
  • Malunion: This typically does not result
    in functional disability because remodeling may achieve partial
    correction. Severe malunion resulting in disability may be treated with
    osteotomy and pinning.
  • Compartment syndrome: This uncommon but
    devastating complication may result in fibrosis of the interossei and
    an intrinsic minus foot with claw toes. Clinical suspicion must be high
    in the appropriate clinical setting; workup should be aggressive and
    treatment expedient, because the compartments of the foot are small in
    volume and are bounded by tight fascial structures.
  • Uncommon; the true incidence is unknown because of underreporting.
  • Ossification of the phalanges ranges from
    3 months in utero for the distal phalanges of the lesser toes, 4 months
    in utero for the proximal phalanges, 6 months in utero for the middle
    phalanges, and up to age 3 years for the secondary ossification centers.


Mechanism of Injury
  • Direct trauma accounts for nearly all
    these injuries, with force transmission typically on the dorsal aspect
    from heavy falling objects or axially when an unyielding structure is
  • Indirect mechanisms are uncommon, with rotational forces from twisting responsible for most.
Clinical Evaluation
  • Patients typically present ambulatory but guarding the affected forefoot.
  • Ecchymosis, swelling, and tenderness to palpation may be appreciated.
  • A neurovascular examination is important,
    with documentation of digital sensation on the medial and lateral
    aspects of the toe as well as an assessment of capillary refill.
  • The entire toe should be exposed and examined for open fracture or puncture wounds.
Radiographic Evaluation
  • AP, lateral, and oblique films of the foot should be obtained.
  • The diagnosis is usually made on the AP
    or oblique films; lateral radiographs of lesser toe phalanges are
    usually of limited value.
  • Contralateral views may be obtained for comparison.
  • Location: toe number, proximal, middle, distal
  • Pattern: spiral, transverse, oblique
  • Angulation
  • Displacement
  • Comminution
  • Articular involvement
  • Nonoperative treatment is indicated for
    almost all pediatric phalangeal fractures unless there is severe
    articular incongruity or an unstable, displaced fracture of the first
    proximal phalanx.
  • Reduction maneuvers are rarely necessary; severe angulation or displacement may be addressed by simple longitudinal traction.
  • External immobilization typically
    consists of simple buddy taping with gauze between the toes to prevent
    maceration; a rigid-soled orthosis may provide additional comfort in
    limiting forefoot motion. This is maintained until the patient is pain
    free, typically between 2 and 4 weeks (Fig. 52.6).
  • Kicking and running sports should be limited for an additional 2 to 3 weeks.


52.6. Method of taping to adjacent toe(s) for fractures or dislocations
of the phalanges. Gauze is placed between the toes to prevent
maceration. The nailbeds are exposed to ascertain that the injured toe
is not malrotated.

(From Weber BG, Brunner C, Freuler F. Treatments of Fractures in Children and Adolescents. New York: Springer-Verlag, 1980:392.)
  • Surgical management is indicated when
    fracture reduction cannot be achieved or maintained, particularly for
    displaced or angulated fractures of the first proximal phalanx.
  • Relative indications include rotational
    displacement that cannot be corrected by closed means and severe
    angular deformities that, if uncorrected, would lead to cock-up toe
    deformities or an abducted fifth toe.
  • Fracture reduction is maintained via retrograde, intramedullary Kirschner wire fixation.
  • Nailbed injuries should be repaired. Open
    reduction may be necessary to remove interposed soft tissue or to
    achieve adequate articular congruity.
  • Postoperative immobilization consists of a rigid-soled orthosis or splint. Kirschner wires are typically removed at 3 weeks.
  • Malunion uncommonly results in functional
    significance, usually a consequence of fractures of the first proximal
    phalanx that may lead to varus or valgus deformity. Cock-up toe
    deformities and fifth toe abduction may cause cosmetically undesirable
    results as well as poor shoe fitting or irritation.

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