Transcript Pediatric Ankle and Foot Fractures

Pediatric Ankle &
Foot Fractures
Steven Rabin, MD
Revised: March 2011
Original authors (2004): Laura Phieffer, MD & Steven Frick, MD
Revised (2006): Steven Frick, MD
Pediatric Ankle Fractures
Epidemiology
• 2nd most common site of physeal fractures
in children
• Most occur between ages 8 - 15 y.o.
• Boys > girls
• Direct and indirect mechanisms of injury
Anatomy
• All ligamentous structures
attach distal to the physis
• Ligaments are stronger than
physis and bone
• Physeal injury more common
than ligament injury
• Anterior Tibio-fibular
ligament important in
transitional fractures when the
physis is closing
Ankle Anatomy
• Distal tibia ossification center appears
between 6 - 24 months
• Distal fibula ossification center appears
between 9 - 24 months
• Medial malleolar extension appears at about
7 years
Physeal Closure
• Distal tibia physis closes:
– About age 12-15 yrs girls
– About age 13-17 yrs boys
• Medial malleolus extension appears ~10 yrs
• Asymmetric closure over ~18 months
– Tibia physis closes in center first then medially and
posteriorly.
– Anterolateral portion of physis is the last to close
• Closure of the distal fibula physis follows distal
tibia physeal closure by ~12-24 months
Distal Tibial Physeal Closure
Age / Fracture Pattern
Spiegel P, et al. Epiphyseal fractures of the distal ends of the
tibia and fibula. J Bone Joint Surg Am. 1978;60(8):1046-50.
Classification
Anatomic
• Salter-Harris
– High
interobserver
correlation
– Correlated with
outcomes
Classification - Ankle Fractures
• Mechanism of injury:
Dias L, Tachdjian M. Physeal injuries of the ankle in
children: classification. Clin Orthop Relat Res. 1978;136:230-
Diagnosis - Ankle Fractures
•
•
•
•
Direct/indirect mechanisms
Acute/subacute
May have subtle exam findings
Differentiate sprain from non-displaced
fracture by location of tenderness
– (Pain over the physis/bone = physeal injury)
– (Pain over the soft tissues = sprain)
Imaging of Ankle Fractures
• Radiographs - AP, LAT, Mortise
– know normal anatomic variants
•
•
•
•
Stress radiographs
CT scan – to assess articular involvement
MRI – role not well defined
Bone Scan – if in doubt about an accessory
ossification center vs. an acute fracture
Accessory Ossification Centers –
Smooth Borders
• Accessory ossification
centers usually appear
between ages of 7 to 10 yrs
• Fuse by skeletal maturity
• Medial (os subtibiale) in
20% of patients
• Lateral (os subfibulare) in
1% of patients
Treatment Considerations
•
•
•
•
Location of fracture
Mechanism of injury
Degree of displacement
Age of child (how much growth remains)
– Distal tibia physis contributes:
• 3-4 mm growth per year
• 35-45% of overall tibial length
Salter-Harris Type I Fracture
• Typically occur in younger pts
• Seen with all mechanisms (SI, SPF, SER,
PER)
• Often missed initially (dx “sprain”):
– Physis weaker than ligaments so physeal injury
is more common than a sprain
• Xrays
– Acute – often normal except for soft tissue
swelling over physis
– Subacute - reveal widening of physis- healing
Salter I Distal Tibia Fractures:
Treatment
• Less than 3 mm displacement
– Cast
– 4-6 weeks depending on the patient’s age
• Greater than 3 mm displacement
–
–
–
–
–
Gentle closed reduction and casting
Usually require anesthesia
If interposed soft tissue, must be removed
If unstable, pin fixation may be needed.
More likely to be unstable if fibula also
fractured
• Follow x-rays for 6-12 months to evaluate
for premature physeal closure
Salter I Fracture Distal Tibia
• Salter I fracture of the
distal tibia (with
metaphyseal fibula
fracture)
• Treated with closed
reduction and pin
fixation
Salter-Harris Type II Fractures
• Most common distal tibia Fx type
• Seen with all mechanisms
(SI, SPF, SER, PER)
• Mechanism deduced by
– Direction of displacement of the
tibial epiphysis,
– Type of associated fibula fx
– Location of metaphyseal spike
Salter-Harris Type II fractures:
Treatment
• Non-displaced fractures
– Short leg cast (SLC) for 3 weeks
– Then walking SLC for 3 weeks
• Displaced fractures
– Avoid repeated attempts at reduction
– If unstable consider a long leg cast for 2-3
weeks, otherwise a short leg cast for 3-4
weeks then a short leg walking cast for 2-3
weeks (depending on age)
– Open reduction infrequently indicated
– Follow for growth arrest
Salter II Fracture of the Distal Tibia
• Salter II fracture
of the distal tibia
– treated with
closed reduction
and cannulated
screw fixation
Salter-Harris Type I & II fxs
• If reduction is incomplete, how much
residual displacement is acceptable?
– Carothers and Crenshaw (1955)
• “accurate reposition of the displaced epiphysis at the
expense of forced or repeated manipulation or
operative intervention is not indicated”
Carothers C, Crenshaw A. Clinical significance of a classification
of epiphyseal injuries at the ankle. Am J Surg. 1955;89(4):879-89.
Salter-Harris Type I & II fxs
• If reduction is incomplete, how much
residual displacement is acceptable?
– Spiegel (1978)
• correlated Salter-Harris classification with risk of
shortening, angular deformity and joint incongruity
• recommended “precise anatomical reduction”
Spiegel P, et al. Epiphyseal fractures of the distal ends of the
tibia and fibula. J Bone Joint Surg Am. 1978;60(8):1046-50.
Salter-Harris Type I & II fxs
• Differing opinions regarding indication for open
reduction for interposition of periosteum =>
widening with minimal angulation
– Kling (1984)
– Phieffer (2000)- Animal model
– Barmada (2005) believes interposed periosteum leads
to growth disturbance
-Kling T, Bright R, Hensinger R. Distal tibial physeal fractures in children that may
require open reduction. J Bone Joint Surg Am. 1984;66(5):647-57.
-Phieffer et al. Effect of interposed periosteum in an animal physeal fracture model.
Clin Orthop Relat Res. 2000;376:15-25.
-Barmada A, Gaynor T, Mubarak SJ. Premature physeal closure following distal tibia
physeal fractures: a new radiographic predictor. J Pediatr Orthop. 2003;23(6):733-9.
Closed reduction with incomplete
reduction because of interposed soft
tissues – removed at ORIF
Salter-Harris Type I & II fxs
• Displaced subacute (>7-10 days out) fxs
– Residual displacement may have to be accepted
– If growth does not sufficiently correct
malunion, corrective osteotomy performed
Salter II Fracture of the Distal Tibia
•
Salter-Harris Type III & IV fxs
• Mechanism of injury similar for both fx
patterns (typically supination-inversion)
• Usually produced by medial corner of talus
being driven into the junction of distal tibial
articular surface and the medial malleolus
• Can see central and lateral fx patterns
Salter-Harris Type III & IV fxs
• Treatment and prognosis are similar
• Anatomic restoration of the articular surface
is a high priority
• Medial pattern appears to be at higher risk
for developing partial growth arrest and
subsequent varus deformity
-Spiegel P, Cooperman D, Laros G. Epiphyseal fractures of the distal ends
of the tibia and fibula. J Bone Joint Surg Am. 1978;60(8):1046-50.
-Kling T, Bright R, Hensinger R. Distal tibial physeal fractures in children
that may require open reduction. J Bone Joint Surg Am. 1984;66(5):647-57.
-Caterini R, Farsetti P, Ippolito E. Long-term followup of physeal injury to
the ankle. Foot Ankle. 1991;11(6):372-83.
Salter-Harris Type III & IV fxs
• Non-displaced fractures (<1 mm)
– Cast for 3-4 wks => SLWC x 3 wks
– May need CT after cast placement to assess
displacement
– Follow with x-rays in cast to assure no
displacement
– Percutaneous fixation is an option
– Follow for growth arrest
Salter IV Minimally Displaced
Distal Tibia Fracture
*Fixation avoids physis
Salter-Harris Type III & IV fxs
• Displaced fractures (>2 mm)
– Require Anatomic reduction
– Closed reduction under general anesthesia
– If continued > 2 mm displacement => open reduction
– Open reduction with epiphyseal fixation parallel to
growth plate if possible, especially if significant growth
remaining
– Postop: Cast (NWB) for 3-4 wks => SLWC x 3 wks
– Follow for growth arrest: 15% incidence of
growth arrest even with anatomic reduction
Salter III Injury- Closed reduction
with percutaneous internal fixation
Salter IV Distal Tibia Fracture
Salter-Harris Type III & IV fxs
• Subacute displaced fxs
– Accept up to 2 mm displacement
– Greater than 2 mm displacement
• Goal to restore joint congruity
• Recommend reduction regardless of time from
injury
• Debridement and interposition graft, if necessary
Delayed diagnosis Salter IV medial malleolus
fracture in 6 yr multi-trauma patient
• Initial radiographs 15 days out from injury
• ORIF 16 days after injury
• Anterior approach
Note Harris growth line parallels physis and
increased distance between markers – normal
growth
• Nine months post-operative
Salter-Harris Type V fxs
• Crush injury to physis
• No associated displacement
• Diagnosis made with follow-up xrays
revealing premature physeal closure
• Treatment directed primarily at sequelae of
growth arrest
High energy injuries to distal tibia
• Uncommon
• Severe injury to distal tibial articular
surface – poor prognosis
• Restore articular surface, if possible
• Length and alignment – bridging external
fixation can be helpful
High energy distal tibia
fracture/subluxation
11 year old female in MVC
CT scan demonstrates significantly
comminuted articular surface and
anterior subluxation of talus
Intraop views – bridging external
fixation and ORIF with pin fixation
One Year Follow Up
12 Year Old – High Velocity GSW
– loss of tibial epiphysis/anterior soft tissues/tendons
- bridging external fixator
- latissimus free flap
-ankle fusion
“Transitional” Fractures
• Fractures occurring during
asymmetric closure of distal
tibial physis
– Triplane fx
• Fracture appears to be in
multiple planes
• May be 2, 3 or 4 part fractures
– Tillaux fx
• Fracture of the anterolateral
epiphysis
“Transitional” Fractures
• Triplane fx
– Tend to be seen in younger
pts than those with Tillaux
fx
– More displacement/swelling
– Appear as Salter III on AP
view and Salter II on lateral
view
– Treatment decisions usually
based on articular
displacement
– CT scan often helpful
Triplane Fractures
• Combination of Salter II
and III fractures: usually
near end of growth
(Complex type IV
fracture)
• Anterior epiphseal fracture
with large posteriomedial
metaphyseal
fragment…fibula may also
be fractured
Triplane Fractures
Results
• Overall results are good following adequate
reduction
– Von Laer (1985)
– Clement and Warlock (1987) - Good early results
– Erlt (1988) - Decline in results over time
-von Laer L. Classification, diagnosis, and treatment of transitional fractures of the
distal part of the tibia. J Bone Joint Surg Am. 1985;67(5):687-98.
-Clement D, Worlock P. Triplane fracture of the distal tibia. A variant in cases with
an open growth plate. J Bone Joint Surg Br. 1987;69(3):412-5.
-Ertl J, Barrack R, Alexander A, VanBuecken K. Triplane fracture of the distal tibial
epiphysis. Long-term follow-up. J Bone Joint Surg Am. 1988;70(7):967-76.
Triplane Fractures
• Non-displaced
– Cast (NWB) 3-4 wks, then SLWC x 3-4 wks
– Monitor in cast to assure no displacement
– FU x-rays every 6-12 months for 2 to 3 yrs to
assess for growth arrest
Triplane Fractures
• Displaced Triplane Fractures (>2 mm)
– Anatomic reduction required
– If closed reduction successful
• Cast: consider a long leg cast with 30 of knee
flexion and foot internally rotated, if unstable
– If closed reduction unsuccessful => ORIF
• Reduction/internal fixation done in step-wise
fashion with small fragment or 4.0 cannulated
screws
– Postop - SLC x 3-4 wks, then SLWC x 3 wks
Adequate Imaging Helps
• CT gives 3D visualization
of fracture patterns
• Essential for planning
Triplane Fracture
• Surgical Correction
“Transitional” Fractures
• Juvenile Tillaux fractures
– Patients tend to be older
than those with triplane fx
– Fibula prevents marked
displacement: may be subtle
– Local tenderness at
anteriolateral joint line
– Mortise view essential
– May need CT scan
– Although literature based
on small series, excellent
results with anatomic
reduction noted
Tillaux Fractures Treatment
• Non-displaced
– Cast (NWB) x 3 wks, then SLWC x 3-4 wks
– CT scan after cast placement may be needed to assure
no displacement
– Radiographs in cast to assure no re-displacement in
cast
– Follow-up x-rays obtained every 6-12 months for 2 to
3 yrs to assess for growth arrest
Tillaux Fractures Treatment
• Displaced (>2mm) Tillaux fxs
– Anatomic reduction required
– If closed reduction achieved
• Long leg cast with knee flexed 30 degrees and foot
internally rotated if unstable
– If closed reduction unsuccessful
• Attempt closed reduction under anesthesia
• If still unsuccessful, may use k-wires to joystick Tillaux
fragment (percutaneously or open)
• Fixation with small fragment or 4.0 cannulated screws
– Postop - SLC x 3-4 wks, then SLWC x 3 wks
Tillaux Fracture Example
• Child with
ankle pain:
– Fracture
difficult to see
Tillaux Fracture Example
• CT shows a Salter III
(“Tillaux”) fracture of
the distal tibia
– Tillaux fractures occur
near the end of growth
as medial portion of
distal tibial physis
closes before the lateral
side closes
Tillaux Fracture Example
• Post-operative and healed x-rays after hardware
removal: no residual deformity
“Other” Distal Tibial Fractures
• Injury to accessory
ossification centers
• Treatment SLWC 3-4
weeks
– Ogden (1990)
• Good results 26/27 patients
with injuries involving the
medial side
• 5/11 pts with injuries
involving the lateral side had
persistent symptoms requiring
excision
Ogden JA, Lee J. Accessory ossification patterns and injuries
of the malleoli. J Pediatr Orthop. 1990;10(3):306-16.
Distal Fibula Fractures
• Typically Salter-Harris I or II fractures
– When isolated, usually minimally displaced
• Can treat with a SLWC for 3-4 wks
– Significant displacement occurs more often
with Salter III and IV distal tibial fractures
• Usually reduces with tibial reduction
– If fracture is unstable
• Can usually fix with smooth intramedullary or
oblique k-wires
• Sometimes plate fixation, especially if comminuted.
Salter I Distal Fibula
typical “goose egg” swelling over distal fibula
with tenderness over distal fibular physis
Pediatric Ankle Sprains
• Should be diagnosis of exclusion
• Tenderness should be over the ligaments
• If tenderness is over the physis, may be a
Salter I ankle fractures or non-displaced
calcaneus fracture
• Treatment as with any sprain: rest, ice,
elevation, and splint until comfortable.
Ankle Fractures
Prognosis
• Depends on mechanism of injury
– Higher energy, worse prognosis
– Greater comminution, worse prognosis
• Depends on age of the patient
– Less chance for re-modeling if older
• Often poor outcome with
– Medial distal tibial physeal injuries
– Residual articular step off
• Presence of an associated fibular fracture– has no
prognostic significance
Ankle Fractures
Complications
• Growth arrest
– Can occur with any
fracture pattern
– Most often with Salter
III and IV fractures
– Usually seen 6 to 18
months after injury
(but as late as 2 yrs
after injury)
Ankle Fractures
Complications
• Growth arrest
– Occur in fractures treated operatively and non-op
– Radiographic Harris growth lines
• Allow for earlier intervention
• Look for in x-rays 6-12 weeks
– LLD tolerated well
– Angular deformity less well tolerated
Growth Arrest
• Treatment:
– Observation if near end of
growth
– Monitor and epiphysiodesis
or bar resection depending
on deformity
– Osteotomy if persistent
deformity after growth has
ceased.
Physeal Injury Simulating Bone
Tumor
• Arrow points to growth arrest line
Other Complications of Ankle
Fractures
•
•
•
•
Arthritis
Malunion
Delayed/nonunion
AVN distal tibial
epiphysis (rare)
10 year old – 3 months after distal
Tibia fracture
CT shows anterior central bar
Ankle Fractures
Summary
• Heterogenous group of fractures
• Age dependent
• Important to have high index of suspicion to
avoid missing diagnosis
• Correlate physical exam and x-ray findings
• Follow until skeletal maturity
• May develop late sequelae
Pediatric Foot Fractures
Epidemiology
• Often missed
• 5-8% of all pediatric fractures
• Reductions of fractures important
– Less remodeling potential
– Reach 50% of mature length of foot bones by
18 mo. (compared to femur/tibia - do not reach
until 3 yrs)
Pediatric Foot Fractures
• Types of foot injuries1
–
–
–
–
–
–
•
Metatarsal fractures
Phalangeal fractures
Navicular fractures
Talar fractures
Calcaneal fractures
Cuboid fractures
1Data
90%
18%
5%
3%
3%
2%
from Cleveland Fracture Service, A.Crawford
(Skeletal Trauma)
Pediatric Foot Anatomy
• Hindfoot: talus, calcaneus
• Midfoot: navicular, cuboid,
3 cuneiforms
• Forefoot:
– 5 metatarsals (distal epiphyses
except for 1st MT - proximal
epiphysis)
• Distal 1st Metatarsal
pseuodoepiphysis may occur
– 14 phalanges (proximal
epiphyses)
• Variable number of
sesamoids/accessory ossicles
Foot Accessory Ossicles
Radiographs
• AP, lateral, oblique XR of foot
• AP, lateral, oblique XR of ankle as well
• Co-existent unrecognized fractures of distal
tibia/fibula occur in up to 8% patients with
foot fractures
• Comparison views of opposite foot may be
helpful
Talus Fractures
• Less than 1% of all pediatric fractures:
–
–
–
–
56 % = Avulsion fractures
20% = Osteochondral lesions
19% = Talar neck fractures
6% = Talar body fractures
Jensen et al. Prognosis of fracture of the talus in children: 21 (7-34)year follow-up of 14 cases. Acta Orthop Scand 1994;65:398-400.
Talus Avulsion fractures
• Usually require only symptomatic treatment
• Splint, cast or brace for comfort
• Usually healed in 2-3 weeks
Kay R, Tang C. Pediatric foot fractures: evaluation and
treatment. J Am Acad Orthop Surg. 2001;9(5):308-19.
Lateral or Medial Process
Talus Fractures
• Lateral/medial process fractures
– Rarely displace
– Symptomatic treatment only
– Non-unions rare
• Usually asymptomatic, if they occur
Talar Dome Fracture
• Example: 14 year old girl.
• Treatment: similar to an adult.
Talar Dome Fracture
• Fixation
Talar Neck & Body Fractures
• Rare injuries
• Neck fractures most common with apex
plantar angulation
• Monitor for 1 year for possible AVN (rare)
Pediatric Talus Neck Fractures
• Hawkins’ Classification (same as in adults)
– Type I = nondisplaced
– Type II = displaced talar neck involving
subtalar joint
– Type III = displaced talar neck fractures
involving both ankle and subtalar joints
– Type IV = displaced talar neck fractures
involving ankle, subtalar and talo-navicular
joints
Hawkins LG: Fractures of the neck of the talus. J Bone Joint Surg
52A:991–1002, 1970.
Canale ST, Kelly FB: Fractures of the neck of the talus, long term
evaluation of seventy one cases. J Bone Joint Surg 60A:143–156, 1978.
Talar Neck Fractures
• If nondisplaced
– Treatment is non-weightbearing in a above-knee cast
for 6-8 weeks.
• If displaced
– Treatment may include ORIF
– Angulation < 5 degrees acceptable
– > 5 degrees angulation requires reduction under general
anesthesia
– Displaced (>2mm) fractures at the articular surface
require ORIF
Kay R, Tang C. Pediatric foot fractures: evaluation and
treatment. J Am Acad Orthop Surg. 2001;9(5):308-19.
Hawkins 2 Talar Neck Fracture with
Distal Fibula Avulsion
• Example: Talar neck fracture
• Distal fibula avulsion with ankle instability.
Talar Neck Fracture with Distal
Fibula Avulsion
• ORIF of both
fractures
– To restore
stability
Displaced talar neck fracture with medial
and lateral malleolar fractures
• Initial x-rays
• Postop x-rays - Anatomic reduction required
(same as in adults)
Talar Neck Fracture
(with bi-malleolar fractures)
• Complication:
– Avascular Necrosis
– Less common than in
adults but can still occur
– Long term follow-up
necessary
Peritalar Dislocations in Children
• Extremely rare injury (case reports only)
• Represent dislocation of subtalar and talonavicular
joints
• Four types based on direction of foot
– Medial most common
– Also lateral, anterior, posterior
• Adults – usually have an associated displaced talar
neck fracture
– But in children, isolated dislocations more common
Peritalar Dislocations in Children
• Often associated foot fracture
• Attempt closed reduction
– Open reductions associated with ultimate decreased
ROM
• Associated intra-articular fracture of talonavicular
joint adversely affects outcome
• No reported cases of associated AVN
Osteochondral Talus Fractures
• Osteochondral fractures
– Inversion/plantar flexion injury
• Posteromedial lesion (more common)
– Eversion/dorsiflexion injury
• Anterolateral lesion
• Often require MRI for diagnosis
• Non-displaced lesion => NWB in cast
• Displaced lesion => excision/currettage
Osteochondral Lesions
(Osteochondritis dissecans)
• Classification
–
–
–
–
Type I lesions are nondisplaced.
Type II lesions are partially detached.
Type III lesions are detached but not displaced.
Type IV lesions are detached and displaced or
rotated.
Berndt AL, Harty M: Transcondylar fractures (osteochondritis
dissecans) of the talus. J Bone Joint Surg 41A:988–1020, 1959.
Osteochondral Lesions
Treatment
• Splint/non-weightbearing for 1-2 months
– The initial treatment for all but type IV for 1 to
2 months. No contact sports for another 2-3
months
• If no symptomatic and/or radiographic
improvement by 3 to 4 months,
– Drilling, debridement, or arthroscopic fixation
may be indicated.
Higuera, et al. Osteochondritis dissecans of the talus during
childhood and adolescence. J Pediatr Orthop 1998;18:328-332.
Ankle sprain that didn’t healAnterolateral Talar
Osteochondral Lesion
Calcaneal Fractures
•
•
•
•
Rare – 2% of all pediatric foot fractures
Result of significant falls
5% associated with lumbar spine injuries
Often missed diagnosis
– Difficult to diagnosis if non-displaced
• Extra-articular fractures are more frequent
– Approximately 65% of calc fxs in children
• Bone scan can confirm diagnosis
Kay R, Tang C. Pediatric foot fractures: evaluation and
treatment. J Am Acad Orthop Surg. 2001;9(5):308-19.
Treatment Calcaneal Fractures
• Treat soft tissues first with elevation
• Non-displaced injuries
– NWB with Jones’ dressing then cast when soft tissue
swelling subsides
– Weightbearing in 3-6 weeks
• Displaced injuries
– ORIF when soft tissues amenable
• Acceptable displacement not well-defined
• Adolescents - same indications as adults
Brunet JA: Calcaneal fractures in children. Long-term
results of treatment. J Bone Joint Surg 82B:211–216, 2000.
Inokuchi S, Usami N, Hiraishi E, Hashimoto T: Calcaneal
fractures in children. J Pediatr Orthop 18:469–474, 1998.
Other Tarsal Fractures
• Fractures of the navicular, cuboid and
cuneiforms
– 2-7% of pediatric foot fractures
– Usually avulsion injuries
• Immobilize 2-3weeks
– If high energy trauma, may have associated
LisFranc and other fractures
• Watch closely for compartment syndrome
• May need ORIF
Kay R, Tang C. Pediatric foot fractures: evaluation and
treatment. J Am Acad Orthop Surg. 2001;9(5):308-19.
Lisfranc Injuries
(Tarsal-metatarsal fractures/dislocations)
• Direct/indirect mechanisms of injury
• Represent significant force
– Fracture of base of 2nd MT - implies more
severe injury
– Associated cuboid fx - implies dislocation
• Treatment - requires anatomic reduction
– Treat soft tissues first with elevation
– Closed reduction/pinning vs. ORIF
– Beware of compartment syndrome
Lisfranc Injuries
• Same treatment classification and options as
in adults.
• Residual pain reported in up to 22% of
pediatric patients.
Johnson GF. Pediatric Lisfranc injury: “Bunk bed”
fracture. AJR Am J Roentgenol. 1981;137:1041-1044.
Wiley JJ: Tarso-metatarsal joint injuries in children. J
Pediatr Orthop. 1981;1:255-260.
Metatarsal Fractures
• Most common pediatric foot fracture (60%)
– 5th metatarsal base is most frequent
• Usually caused by direct trauma
– Except base of 5th more often avulsion
• Metatarsal shaft fractures most common
– Lateral displacement – acceptable (if Lisfranc joint
intact)
– Significant dorsal/plantar angulation not acceptable,
requires closed reduction/pinning
Owen RJT, Hickey FG, Finlay DB: A study of metatarsal
fractures in children. Injury 1995;26:537-538.
Metatarsal Fractures
• 1st metatarsal fractures
– Can see buckle fracture just distal to proximal
physis (treatment – SLWC x 3 wks)
– Do not confuse pseudoepiphysis at distal end
with fracture
Owen RJT, Hickey FG, Finlay DB: A study of metatarsal
fractures in children. Injury 1995;26:537-538.
Metatarsal Fractures
• 5th metatarsal fractures
– Proximal metaphyseal transverse fractures most
common
– Treatment SLWC x 6 wks
– Distinguish from “Jones” fractures
• Occur in proximal diaphysis
• Occur in older children (15 - 20 y.o.)
– Do not confuse os vesalianum (os peronei) with
fracture (oblique orientation proximally)
Owen RJT, Hickey FG, Finlay DB: A study of metatarsal
fractures in children. Injury 1995;26:537-538.
Metatarsal Fractures
• Metatarsal base fractures
– Require significant force
– Consider early fasciotomy if significant
swelling/venous congestion in toes
• No reported compartment pressures to guide
• Use clinical judgment
Owen RJT, Hickey FG, Finlay DB: A study of metatarsal
fractures in children. Injury 1995;26:537-538.
Metatarsal Fractures and Growth
Deformity
• Physeal fractures of the base of the first
metatarsal may cause abnormal growth with
shortening of the first ray.
• Overgrowth may also occur after metatarsal
fractures.
– Overgrowth is more common than growth
inhibition
Owen RJT, Hickey FG, Finlay DB: A study of metatarsal
fractures in children. Injury 1995;26:537-538.
Growth Plate Injuries
• Treatment of Physeal
Injuries
– Non-displaced
• SLWC x 4-6 wks
– Displaced
• Finger-trap traction until
swelling subsides then
percutaneous pinning
• Open reduction if unable
to obtain adequate
alignment
Owen RJT, Hickey FG, Finlay DB: A study of metatarsal
fractures in children. Injury 1995;26:537-538.
Pediatric Phalangeal Fractures
• 18% of children’s foot fractures
– 2/3 involve proximal phalanges
– 1/3 middle phalanges
– Rarely distal phalanges
• Treatment
– Traction, closed reduction, buddy taping, hard
sole shoe
• Open injures require I&D/IV antibiotic
– Osteomyelitis can occur
Pediatric Phalangeal Fractures
• Great toe distal phalangeal fractures
– Beware of crush injuries
– May represent open fractures
– If suspect open injury, treat with I&D and
antibiotics to avoid complication of
osteomyelitis
Owen RJT, Hickey FG, Finlay DB: A study of metatarsal
fractures in children. Injury 1995;26:537-538.
Lawnmower Injuries
• Common cause of
pediatric open fractures
• 70% are bystanders
• Occur with all types of
mowers but majority
are riding mowers.
• Distribution of injuries
– Head/eye 24%
– Upper extremity 36%
– Lower extremity 39%
Alonso JE, Sanchez FL. Lawn mower injuries in children: A
preventable impairment. J Pediatr Orthop. 1995;15:83-89.
Lawnmower Injuries
• Highly contaminated
injuries
– Initial irrigation &
debridment/antibiotic
coverage
– Repeat debridements
until wound is clean
Lawn Mower Injuries
• May require internal or
external fixation of
fractures
• Attempt coverage by
7-14 days, if possible
• >50% require skin
grafting or flap
coverage
Dormans JP, Azzoni M, Davidson RS, Drummond DS.
Major lower extremity lawn mower injuries in children.
J Pediatr Orthop. 1995;15:78-82.
Lawn Mower Injuries
• High complication rate
– Infection
– Growth arrest
– Amputation rates
• 16-78%
• > 50% unsatisfactory
results
Dormans JP, Azzoni M, Davidson RS, Drummond DS.
Major lower extremity lawn mower injuries in children.
J Pediatr Orthop. 1995;15:78-82.
Lawnmower Injuries
Long-term follow-up
• Late deformity may
occur
– Muscle imbalances
from loss of soft
tissue attachments
– Due to growth arrest
and asymmetric
growth.
Needs Long Term
Follow-up
• Varus Deformity of the
first ray
– This deformity likely to
progress due to muscle
imbalances and medial
over-growth (intact 1st
MT,PP,DP and 2nd MT
physes) without lateral
growth (loss of 3rd, 4th, and
5th MT physes)
Lawn Mower Injuries
• Difficult area to obtain
adequate durable soft tissue
coverage
• May require revisions of
flaps or skin grafts
– Insensate
– Potential for graft breakdown
– May need special
shoes/orthotics/fillers
– Orthotics & fillers may need
yearly replacement.
Dormans JP, Azzoni M, Davidson RS, Drummond DS.
Major lower extremity lawn mower injuries in children.
J Pediatr Orthop. 1995;15:78-82.
Lawnmower Injuries
• Education/ Prevention key
• Children
– < 14 years old shouldn’t operate a lawnmower
– And no riders other than mower operator
– Small children should not be present in yard
while mower is being operated
If you would like to volunteer as an author for
the Resident Slide Project or recommend
updates to any of the following slides, please
send an e-mail to [email protected]
E-mail OTA
about
Questions/Comments
Return to
Pediatrics
Index
Bibliography
• Review Articles
• Kay R, Tang C. Pediatric foot fractures: evaluation and treatment. J Am Acad
Orthop Surg. 2001;9(5):308-19.
• Ribbans WJ, Natarajan R, Alavala S. Pediatric foot fractures. Clin Orthop Relat
Res. 2005 Mar;(432):107-15.
• Original Articles
• Alonso JE, Sanchez FL. Lawn mower injuries in children: A preventable
impairment. J Pediatr Orthop. 1995;15:83-89.
• Barmada A, Gaynor T, Mubarak SJ. Premature physeal closure following distal
tibia physeal fractures: a new radiographic predictor. J Pediatr Orthop.
2003;23(6):733-9.
• Berndt AL, Harty M: Transcondylar fractures (osteochondritis dissecans) of the
talus. J Bone Joint Surg. 41A:988–1020, 1959.
• Brunet JA: Calcaneal fractures in children. Long-term results of treatment. J
Bone Joint Surg. 82B:211–216, 2000.
Bibliography
• Canale ST, Kelly FB: Fractures of the neck of the talus, long term evaluation of
seventy one cases. J Bone Joint Surg. 60A:143–156, 1978.
• Carothers C, Crenshaw A. Clinical significance of a classification of epiphyseal
injuries at the ankle. Am J Surg. 1955;89(4):879-89.
• Caterini R, Farsetti P, Ippolito E. Long-term followup of physeal injury to the
ankle. Foot Ankle. 1991;11(6):372-83.
• Clement D, Worlock P. Triplane fracture of the distal tibia. A variant in cases
with an open growth plate. J Bone Joint Surg Br. 1987;69(3):412-5.
• Dias L, Tachdjian M. Physeal injuries of the ankle in children: classification. Clin
Orthop Relat Res. 1978;136:230-3.
• Dormans JP, Azzoni M, Davidson RS, Drummond DS. Major lower extremity
lawn mower injuries in children. J Pediatr Orthop. 1995;15:78-82.
• Ertl J, Barrack R, Alexander A, VanBuecken K. Triplane fracture of the distal
tibial epiphysis. Long-term follow-up. J Bone Joint Surg Am. 1988;70(7):967-76.
• Hawkins LG: Fractures of the neck of the talus. J Bone Joint Surg. 52A:991–
1002, 1970.
Bibliography
• Higuera J, Laguna R, Peral M, Aranda E, Soleto J: Osteochondritis dissecans of
the talus during childhood and adolescence. J Pediatr Orthop. 1998;18:328-332.
• Inokuchi S, Usami N, Hiraishi E, Hashimoto T: Calcaneal fractures in children. J
Pediatr Orthop. 18:469–474, 1998.
• Jensen et al. Prognosis of fracture of the talus in children: 21 (7-34)-year followup of 14 cases. Acta Orthop Scand. 1994;65:398-400.
• Johnson GF. Pediatric Lisfranc injury: “Bunk bed” fracture. AJR Am J
Roentgenol. 1981;137:1041-1044.
• Kling T, Bright R, Hensinger R. Distal tibial physeal fractures in children that
may require open reduction. J Bone Joint Surg Am. 1984;66(5):647-57.
• Ogden JA, Lee J. Accessory ossification patterns and injuries of the malleoli. J
Pediatr Orthop. 1990;10(3):306-16.
• Owen RJT, Hickey FG, Finlay DB: A study of metatarsal fractures in children.
Injury. 1995;26:537-538.
• Phieffer et al. Effect of interposed periosteum in an animal physeal fracture
model. Clin Orthop Relat Res. 2000;376:15-25.
Bibliography
• Spiegel P, Cooperman D, Laros G. Epiphyseal fractures of the distal ends of the
tibia and fibula. J Bone Joint Surg Am. 1978;60(8):1046-50.
• von Laer L. Classification, diagnosis, and treatment of transitional fractures of
the distal part of the tibia. J Bone Joint Surg Am. 1985;67(5):687-98.
• Wiley JJ: Tarso-metatarsal joint injuries in children. J Pediatr Orthop.
1981;1:255-260.
If you would like to volunteer as an author for
the Resident Slide Project or recommend
updates to any of the following slides, please
send an e-mail to [email protected]
E-mail OTA
about
Questions/Comments
Return to
Pediatrics
Index