A child’s foot is significantly more cartilaginous than an adult foot, making foot fractures an uncommon injury in children. Foot fractures constitute about 5-8% of paediatric fractures. Evaluation and management of a paediatric foot injury requires an understanding of paediatric anatomy, a careful history, clinical examination, and potentially radiography.
Normal anatomy
The foot is anatomically divided into 3 sections: hindfoot, midfoot and forefoot.
The hindfoot includes the talus and calcaneus. The inferior surface of the talus is more prone to avascular necrosis due to its retrograde blood supply. The large posterior facet of the calcaneus is most prone to fracture.
The midfoot includes the navicular, cuboid and the three cuneiform bones.
The forefoot includes the metatarsals and phalanges.
Evaluation of foot injuries
History
The following specific enquiries should be made about the injury:
- The mechanism of injury (high/low velocity, twisting, compression, direct blow)
- Characteristics of pain (worse at the time of injury vs late onset)
- Location of pain
- Consistency and plausibility of the history, excluding concerns about non-accidental injury
- The effect of the injury on the child (limping, the distance the child can move)
- The efficacy of pain relief
Examination
Clinical examination should be tailored to the history.
Look
For external skin abrasions or obvious open fractures.
Feel
Palpation of the bones: tarsals, metatarsals, toes and the base of the 5th metatarsal.
Palpation for tenderness along the ligaments: deltoid ligament on the medial side and anterior talofibular, calcaneofibular and posterior talofibular ligaments on the lateral side.
Move
The active movement should be followed by passive movement as much as pain allows.
The usual range of movements are: subtalar eversion (15-20°), subtalar inversion (35-40°), forefoot adduction (20°), forefoot abduction (10°), 1st metatarsal phalangeal (MTP) flexion (45°), 1st MTP extension (70-90°) and free motion of lesser toes.
Neurovascular examination
Two pulses: dorsalis pedis and posterior tibial.
Five sensory nerves: saphenous (medial calf and hindfoot), superficial peroneal (dorsum of the foot), deep peroneal (1st dorsal webspace), sural (lateral foot) and posterior tibial nerve (plantar foot and heel).
Imaging
The Ottawa foot rules can be applied to children. The rules have 97-100% sensitivity in paediatric injury investigation. According to the rules, x-rays of the foot are required if the child is unable to bear weight both immediately after the injury and in the ED, plus bony tenderness over the base of the 5th metatarsal or the navicular. Â
Accessory ossicles
Accessory foot ossicles can cause pain as a result of stress injuries. The navicular ossicles arise either on the medial side of (os tibiale externum) or on the lateral tubercle of the navicular bone (os trigonum).
Os tibiale externum
This is an ossification centre that arises at the site of the tibialis posterior tendon on the medial side of the navicular bone. It becomes an accessory bone when it fails to fully ossify. It is present in 4-14% of patients.
The usual presentation is in adolescence when the patient has pain from overuse, especially in athletes.
Examination may reveal pes planus (flat foot). This happens as the tibialis posterior tendon, maintaining the medial longitudinal arch, attaches to the accessory bone rather than the navicular bone.
Investigations include plain films and, occasionally, MRI scans. Â
Treatment is initially conservative, with orthotics and casting. If these measures fail to resolve the pain, the ossicle is excised.
Os trigonum
This is present in 10-25% of the population. It is often associated with heel pain in ballet dancers due to repetitive microtrauma.
Hindfoot fractures
These are rare, constituting only 0.008% of all paediatric fractures. Children usually present after falling from a height or after a motor vehicle injury. The talus can be fractured in multiple places, including avulsion fractures.
‘Snowboarder’s fracture’ is a fracture of the lateral process of the talus. The mechanism of injury involves dorsiflexion and inversion.
Do not miss: Snowboarder’s fractures are often misdiagnosed as an ankle sprain. If not evident on x-ray, a CT or MRI should be performed if there is clinical suspicion. Think carefully about the mechanism.
Calcaneus fractures typically occur due to axial loading and are frequently associated with vertebral compression fractures. Radiography should include AP, lateral and axial views. The axial view offers a better view of the fracture.
Treatment of talus and calcaneus fractures is dependent on the degree of displacement.
- Non- or minimally displaced avulsion fractures or extra-articular fractures should be managed in a posterior short-leg splint and non–weight–bearing with crutches for 3 to 4 weeks.
- Displaced fractures require reduction, by an orthopaedic surgeon, followed by immobilisation with a splint or cast. Severely displaced, comminuted or intra-articular fragments may require ORIF.
Midfoot fractures
These are also rare fractures and usually result from severe blunt injury. Most fractures are avulsion or stress fractures and are associated with other injuries.
Treatment depends on the severity of displacement of the fracture and associated injuries.
- Non or minimally displaced fractures (the majority of these fractures) can be treated with a walking cast.
- Displacement of the fracture fragment greater than 2mm should be managed with reduction and stabilisation before immobilisation.
Midfoot fractures have minimal long-term sequelae.
Forefoot fractures
Forefoot fractures represent about 60% of paediatric foot fractures and can result from either direct or indirect trauma. They are easily missed: about 41% are missed due to high-energy trauma causing other significant injuries.
Lisfranc fracture
Lisfranc fractures occur due to axial loading, forced plantar flexion (commonly seen in bicycle or horseback riders, where a foot gets caught in a pedal or stirrup), or a crush injury.
Clinical examination
- Tenderness over the dorsum of the foot with swelling and inability to bear weight.
- Plantar bruising is a consistent sign and, if present, should raise suspicion of the injury. Â
Diagnosis is made with a weight bearing x-rays (as the fracture may not be evident on non-weight bearing views) – AP, lateral and oblique radiographs of the foot. The normal alignment of the foot should have the 2nd metatarsal aligning with the intermediate cuneiform on the dorsoplantar view and the 3rd metatarsal aligning with the lateral cuneiform on the oblique view. The Lisfranc ligament connects the cuneiforms to the 2nd metatarsal. Disruption of this ligament leaves the foot unstable, and hence, it is important not to miss this injury. Due to the ligament attachment, there is often an associated fracture of the bases of the 1st or 2nd metatarsal in a Lisfranc injury.
Treatment depends on the degree of severity of the injury.
- Partial tears with < 2mm malalignment require immobilisation or a walking boot for 4-6 weeks. The patient should be referred to orthopaedic surgeons within 3-5 days due to the high rate of late complications.
- More severe injuries require operative treatment with internal fixation.
There is a high rate of residual pain in children with a Lisfranc injury.
Metatarsal fractures
Metatarsal fractures are associated with athletic activity and are becoming more common. The 5th metatarsal is the most commonly fractured metatarsal in paediatric patients. It can result from twisting, repetitive stress or direct trauma. 1st and 5th metatarsal fractures can be isolated, whereas 2nd-4th metatarsal fractures often occur along with other metatarsal fractures. It is a frequently missed fracture on a radiograph.
Children younger than 5 years of age are more likely to be injured by a fall from height and fracture the 1st metatarsal. Older children are more likely to fracture it from falling from a standing position during sports and tend to fracture the 5th metatarsal.
Pseudo-Jones fracture
A Pseudo-Jones fracture is an avulsion fracture of the base of the 5th metatarsal resulting from a twisting injury of the foot. The examination will reveal focal point tenderness. The patient should be immobilised for 3-4 weeks in a weight-bearing cast.
Treat with a short walking boot or hard-sole shoe for 6 weeks. Follow-up with orthopaedic surgeons.
Jones fracture
The Jones fracture is a fracture of the metaphyseal-diaphyseal junction at the base of the 5th metatarsal bone. It is the most common metatarsal fracture (40%) and represents about 25% of all paediatric foot fractures.
Fractures at or distal to the metaphyseal-diaphyseal junction require 6 weeks in a non–weight–bearing cast with crutches. All patients should be referred to orthopaedic surgeons as there is a high incidence of delayed union of the fracture. Many of these patients will require ORIF subsequently.
The apophysis of the base of the 5th metatarsal appears at age 10 for girls and at age 12 for boys. An unfused apophysis runs longitudinally, whereas a pseudo-Jones fracture runs transversely.
Toe fractures
Toe fractures are one of the most common fractures in the paediatric population. Phalangeal fractures constitute about 3-7% of all physeal fractures and are usually Salter-Harris I or II injuries. They are more common in boys than girls and are mostly closed in nature.
The patient may present with localised tenderness to the toe, a limp or inability to bear weight. Nail bed bleeding and bleeding from or around the nail fold should prompt the possibility of an open fracture through the nail bed. Alignment, rotation and neurovascular status should be checked.
Fractures of the 2nd-5th toes are usually treated by buddy strapping and weight bearing as much as possible. Healing can take up to 3-4 weeks. A hard-soled shoe or walking boot may be used for patient comfort. Follow-ups with orthopaedic surgeons can cease 3 weeks after the injury. If there is possible injury to physis then follow-up should continue for 1-2 years to detect abnormal growth.
The big toe
The big toe plays an important part in bearing weight, so its fractures are managed slightly differently. Salter-Harris III or IV fractures of the proximal phalanx of the hallux are often intra-articular.
Urgent orthopaedic consultation for closed or open reduction for K wiring if:
- more than one-third of the joint surface is involved or
- displacement is more than 2-3mm
In other cases, toe platform cast or a walking boot is used.
The epiphysis of the proximal phalanx of the 1st toe is sometimes bipartite, simulating a Salter-Harris III fracture. If there is no tenderness on the 1st toe, no treatment is indicated.
Phalangeal open fractures require thorough irrigation and debridement in addition to antibiotics to avoid osteomyelitis. A nail-bed injury to the germinal matrix will require surgical repair.
Long-term complications include growth arrest and angular deformities from physeal injury, degenerative joint disease from intra-articular fractures and osteomyelitis from open fractures.
References
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