Fractures of the foot can result from numerous mechanisms including direct blows, inversions of the ankle, twisting forces, falls, and axial loading. The vast majority of foot fractures involve the forefoot, which consists of the metatarsals and phalanges. Management is typically immobilization and most do well. However, there are some injuries that require surgical fixation and rare injuries such as the Lisfranc or hind foot fractures can have complications if unrecognized.
Metatarsal fractures account for 61% of fractures in the foot, and they may be associated with an impressive amount of soft-tissue swelling. Younger children are more likely to fracture the first metatarsal in falls from a height, whereas children older than 5 years of age are more likely to fracture the fifth metatarsal during sporting activities. Many of these fractures are suspected after examination. Standard radiographs should include an oblique view. The first and fifth metatarsals are frequently solitary fractures, but beware of what appears to be solitary fractures of the second, third, or fourth metatarsal because many of these will have adjoining fractures.17 The famous “Jones fracture,” occurring in the proximal diaphyseal region of the fifth metatarsal, is uncommon in children. The transverse fractures and avulsions off the fifth metatarsal base (Fig. 31-12) are routine. It is important to recognize the differences between these common fractures and the rare Jones injury because outcomes are much better and surgical intervention is rare. If complications do arise with metatarsal fractures, it is often because of compartment syndrome after severe swelling. The majority of metatarsal fractures can be effectively treated with a short-leg splint, closed reduction if displaced, and an emphasis on supportive care to prevent swelling.
Fractures of the fifth metatarsal are much more likely to be avulsions or shaft fractures in pediatrics. The Jones fracture occurs at the metaphyseal–diaphyseal junction and is rare in children.
Phalangeal fractures are also common but are straightforward to manage. They can be recognized by point tenderness and radiographic findings. Immobilization is achieved with either a hard-sole shoe or a short-leg splint depending upon the family's preference. SH II fractures may require reduction following a digital block. Indications for surgical fixation are intra-articular fractures of the great toe with displacement at the proximal phalanx, open fractures, or any significant displacement.
Midfoot fractures involving the tarsal bones of the navicular, cuneiforms, and cuboid are rare. These fractures usually result from direct trauma to the midfoot and may be difficult to detect. They are best managed with a nonweight-bearing posterior splint and follow-up unless significantly displaced. The tarsometatarsal fracture/dislocation (Lisfranc) involves the midfoot and is very rare in children (Fig. 31-13). The “Lisfranc joint” is the entire tarsometatarsal junction where the second metatarsal acts as a keystone with very strong ligamentous support. The Lisfranc fracture presents with swelling in the midfoot, marked tenderness, and radiographic suspicion of a fracture at the base of the second metatarsal with tarsometatarsal dislocation. Diagnosing the Lisfranc injury on standard two-view x-ray is difficult, and oblique views are mandatory if suspected. The mechanism is usually a force of strong plantar flexion or abduction of the foot. Recognizing this injury is important because surgical fixation is usually required.
The rare Lisfranc injury consists of a tarsal–metatarsal dislocation. A fracture of the second metatarsal with dislocation is the most common pattern.
Hindfoot injuries involving the talus and calcaneus are rare in children. Calcaneal fractures in adults are seen with significant falls from height and are often associated with vertebral fractures, contralateral calcaneal fractures, and renal pedicle injuries. These accompanying injuries may occur in children but are much less common. Radiographs of the calcaneus are difficult to interpret and require AP, lateral, and axial views when a fracture is suspected. Some injuries may even require oblique views or a CT scan to make the diagnosis. Subtle compression fractures in adolescents may be detected using Bohler's angle on lateral radiographs, but this measurement is much less reliable in younger children (Fig. 31-14). Any patient with a calcaneal fracture may need AP and lateral views of the thoracolumbar spine to look for an accompanying vertebral fracture. Pain and swelling is often impressive with calcaneal injuries, and ED management consists of nonweight-bearing immobilization with a bulky posterior splint. Nonoperative management of pediatric calcaneal fractures is usually very successful.
Bohler's angle to detect compression fractures of the calcaneus may be useful in adolescents, but it is unreliable in younger children.
Hindfoot fractures of the talus are also rare, and typically involve the talar neck after a mechanism of forced dorsiflexion. Patients present with anterior ankle pain, swelling, and inability to ambulate. Routine radiographs usually reveal the diagnosis, but occasionally a CT scan may be indicated. A talar fracture of recent note is the “snowboarder's fracture.” This fracture of the lateral talar process occurs with dorsiflexion of the ankle and inversion of the hind-foot which is common during snowboarding. Be suspicious of any snowboarder presenting with anterolateral ankle pain. Unless displaced, fractures of the talus can be managed in the ED with nonweight-bearing immobilization in a posterior splint and close orthopedic follow-up. Displacement usually warrants surgical repair, and all talar fractures must be followed closely by an orthopedist because of the risk for osteonecrosis.18