Foot pain in children is common and varied. During the first decade of life, foot pain is usually due to traumatic and inflammatory problems, such as injuries and infections, and is seldom due to deformity. During the second decade, foot pain is often secondary to deformity.
Determining the PMT is especially useful about the foot because the structures are subcutaneous and easily examined. This localization often allows a presumptive diagnosis.
Stress–occult fractures Fractures without trauma history are not uncommon in infants and young children. They may be considered as part of the toddler fracture spectrum. Fractures of the cuboid, calcaneus, and metatarsal bones can be best identified by bone scans.
Tendonitis–fascitis Repetitive microtrauma is a common source of heel pain in children. This is most common about the os calcis either at the attachment of the heel-cord or the plantar fascia.
Infections of the foot are relatively common. Septic arthritis commonly affects the ankle and occasionally other joints of the foot. Osteomyelitis may occur in the calcaneus and tarsal bones. Infection may be hematogenous or iatrogenic (heel sticks for blood sampling) or result from penetrating injuries.
Nail puncture wounds are common injuries that may be complicated by osteomyelitis. About 5% of nail penetrations become infected, but less than 1% develop osteomyelitis. Puncture wounds under the metatarsal are more likely to be caused by pseudomonas septic arthritis. Infections in the heel are commonly from staphylococcus or streptococcus.
Initial management Examine the foot and remove any protruding foreign material. Probing the wound will be unpleasant and unrewarding. Update tetanus immunization. Usually infections will show signs several days after the injury and include increasing discomfort, swelling on the dorsum of the foot, and fever.
Management of infection Culture the wound and obtain an AP radiograph of the foot to serve as a baseline. The time of onset of signs of an infection suggests the infecting agent. If the interval between penetration and infection is 1 day, the organism is likely to be streptococcus. If the interval is 3 days, staphylococcus is most likely, and if a week, pseudomonas. Children with pseudomonas infections were usually wearing shoes at the time of the penetration. Operative debridement and drainage are indicated in all pseudomonas infections. Drainage is also indicated in all infections that fail to improve promptly with antibiotic treatment.
Ingrown toenails are common infections resulting from a combination of anatomical predisposition, improper nail trimming, and trauma. Injury or constricting shoes or stockings may initiate the infection. In children prone to developing this problem, the nail is abnormal, often showing a greater lateral curvature of the nail into the nailbed.
Management of early infections Choose treatment based on the severity of the inflammation. Mild irritation requires only proper trimming of the nail and properly fitting shoes. Nails should be trimmed at right angles. Avoid trimming the nail to create a convex end. Instruct the family to trim the nail to create a concave end that leaves the nail edges extending beyond the skin to prevent recurrent ingrowth. Elevate the soft tissue from the nail plate with a wisp of cotton. Avoid forcefull packing. Repeat this several times if necessary to lift the inflamed soft tissue from the nail plate. If inflammation is more severe, rest, elevation, protection from injury, soaking to clean and promote drainage, and antibiotics may be necessary.
Management of late infections Persistent severe lesions require operative management. The hypertrophic chronic granulation tissue is excised.