Foot fractures in children account for about 6% of all fractures and about half involve the metatarsals (MTs). Soft tissue injuries are relatively common because the child’s foot is vulnerable to injury.
Toe fractures sometimes require reduction and can often be immobilized by taping the toe to the adjacent digit.
Metatarsal fractures are varied.
First metatarsal In early childhood, the first MT is most commonly fractured. These fractures remodel well, and closed management is usually satisfactory.
Stress fractures become more common during adolescence.
Fifth metatarsal fractures may take a variety of forms.
Apophysis The apophysis of the tuberosity may be confused with a nondisplaced tuberosity fracture. A normal apophysis has a smooth radiolucent line parallel to the shaft of the metatarsal. This is seen in girls 9 to 11 years, in boys 11 to 14 years of age. This is differentiated from a fracture by the lack of tenderness over the apophysis.
Accessory ossicles These are either the os peroneum, located next to the lateral border of the cuboid, or the os vesalium, at the insert of the peroneus brevis. These ossicles are nontender and have a rounded appearance.
Metaphyseal fractures These are usually undisplaced and heal quickly with simple immobilization in a short-leg cast.
Metaphyseal-diaphyseal fractures These junctional fractures heal more slowly and require 4 weeks nonweight-bearing in a short-leg cast. Additional immobilization and sometimes screw fixation are required to achieve union.
Cuboid fractures make up about 5% of foot fractures.
Acute fractures in children may be caused by trauma or forced abduction of the foot. These are uncommon fractures. Suspect this fracture if tenderness and swelling over the cuboid is present. Make oblique radiographs if necessary to establish the diagnosis. An anatomic or near anatomic reduction is necessary in the older child if the articular surface is deformed.
Stress fractures in children are most common in early childhood and are frequently missed unless identified by a bone scan. Consider this diagnosis in the child with an undiagnosed limp.
Navicular fractures are rare injuries and, if displaced, may require open reduction.
Talus fractures are rare injuries. Manage nondisplaced fractures by cast immobilization. Reduce articular fractures and fix anatomically. Outcomes are generally good. AVN and degenerative changes are rare complications.
Calcaneal fractures can be divided into acute or stress fractures.
Acute fractures can be classified like adult fractures. About 60% are extraarticular. Comminution is less common in children. Manage most with a short-leg cast. Avulsion of the tendo-Achilles can be managed closed if displacement is minimal. The prognosis is usually good. Anatomically reduce and fix displaced articular fractures.
Stress fractures cause limping in infants and children. The diagnosis can often be established by finding tenderness over the heel. Treat with a short-leg cast for 3 weeks. If the diagnosis is unclear, a bone scan is diagnostic. Follow-up radiographs taken at 3 weeks will often show the arc of sclerosis across the calcaneal tuberosity.
Lawn Mower Injuries to the Foot
These devastating injuries are usually due to falls from riding mowers. Most serious injuries involve the plantar–medial aspect of the foot. Microvascular repairs, composite, cross-leg, and free grafts are often necessary for management. Attempts at preservation are justified because of the child’s great potential for healing.
Include high-resolution radiographs of the feet in the skeletal survey performed for suspected abuse. Torus and other subtle fractures are typical findings.
Burns of the Feet
Burns often result in severe contracture formation Management may require releases and grafting or gradual correction with an Ilizarov frame.
Bicycle Spoke Injuries
These accidents often cause soft tissue injuries and occasionally fractures. They usually occur while riding with an adult.
Soft Tissue Injuries
Compartment syndromes Swelling, pain with passive motion, and elevated compartment pressure establish the diagnosis. Treat with multicompartment releases and delayed skin closure.
Severe soft tissue injuries may result in necrosis, skin loss, or neurovascular complications. The healing potential of the child may result in less of a disability compared to an equivalent injury in an adult.